DHS 10.31 Note
Note: This provision allows anyone acting responsibly for a person who is incapacitated to begin the application process for financial assistance with the costs of long-term care services. Other decisions regarding receipt of health or long-term care services, including placement in a long-term care facility, require consent of the individual or authorization by a person or court with the specific authority to make treatment or placement decisions.
DHS 10.31(5)
(5)
Verification of information. A financial and non-financial eligibility application for the family care benefit shall be denied when the applicant or enrollee is able to produce required verifications but refuses or fails to do so. If the applicant or enrollee is not able to produce verifications or requires assistance to do so, the agency taking the application may not deny assistance but shall proceed immediately to assist the person to secure necessary verifications.
DHS 10.31(6)(a)(a)
Decision date for financial and non-financial eligibility. Except as provided in par.
(b), as soon as practicable, but not later than 30 days from the date the agency receives a financial and non-financial eligibility application that includes at least the applicant's name, address, unless the applicant is homeless, and signature, the agency shall determine the applicant's financial and non-financial eligibility and cost sharing requirements for the family care benefit. If the applicant is the spouse of a family care member, the agency shall notify both spouses in accordance with the requirements of s.
49.455 (7), Stats.
DHS 10.31(6)(am)
(am)
Decision date for functional eligibility. Except as provided in par.
(b), as soon as practicable, but not later than 30 days from the date the resource center receives verbal acceptance from the applicant to proceed with the functional screen, the resource center will determine the applicant's functional eligibility for the family care benefit.
DHS 10.31(6)(b)
(b)
Notice. The agency shall notify the applicant in writing of its determination. If a delay in processing the financial and non-financial eligibility application or determining functional eligibility occurs because of a delay in securing necessary information, the agency shall notify the applicant that there is a delay in processing the application. Communications with the applicant, either orally or in writing, in the attempt to obtain the missing information shall serve as notice of the delay. If the delay is not resolved within 30 days following this notice to the applicant of the missing information, the agency shall notify the applicant in writing of the delay in completing the determination, specify the reason for the delay, and inform the applicant of their right to appeal the delay by requesting a fair hearing under s.
DHS 10.55.
DHS 10.31(7)
(7)
Enrollment. The agency shall complete and transmit, as directed by the department, all enrollment forms and materials required to enroll persons who are eligible and who choose to enroll in a care management organization.
DHS 10.31(8)
(8)
Fraud. When the agency director or designee has reason to believe that an applicant or enrollee, or the representative of an applicant or enrollee, has committed fraud, the agency director or designee shall refer the case to the district attorney.
DHS 10.31 History
History: Cr.
Register, October, 2000, No. 538, eff. 11-1-00;
CR 04-040: am. (6) (a)
Register November 2004 No. 587, eff. 12-1-04;
EmR2121: emerg. am. (4) (b), eff. 8-5-21;
CR 21-081: am. (4) (b)
Register May 2022 No. 797, eff. 6-1-22, am. (4) (b) eff. upon the termination of the Appendix K: Emergency Preparedness and Response and COVID-19 Addendum to the 1915 (c) Family Care program waiver;
CR 22-026: am. (4) (a), (b), (5), (6) (a), cr. (6) (am), am. (6) (b)
Register May 2023 No. 809, eff. 6-1-23.
DHS 10.32
DHS 10.32 General conditions of eligibility. DHS 10.32(1)(1)
Conditions. To be eligible for the family care benefit, a person shall meet all of the following conditions:
DHS 10.32(1)(a)
(a) Age. The person is at least 18 years of age at the time of application.
DHS 10.32(1)(b)
(b) Residency. The person is a resident of a county, family care district or service area of a tribe in which the family care benefit is available through a care management organization. This requirement does not apply to a person who is either of the following:
DHS 10.32(1)(b)1.
1. An enrollee who was a resident of the county, family care district or tribal area when he or she enrolled in family care, but currently resides in a long-term care facility outside the service area of the CMO under a plan of care approved by the CMO.
DHS 10.32(1)(b)2.
2. An applicant who, on the date that the family care benefit first became available in the county, was receiving services in a long-term care facility funded under any of the programs specified under s.
DHS 10.33 (3) (c) administered by that county.
DHS 10.32(1)(c)
(c) Family care target group. The person has a physical disability, is a frail elder, or has a developmental disability.
DHS 10.32(1)(g)
(g)
Acceptance of medical assistance if eligible. If the person is eligible for medical assistance, he or she applies for and accepts the medical assistance.
DHS 10.32(1)(h)
(h)
Other non-financial conditions. The person meets the nonfinancial conditions of eligibility for medical assistance under s.
DHS 103.03 (2) to
(9).
DHS 10.32(2)
(2)
Provision of necessary information. A client or person acting on behalf of a client shall provide full, correct and truthful information necessary to determine family care eligibility, entitlement status and cost sharing requirements, including the following:
DHS 10.32(2)(a)
(a) A declaration of assets on a form prescribed by the department.
DHS 10.32(2)(b)
(b) A declaration of income on a form prescribed by the department.
DHS 10.32(2)(c)
(c) Information related to the person's health and functional status, as required by the department.
