46.283(3)(b)
(b) A determination of functional eligibility for the family care benefit.
46.283(3)(c)
(c) Within the limits of available funding, prevention and intervention services.
46.283(3)(d)
(d) Counseling concerning public and private benefits programs.
46.283(3)(e)
(e) A determination of financial eligibility and of the maximum amount of cost sharing required for a person who is seeking long-term care services, under standards prescribed by the department.
46.283(3)(f)
(f) Assistance to a person who is eligible for the family care benefit with respect to the person's choice of whether or not to enroll in a care management organization and, if so, which available care management organization would best meet his or her needs.
46.283(3)(g)
(g) Assistance in enrolling in a care management organization for persons who choose to enroll.
46.283(3)(h)
(h) Equitable assignment of priority on any necessary waiting lists, consistent with criteria prescribed by the department, for persons who are eligible for the family care benefit but who do not meet the criteria under
s. 46.286 (3).
46.283(3)(i)
(i) Assessment of risk for each person who is on a waiting list, as described in
par. (h), development with the person of an interim plan of care and assistance to the person in arranging for services.
46.283(3)(j)
(j) Transitional services to families whose children with physical or developmental disabilities are preparing to enter the adult service system.
46.283(4)
(4) Duties. A resource center shall do all of the following:
46.283(4)(a)
(a) Provide services within the entire geographic area prescribed for the resource center by the department.
46.283(4)(b)
(b) Submit to the department all reports and data required or requested by the department.
46.283(4)(c)
(c) Implement internal quality improvement and quality assurance processes that meet standards prescribed by the department.
46.283(4)(d)
(d) Cooperate with any review by an external advocacy organization.
46.283(4)(e)
(e) Within 6 months after the family care benefit is available to all eligible persons in the area of the resource center, provide information about the services of the resource center, including the services specified in
sub. (3) (d), about assessments under
s. 46.284 (4) (b) and care plans under
s. 46.284 (4) (c) and about the family care benefit to all older persons and persons with a physical disability who are residents of nursing homes, community-based residential facilities, adult family homes and residential care apartment complexes in the area of the resource center.
46.283(4)(f)
(f) Provide a functional and financial screen to any resident, as specified in
par. (e), who requests a screen and assist any resident who is eligible and chooses to enroll in a care management organization to do so.
46.283(4)(g)
(g) Provide a functional and financial screen to any person seeking admission to a nursing home, community-based residential facility, residential care apartment complex or adult family home if the secretary has certified that the resource center is available to the person and the facility and the person is determined by the resource center to have a condition that is expected to last at least 90 days that would require care, assistance or supervision. A resource center may not require a financial screen for a person seeking admission or about to be admitted on a private pay basis who waives the requirement for a financial screen under this paragraph, unless the person is expected to become eligible for medical assistance within 6 months. A resource center need not provide a functional screen for a person seeking admission or about to be admitted who has received a screen for functional eligibility under
s. 46.286 (1) (a) within the previous 6 months.
46.283(4)(h)
(h) Provide access to services under
s. 46.90 and
ch. 55 to a person who is eligible for the services, through cooperation with the county agency or agencies that provide the services.
46.283(4)(i)
(i) Assure that emergency calls to the resource center are responded to promptly, 24 hours per day.
46.283(5)
(5) Funding. From the appropriation accounts under
s. 20.435 (4) (b),
(bm),
(pa), and
(w) and
(7) (b),
(bd), and
(md), the department may contract with organizations that meet standards under
sub. (3) for performance of the duties under
sub. (4) and shall distribute funds for services provided by resource centers.
46.283(6)
(6) Governing board. A resource center shall have a governing board that reflects the ethnic and economic diversity of the geographic area served by the resource center. 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.
46.283(7)
(7) Confidentiality; exchange of information. No record, as defined in
s. 19.32 (2), of a resource center that contains personally identifiable information, as defined in
s. 19.62 (5), concerning an individual who receives services from the resource center may be disclosed by the resource center without the individual's informed consent, except as follows:
46.283(7)(b)
(b) 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 resource center 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),
46.284 (7),
46.2895 (10),
51.42 (3) (e) or
51.437 (4r) (b) in the county of the resource center, if necessary to enable the resource center to perform its duties or to coordinate the delivery of services to the client.
46.283 History
History: 1999 a. 9;
2001 a. 16,
103.
46.284
46.284
Care management organizations. 46.284(1)(a)(a) After considering recommendations of the local long-term care council under
s. 46.282 (3) (a) 1., a county board of supervisors and, in a county with a county executive or a county administrator, the county executive or county administrator, may decide all of the following:
46.284(1)(a)1.
1. Whether to authorize one or more county departments under
s. 46.21,
46.215,
46.22 or
46.23 or an aging unit under
s. 46.82 (1) (a) 1. or
2. to apply to the department for a contract to operate a care management organization and, if so, which to authorize and what client group to serve.
46.284(1)(a)2.
