SB45: Bill Text

SB45,609,21 2. Whether to create a family care district to apply to the department for a contract to operate a care management organization.

SB45,609,25 (b) The governing body of a tribe or band or of the Great Lakes inter-tribal council, inc., may decide whether to authorize a tribal agency to apply to the department for a contract to operate a care management organization for tribal members and, if so, which client group to serve.

SB45,610,5 (c) Under the requirements of par. (a), a county board of supervisors may decide to apply to the department for a contract to operate a multicounty care management organization in conjunction with the county board or boards of one or more other counties or a county-tribal care management organization in conjunction with the governing body of a tribe or band or the Great Lakes inter-tribal council, inc.

SB45,610,10 (d) Under the requirements of par. (b), the governing body of a tribe or band may decide to apply to the department for a contract to operate a care management organization in conjunction with the governing body or governing bodies of one or more other tribes or bands or the Great Lakes inter-tribal council, inc., or with a county board of supervisors.

SB45,610,15 (2) Contracts. (a) The department may contract for operation of a care management organization only with an entity that is certified as meeting the requirements under sub. (3). No entity may operate as a care management organization under the requirements of this section unless so certified and under contract with the department.

SB45,611,2 (b) Within each county, the department shall initially contract to operate a care management organization with the county or a family care district if the county elects to operate a care management organization and the care management organization meets the requirements of sub. (3) and performance standards prescribed by the department. A county that contracts under this paragraph may operate the care management organization for all of the target groups or for a selected group or groups. During the first 24 months in which the county has a contract under which it accepts a per person per month payment for each enrollee in the care management organization, the department may not contract with another organization to operate a care management organization in the county unless any of the following applies:

SB45,611,4 1. The county agrees in writing that at least one additional care management organization is necessary or desirable.

SB45,611,7 2. The county does not have the capacity to serve all county residents who are entitled to the family care benefit in the client group or groups that the county serves and cannot develop the capacity.

SB45,611,10 3. The governing body of a tribe or band or the Great Lakes inter-tribal council, inc., elects to operate a care management organization within the area and is certified under sub. (3).

SB45,611,16 (c) For contracts following the initial contracts specified in par. (b), the department shall, after consulting with the council on long-term care, prescribe criteria to determine the number of care management organizations that are necessary for operation in a county. Under these criteria, the department shall solicit applications, certify those applicants that meet the requirements specified in sub. (3) (a), select certified applicants for contract and contract with the selected applicants.

SB45,611,20 (3) Certification; requirements. (a) If an entity meets the requirements under par. (b) and applicable rules of the department and submits to the department an application for initial certification or certification renewal, the department shall certify that the entity meets the requirements for a care management organization.

SB45,611,22 (b) To be certified as a care management organization, an applicant shall demonstrate or ensure all of the following:

SB45,612,2 1. Adequate availability of providers with the expertise and ability to provide services that are responsive to the disabilities or conditions of all of the applicant's proposed enrollees and sufficient representation of programmatic philosophies and cultural orientations to accommodate a variety of enrollee preferences and needs.

SB45,612,5 2. Adequate availability of providers that can meet the preferences and needs of its proposed service recipients for services at various times, including evenings, weekends and, when applicable, on a 24-hour basis.

SB45,612,8 3. Adequate availability of providers that are able and willing to perform all of the tasks that are likely to be identified in proposed enrollees' service and care plans.

SB45,612,10 4. Adequate availability of residential and day services that are geographically accessible to proposed enrollees' homes, families or friends.

SB45,612,12 5. Adequate supported living arrangements of the types and sizes that meet proposed enrollees' preference and needs.

SB45,612,15 6. Expertise in determining and meeting the needs of every target population that the applicant proposes to serve and connections to the appropriate service providers.

SB45,612,16 7. Thorough knowledge of local long-term care and other community resources.

SB45,612,19 8. The ability to manage and deliver, either directly or through subcontracts or partnerships with other organizations, the full range of benefits to be included in the monthly payment amount.

SB45,612,21 9. Thorough knowledge of methods for maximizing informal caregivers and community resources and integrating them into a service or care plan.

SB45,612,22 10. Coverage for a geographic area specified by the department.

SB45,613,2 11. The ability to develop strong linkages with systems and services that are not directly within the scope of the applicant's responsibility but that are important to the target group that it proposes to serve, including primary and acute health care services.