DHS 10.32(3)
(3)
Reporting of changes required. An enrollee shall report to the county agency any change in circumstances that would affect his or her eligibility under this section, including income and asset changes that would affect cost sharing obligations, as specified under s.
DHS 10.34 (3) (f).
DHS 10.32(4)
(4) Review of eligibility.
Enrollees' eligibility for the family care benefit shall be re-determined annually or more often when a county agency has information indicating that a change has occurred in an enrollee's circumstances that would affect his or her eligibility or cost sharing requirements.
DHS 10.32 History
History: Cr.
Register, October, 2000, No. 538, eff. 11-1-00;
CR 04-040: am. (1) (b) 2. and (c)
Register November 2004 No. 587, eff. 12-1-04; corrections in (1) (h) and (i) made under s.
13.92 (4) (b) 7., Stats.,
Register November 2008 No. 635;
EmR2121: emerg. r. (4), eff. 8-5-21;
CR 21-081: am. (4)
Register May 2022 No. 797, eff. 6-1-22, am. (4) eff. the first day of the month after the emergency period, as defined in section 1135 (g) (1) (b) of the Social Security Act,
42 USC 1320b-5 (g) (1) (B) and declared in response to the COVID-19 pandemic, ends; correction in (4) made under s.
35.17, Stats.,
Register May 2022 No. 797;
CR 23-046: am. (1) (a) Register April 2024 No. 820, eff. 5-1-24. DHS 10.33
DHS 10.33 Conditions of functional eligibility. DHS 10.33(1)(c)
(c) “Appropriately" means suitable in terms of time and place.
DHS 10.33(1)(d)
(d) “Long-term or irreversible condition" means a physical or cognitive impairment that is expected to last for more than 90 days or result in death within one year.
DHS 10.33(1)(e)
(e) “Requires ongoing care, assistance or supervision" means a person cannot safely or appropriately perform one or more ADLs or IADLs, as is evidenced by findings from functional screening.
DHS 10.33(1)(f)
(f) “Safely" means without significant risk of harm to oneself or others.
DHS 10.33(2)(a)
(a)
Determination. Functional eligibility for the family care benefit shall be determined pursuant to s.
46.286 (1), Stats., and this chapter, using a uniform functional screening prescribed by the department. To have functional eligibility for the family care benefit, the functional eligibility condition under par.
(b) shall be met and, except as provided under sub.
(3), the functional capacity level under par.
(c) or
(d) shall be met.
DHS 10.33(2)(b)
(b)
Long-term condition. The person shall have a long-term or irreversible condition.
DHS 10.33(2)(c)
(c)
Nursing home level. A person is functionally eligible at the nursing home level if the person requires ongoing care, assistance or supervision from another person, as is evidenced by any of the following findings from application of the functional screening:
DHS 10.33(2)(c)1.
1. The person cannot safely or appropriately perform 3 or more activities of daily living.
DHS 10.33(2)(c)2.
2. The person cannot safely or appropriately perform 2 or more ADLs and one or more instrumental activities of daily living.
DHS 10.33(2)(c)3.
3. The person cannot safely or appropriately perform 5 or more IADLs.
DHS 10.33(2)(c)4.
4. The person cannot safely or appropriately perform one or more ADL and 3 or more IADLs and has cognitive impairment.
DHS 10.33(2)(c)5.
5. The person cannot safely or appropriately perform 4 or more IADLs and has cognitive impairment.
DHS 10.33(2)(c)6.
6. The person has a complicating condition that limits the person's ability to independently meet his or her needs as evidenced by meeting both of the following conditions:
DHS 10.33(2)(c)6.a.
a. The person requires frequent medical or social intervention to safely maintain an acceptable health or developmental status; or requires frequent changes in service due to intermittent or unpredictable changes in his or her condition; or requires a range of medical or social interventions due to a multiplicity of conditions.
DHS 10.33(2)(c)6.b.
b. The person has a developmental disability that requires specialized services; or has impaired cognition exhibited by memory deficits or disorientation to person, place or time; or has impaired decision making ability exhibited by wandering, physical abuse of self or others, self neglect or resistance to needed care.
DHS 10.33(2)(d)
(d)
Non-nursing home level A person is functionally eligible at the non-nursing home level if the person is at risk of losing his or her independence or functional capacity unless he or she receives assistance from others, as is evidenced by a finding from application of the functional screening that the person needs assistance to safely or appropriately perform either of the following:
DHS 10.33 History
History: Cr.
Register, October, 2000, No. 538, eff. 11-1-00;
CR 04-040: am. (1) (c) and (2) (a), (c) and (d)
Register November 2004 No. 587, eff. 12-1-04;
CR 22-026: r. (3)
Register May 2023 No. 809, eff. 6-1-23;
CR 23-046: renum. (1) (a) to (d) to be (1) (c) to (f), cr. (1) (a), (b), am. (2) (c) (intro.), (d) (intro.) Register April 2024 No. 820, eff. 5-1-24. DHS 10.34
DHS 10.34 Financial eligibility and cost sharing. DHS 10.34(1)(a)
(a) “Actual maintenance costs" means the sum of the following:
DHS 10.34(1)(b)
(b) “Certification period" means a 12-month period for which financial eligibility and cost sharing requirements for the family care benefit are determined for a non-MA eligible person.