2. Whether to create a family care district to apply to the department for a contract to operate a care management organization.
46.284(1)(b)
(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.
46.284(1)(c)
(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.
46.284(1)(d)
(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.
46.284(2)(a)(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.
46.284(2)(b)
(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. With respect to contracts exclusively with counties to operate a care management organization, all of the following apply:
46.284(2)(b)1.
1. Before January 1,
2003, the department may not contract with an organization other than the county to operate a care management organization in the county unless any of the following applies:
46.284(2)(b)1.a.
a. The county and the local long-term care council agree in writing that at least one additional care management organization is necessary or desirable.
46.284(2)(b)1.b.
b. 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).
46.284(2)(b)2.
2. After December 31,
2002, and before January 1, 2004, the department may not contract with an organization other than the county to operate a care management organization in the county unless any of the following applies:
46.284(2)(b)2.b.
b. The county fails to meet requirements of
sub. (3) and performance standards prescribed by the department.
46.284(2)(b)2.c.
c. 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. If this
subd. 2. c. applies, the department may contract with an organization in addition to the county.
46.284(2)(b)3.
3. After December 31,
2003, the department may contract with counties, family care districts, the governing body of a tribe or band or the Great Lakes inter-tribal council, inc., or under a joint application of any of these, or with a private organization that has no significant connection to an entity that operates a resource center. Proposals for contracts under this subdivision shall be solicited under a competitive sealed proposal process under
s. 16.75 (2m) and, after consulting with the local long-term care council for the county or counties, the department shall evaluate the proposals primarily as to the quality of care that is proposed to be provided, certify those applicants that meet the requirements specified in
sub. (3) (a), select certified applicants for contract and contract with the selected applicants.
46.284(3)(a)(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. An application shall include comments about the applicant and recommendations about the application that are provided by the appropriate local long-term care council, as specified under
s. 46.282 (3) (a) 3.
46.284(3)(b)
(b) To be certified as a care management organization, an applicant shall demonstrate or ensure all of the following:
46.284(3)(b)1.
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.
46.284(3)(b)2.
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.
46.284(3)(b)3.
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.
46.284(3)(b)4.
4. Adequate availability of residential and day services that are geographically accessible to proposed enrollees' homes, families or friends.
46.284(3)(b)5.
5. Adequate supported living arrangements of the types and sizes that meet proposed enrollees' preference and needs.
46.284(3)(b)6.
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.
46.284(3)(b)7.
7. Thorough knowledge of local long-term care and other community resources.
46.284(3)(b)8.
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.
46.284(3)(b)9.
9. Thorough knowledge of methods for maximizing informal caregivers and community resources and integrating them into a service or care plan.
46.284(3)(b)10.
10. Coverage for a geographic area specified by the department.
46.284(3)(b)11.
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.
46.284(3)(b)12.
12. Adequate and competent staffing by qualified personnel to perform all of the functions that the applicant proposes to undertake.
46.284(4)
(4) Duties. A care management organization shall, in addition to meeting all contract requirements, do all of the following:
46.284(4)(a)
(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.
46.284(4)(b)
(b) Conduct a comprehensive assessment for each enrollee, including an in-person interview with the enrollee, using a standard format developed by the department.
46.284(4)(c)
(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.
46.284(4)(d)
(d) Provide or contract for the provision of necessary services and monitor the provided or contracted services.
46.284(4)(e)
(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.
46.284(4)(f)
(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.
46.284(4)(g)
(g) Meet all performance standards required by the federal government or promulgated by the department by rule.
46.284(4)(h)
(h) Submit to the department reports and data required or requested by the department.
46.284(4)(i)
(i) Implement internal quality improvement and assurance processes that meet standards prescribed by the department by rule.
46.284(4)(j)
(j) Cooperate with external quality assurance reviews.
46.284(4)(k)
(k) Meet departmental requirements for protection of solvency.
46.284(4)(L)
(L) Annually submit to the department an independent financial audit that meets federal requirements.
46.284(5)(a)(a) From the appropriation accounts under
s. 20.435 (4) (b),
(g),
(im),
(o), and
(w) 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.
46.284(5)(b)
(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.
46.284(5)(c)
(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.
46.284(5)(d)
(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:
46.284(5)(d)1.
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.
46.284(5)(d)2.
2. The requirement that interest accruing to the risk reserve remain in the escrow account for the risk reserve.
46.284(5)(d)3.
3. Limitations on the distribution of funds from the risk reserve.
46.284(5)(d)4.
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.
46.284(5)(e)1.1. 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.
46.284(5)(e)2.
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.
46.284(6)
(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.
46.284(7)
(7) Confidentiality; exchange of information. No record, as defined in
s. 19.32 (2), of a care management organization that contains personally identifiable information, as defined in
s. 19.62 (5), concerning an individual who receives services from the care management organization may be disclosed by the care management organization without the individual's informed consent, except as follows:
46.284(7)(b)
(b) 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.