SB45,613,4 12. Adequate and competent staffing by qualified personnel to perform all of the functions that the applicant proposes to undertake.

SB45,613,6 (4) Duties. A care management organization shall, in addition to meeting all contract requirements, do all of the following:

SB45,613,14 (a) Accept requested enrollment of any person who is entitled to the family care benefit and of any person who is eligible for the family care benefit and for whom funding is available. No care management organization may disenroll any enrollee, except under circumstances specified by the department by contract. No care management organization may encourage any enrollee to disenroll in order to obtain long-term care services under the medical assistance fee-for-service system. No involuntary disenrollment is effective unless the department has reviewed and approved it.

SB45,613,17 (b) Conduct a comprehensive assessment for each enrollee, including an in-person interview with the enrollee, using a standard format developed by the department.

SB45,613,20 (c) With the enrollee and the enrollee's family or guardian, if appropriate, develop a comprehensive care plan that reflects the enrollee's values and preferences.

SB45,613,22 (d) Provide or contract for the provision of necessary services and monitor the provided or contracted services.

SB45,614,5 (e) Provide, within guidelines established by the department, a mechanism by which an enrollee may arrange for, manage and monitor his or her family care benefit directly or with the assistance of another person chosen by the enrollee. The care management organization shall monitor the enrollee's use of a fixed budget for purchase of services or support items from any qualified provider, monitor the health and safety of the enrollee and provide assistance in management of the enrollee's budget and services at a level tailored to the enrollee's need and desire for the assistance.

SB45,614,7 (f) Provide, on a fee-for-service basis, case management services to persons who are functionally eligible but not financially eligible for the family care benefit.

SB45,614,9 (g) Meet all performance standards required by the federal government or promulgated by the department by rule.

SB45,614,11 (h) Submit to the department reports and data required or requested by the department.

SB45,614,13 (i) Implement internal quality improvement and assurance processes that meet standards prescribed by the department by rule.

SB45,614,14 (j) Cooperate with external quality assurance reviews.

SB45,614,15 (k) Meet departmental requirements for protection of solvency.

SB45,614,17 (L) Annually submit to the department an independent financial audit that meets federal requirements.

SB45,614,24 (5) Funding and risk-sharing. (a) From the appropriation accounts under s. 20.435 (4) (b), (g) and (o) and (7) (b) and (bd), the department shall provide funding on a capitated payment basis for the provision of services under this section. Notwithstanding s. 46.036 (3) and (5m), a care management organization that is under contract with the department may expend the funds, consistent with this section, including providing payment, on a capitated basis, to providers of services under the family care benefit.

SB45,615,5 (b) If the expenditures by a care management organization under par. (a) exceed payments received from the department under par. (a), as determined by the department by contract, the department may share the loss with the care management organization, within the limits prescribed under the contract with the department.

SB45,615,10 (c) If the payments received from the department under par. (a) exceed the expenditures by a care management organization under par. (a), as determined by the department by contract, the care management organization may retain a portion of the excess payments, within the limits prescribed under the contract with the department, and shall return the remainder to the department.

SB45,615,13 (d) The department may, by contract, impose solvency protections that the department determines are reasonable and necessary to retain federal financial participation. These protections may include all of the following:

SB45,615,16 1. The requirement that a care management organization segregate a risk reserve from other funds of the care management organization or the authorizing body for the care management organization.

SB45,615,18 2. The requirement that interest accruing to the risk reserve remain in the escrow account for the risk reserve.

SB45,615,19 3. Limitations on the distribution of funds from the risk reserve.

SB45,616,5 4. The requirement that a care management organization place funds in a risk reserve and maintain the risk reserve in an interest-bearing escrow account with a financial institution, as defined in s. 69.30 (1) (b), or invest funds as specified in s. 46.2895 (4) (j) 2. or 3. Moneys in the risk reserve or invested as specified in this subdivision may be expended only for the provision of services under this section. If a care management organization ceases participation under this section, the funds in the risk reserve or invested as specified in this subdivision, minus any contribution of moneys other than those specified in par. (c), shall be returned to the department. The department shall expend the moneys for the payment of outstanding debts to providers of family care benefit services and for the continuation of family care benefit services to enrollees.