DHS 10.34(1)(c)
(c) “Consumer price index" means the consumer price index for all urban consumers, U.S. city average, as determined by the U.S. department of labor.
DHS 10.34(2)
(2)
Individuals eligible for medical assistance. A person who is eligible for medical assistance under ch.
49, Stats., and chs.
DHS 101 to
108 is financially eligible for the family care benefit. Cost sharing requirements for the family care benefit for a medical assistance-eligible person are those that apply under ch.
49, Stats., and chs.
DHS 101 to
108.
DHS 10.34(3)
(3)
Individuals not eligible for medical assistance. DHS 10.34(3)(a)
(a) Conditions of financial eligibility. Eligibility under this subsection is effective beginning July 1, 2000. For persons who are not eligible for medical assistance, financial eligibility and cost sharing requirements for the family care benefit shall be determined pursuant to applicable provisions of s.
46.286 (1) (b) and
(2), Stats., and this chapter. The maximum cost-sharing requirement for a non-MA-eligible person shall be determined by a county agency using a uniform financial eligibility and cost-sharing screening prescribed by the department. A non-MA-eligible person is financially eligible for the family care benefit if the projected cost of the person's care plan exceeds the person's maximum cost-sharing requirement.
DHS 10.34(3)(b)
(b)
Calculation of maximum cost share requirement at initial determination and annual re-determination of eligibility. A non-MA-eligible family care enrollee shall contribute to the cost of his or her care an amount that is calculated as provided under this section. Treatment of assets, including assets in trusts, and income shall be as provided under ss.
49.454 and
49.47, Stats., and ss.
DHS 103.06 and
103.07 unless specified otherwise in this section. All dollar amounts specified in this section shall be updated annually based on changes in the consumer price index. The following calculation shall determine the applicant's or enrollee's maximum cost-sharing requirement:
DHS 10.34(3)(b)1.
1. Determine total countable assets according to ss.
49.454 and
49.47, Stats., and s.
DHS 103.06. If the applicant or enrollee is legally married, include the countable assets of both members of the couple.
DHS 10.34(3)(b)2.
2. Determine monthly net countable assets by subtracting from total countable assets the following allowances, as applicable, and dividing the result by 12:
DHS 10.34(3)(b)2.a.
a. Subject to subd.
6., if the applicant or enrollee is a family care spouse, the amount of the community spouse resource allowance under s.
49.455 (6) (b), Stats.
DHS 10.34(3)(b)2.b.
b. If the person resides in a nursing home, community-based residential facility or adult family home, an allowance of $9,000.
DHS 10.34(3)(b)2.c.
c. If the person resides in his or her own home, including a residential care apartment complex or in the private home of a relative or other person, an allowance of $12,000.
DHS 10.34(3)(b)3.
3. Determine countable monthly income by adding together all of the following:
DHS 10.34(3)(b)3.a.
a. Monthly unearned income less a $20 disregard from unearned income, or if the person has less than $20 of unearned income, the remainder from earned income.
DHS 10.34(3)(b)3.b.
b. Total monthly earned income, less the first $200, and then less two-thirds of any remaining earned income.
DHS 10.34(3)(b)4.
4. Add together the monthly net countable assets and the countable monthly income.
DHS 10.34(3)(b)5.b.
b. The amount of any payments the person is required to pay by court order.
DHS 10.34(3)(b)5.c.
c. If the person resides in a nursing home, community-based residential facility or adult family home, a personal maintenance allowance of $65.
DHS 10.34(3)(b)5.d.
d. If the person resides in his or her own home, including a residential care apartment complex or the home of another person, a personal maintenance allowance equal to the greater of the combined benefit amount available under
42 USC 1381 to
1383 and s.
49.77 (3s), Stats., or actual maintenance costs, as defined under sub.
(1) (a), up to the maximum personal maintenance allowance for persons receiving home and community-based waiver services funded under
42 USC 1396 (b) or (c).
DHS 10.34(3)(b)5.e.
e. If the person resides in a medical institution, the monthly cost of maintaining a homestead property when the applicant or enrollee can reasonably be expected to return within 6 months or the anticipated absence of the applicant or enrollee from the home is for more than 6 months but there is a realistic expectation, as verified by a physician, that the person will return to the home. The monthly cost shall not exceed the SSI payment level for one person living in that person's own household.
DHS 10.34(3)(b)5.f.
f. The average monthly out-of-pocket cost of necessary medical or remedial care, including health insurance premiums and cost-sharing requirements for other state or federal programs.
DHS 10.34(3)(b)5.g.
g. An allowance for dependents who live in the home of the person or the person's community spouse equal to the allowance payable under s.
49.455 (4) (a) 3., Stats.
DHS 10.34(3)(b)6.
6. If both members of a married couple are family care spouses, the community spouse resource allowance under subd.
2. a. and the community spouse monthly income allowance under subd.
5. a. may be included in the calculation of cost share for either spouse, but not for both.