SB45,616,8 (e) 1. Subject to subd. 2., a care management organization may enter into contracts with providers of family care benefit services and may limit profits of the providers under the contracts.

SB45,616,12 2. The department shall review the contracts in subd. 1., including rates for the provision of service, to ensure that the contract terms protect services access by enrollees and financial viability of the care management organization, and may require contract revision.

SB45,616,18 (6) Governing board. A care management organization shall have a governing board that reflects the ethnic and economic diversity of the geographic area served by the care management organization. At least one-fourth of the members of the governing board shall be older persons or persons with physical or developmental disabilities or their family members, guardians or other advocates who are representative of the care management organization's enrollee.

SB45,617,2 (7) Exchange of information. Notwithstanding ss. 48.78 (2) (a), 49.45 (4), 49.83, 51.30, 51.45 (14) (a), 55.06 (17) (c), 146.82, 252.11 (7), 253.07 (3) (c) and 938.78 (2) (a), a care management organization acting under this section may exchange confidential information about a client, as defined in s. 46.287 (1), without the informed consent of the client, under s. 46.21 (2m) (c), 46.215 (1m), 46.22 (1) (dm), 46.23 (3) (e), 46.283 (7), 46.2895 (10), 51.42 (3) (e) or 51.437 (4r) (b) in the county of the care management organization, if necessary to enable the care management organization to perform its duties or to coordinate the delivery of services to the client.

SB45, s. 1076 Section 1076. 46.284 (2) (c) of the statutes, as created by 1999 Wisconsin Act .... (this act), is amended to read:

SB45,617,10 46.284 (2) (c) For contracts following the initial contracts specified in par. (b), the department shall, after consulting with the council on long-term care, prescribe criteria to determine the number of care management organizations that are necessary for operation in a county. Under these criteria, the department shall solicit applications, certify those applicants that meet the requirements specified in sub. (3) (a), select certified applicants for contract and contract with the selected applicants.

SB45, s. 1077 Section 1077. 46.285 of the statutes is created to read:

SB45,617,18 46.285 Operation of resource center and care management organization. In order to meet federal requirements and assure federal financial participation in funding of the family care benefit, a county, a tribe or band, a family care district or an organization, including a private, nonprofit corporation, may not directly operate both a resource center and a care management organization. All of the following apply to operation of both a resource center and a care management organization:

SB45,617,23 (1) County operation. (a) If a county board of supervisors and, if applicable, a county executive or a county administrator, elect to apply to the department for a contract to operate a resource center, the county board of supervisors may create a family care district to apply to the department for a contract to operate a care management organization.

SB45,618,2 (b) If a county board of supervisors and, if applicable, a county executive or a county administrator, elect to apply to the department for a contract to operate a care management organization, the county board of supervisors may create a family care district to apply to the department to operate a resource center.

SB45,618,8 (2) Tribal or band organization. (a) If the governing body of a tribe or band elects to apply to the department for a contract directly to operate a resource center, tribal or band members may form a separate corporation to apply to the department for a contract to operate a care management organization. No members of the governing board of the corporation may be members of the tribal or band governing body.

SB45,618,13 (b) If the governing body of a tribe or band elects to apply to the department for a contract directly to operate a care management organization, tribal or band members may form a separate corporation to apply to the department for a contract to operate a resource center. No members of the governing board of the corporation may be members of the tribal or band governing body.

SB45,618,18 (3) Joint county and tribal or band operation. Any county or family care district that seeks to operate jointly with a tribe or band or tribal or band corporation a care management organization or resource center shall submit jointly with the tribe or band or tribal or band corporation an application to the department to operate the care management organization or resource center.

SB45, s. 1078 Section 1078. 46.286 of the statutes is created to read:

SB45,618,24 46.286 Family care benefit. (1) Eligibility. Except as provided in sub. (1m), a person is eligible for, but not necessarily entitled to, the family care benefit if the person is at least 18 years of age; does not have a primary disabling condition of mental illness, substance abuse or developmental disability; and meets all of the following criteria:

SB45,619,2 (a) Functional eligibility. A person is functionally eligible if any of the following applies, as determined by the department or its designee:

SB45,619,3 1. The person's functional capacity is at either of the following levels:

SB45,619,6 a. The comprehensive level, if the person has a long-term or irreversible condition, expected to last at least 90 days or result in death within one year of the date of application, and requires ongoing care, assistance or supervision.

SB45,619,10 b. The intermediate level, if the person has a condition that is expected to last at least 90 days or result in death within 12 months after the date of application, and is at risk of losing his or her independence or functional capacity unless he or she receives assistance from others.

SB45,619,15 2. The person has a condition that is expected to last at least 90 days or result in death within 12 months after the date of application and, on the date that the family care benefit became available in the person's county of residence, the person was a resident in a nursing home or was receiving long-term care services, as specified by the department, funded under any of the following:

SB45,619,16 a. The long-term support community options program under s. 46.27.

SB45,619,18 b. Home and community-based waiver programs under 42 USC 1396n (c), including community integration program under s. 46.275, 46.277 or 46.278.

SB45,619,19 c. The Alzheimer's family caregiver support program under s. 46.87.

SB45,619,21 d. Community aids under s. 46.40, if documented by the county under a method prescribed by the department.

SB45,619,23 e. County funding, if documented by the county under a method prescribed by the department.

SB45,619,25 (b) Financial eligibility. A person is financially eligible if all of the following apply:

SB45,620,2 1. As determined by the department or its designee, either of the following applies:

SB45,620,7 a. The person would qualify for medical assistance except for financial criteria, and the projected cost of the person's care plan, as calculated by the department or its designee, exceeds the person's gross monthly income, plus one-twelfth of his or her countable assets, less deductions and allowances permitted by rule by the department.

SB45,620,8 b. The person is eligible under ch. 49 for medical assistance.

SB45,620,10 2. If subd. 1. b. applies, the person accepts medical assistance unless he or she is exempt from the acceptance under rules promulgated by the department.

SB45,620,15 (1m) Eligibility exception. A person whose primary disabling condition is developmental disability is eligible for the family care benefit if the person is a resident of a county or is a member of a tribe or band that has operated, before July 1, 2001, a care management organization under s. 46.281 (1) (d) and meets all other eligibility criteria under this subsection.

SB45,620,20 (2) Cost sharing. (a) A person who is determined to be financially eligible under sub. (1) (b) shall contribute to the cost of his or her care an amount that is calculated by the department or its designee after subtracting from the person's gross income, plus one-twelfth of countable assets, the deductions and allowances permitted by the department by rule.

SB45,620,22 (b) Funds received under par. (a) shall be used by a care management organization to pay for services under the family care benefit.

SB45,621,2 (c) A person who is required to contribute to the cost of his or her care but who fails to make the required contributions is ineligible for the family care benefit unless he or she is exempt from the requirement under rules promulgated by the department.

SB45,621,7 (3) Entitlement. (a) Subject to pars. (c) and (d), a person is entitled to and may receive the family care benefit through enrollment in a care management organization if he or she meets the requirements of sub. (1) (intro.), is financially eligible, fulfills any applicable cost-sharing requirements and meets any of the following criteria:

SB45,621,8 1. Is functionally eligible at the comprehensive level.

SB45,621,10 2. Is functionally eligible at the intermediate level and is eligible under sub. (1) (b) 1. b.

SB45,621,13 3. Is functionally eligible at the intermediate level and is determined by an agency under s. 46.90 (2) or specified in s. 55.05 (1t) to be in need of protective services under s. 55.05 or protective placement under s. 55.06.

SB45,621,14 4. Is functionally eligible under sub. (1) (a) 2.

SB45,621,15 5. Is eligible under sub. (1m).

SB45,621,17 (b) An entitled individual who is enrolled in a care management organization may not be involuntarily disenrolled except as follows:

SB45,621,18 1. For cause, subject to the requirements of s. 46.284 (4) (a).

SB45,621,23 2. If the contract between the care management organization and the department is canceled or not renewed. If this circumstance occurs, the department shall assure that enrollees continue to receive needed services through another care management organization or through the medical assistance fee-for-service system or any of the programs specified under sub. (1) (a) 2. a. to d.

SB45,622,5 (c) Within each county and for each client group, par. (a) shall first apply on the effective date of a contract under which a care management organization accepts a per person per month payment to provide services under the family care benefit to eligible persons in that client group in the county. Within 24 months after this date, the department shall assure that sufficient capacity exists within one or more care management organizations to provide the family care benefit to all entitled persons in that client group in the county.