46.286(1)(a)
(a)
Functional eligibility. A person is functionally eligible if any of the following applies, as determined by the department or its designee:
46.286(1)(a)1.
1. The person's functional capacity is at either of the following levels:
46.286(1)(a)1.a.
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.
46.286(1)(a)1.b.
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.
46.286(1)(a)2.
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 but that does not meet the level specified under
subd. 1. a. or
b.; the person first applies for eligibility for the family care benefit within 36 months after the date on which the family care benefit is initially available in the person's county residence; 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 had been receiving for at least 60 days, under a written plan of care, long-term care services, as specified by the department, that were funded under any of the following:
46.286(1)(a)2.d.
d. Community aids under
s. 46.40, if documented by the county under a method prescribed by the department.
46.286(1)(a)2.e.
e. County funding, if documented by the county under a method prescribed by the department.
46.286(1)(b)
(b)
Financial eligibility. A person is financially eligible if all of the following apply:
46.286(1)(b)1.
1. As determined by the department or its designee, either of the following applies:
46.286(1)(b)1.a.
a. The person would qualify for medical assistance except for financial or disability 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.
46.286(1)(b)2.
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.
46.286(2)(a)(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.
46.286(2)(b)
(b) Funds received under
par. (a) shall be used by a care management organization to pay for services under the family care benefit.
46.286(2)(c)
(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.
46.286(3)(a)(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 is at least 18 years of age, has a physical disability, as defined in
s. 15.197 (4) (a) 2., a developmental disability, as defined in
s. 51.01 (5) (a), or infirmities of aging, as defined in
s. 55.01 (3), is financially eligible, fulfills any applicable cost-sharing requirements and meets any of the following criteria:
46.286(3)(a)1.
1. Is functionally eligible at the comprehensive level.
46.286(3)(a)3.
3. Is functionally eligible at the intermediate level and is determined by an agency under
s. 46.90 (2) or specified in
s. 55.01 (1t) to be in need of protective services under
s. 55.05 or protective placement under
s. 55.06.
46.286(3)(a)6.
6. Is functionally eligible at the intermediate level and meets all of the following criteria:
46.286(3)(a)6.a.
a. On the date on which the family care benefit is initially available in the person's county of residence, is a resident in a nursing home or has been receiving for at least 60 days, under a written plan of care, long-term care services, as specified by the department, which are funded as specified under
sub. (1) (a) 2. a.,
b.,
c.,
d., or
e.
46.286(3)(a)6.b.
b. Enrolls within 36 months after the date on which the family care benefit is initially available in the person's county of residence.
46.286(3)(b)
(b) An entitled individual who is enrolled in a care management organization may not be involuntarily disenrolled except as follows:
46.286(3)(b)2.
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.
46.286(3)(b)3.
3. The department or its designee determines that the person no longer meets eligibility criteria under
sub. (1).
46.286(3)(c)
(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.
46.286(3)(d)
(d) The department shall determine the date, which shall not be later than January 1, 2006, on which
par. (a) shall first apply to persons who are not eligible for medical assistance under
ch. 49. Before the date determined by the department, persons who are not eligible for medical assistance may receive the family care benefit within the limits of state funds appropriated for this purpose and available federal funds.
46.286(3m)
(3m) Information about family care enrollees. 46.286(3m)(b)
(b) An insurer that issues or delivers a disability insurance policy that provides coverage to a resident of this state shall provide to the department, upon the department's request, information contained in the insurer's records regarding all of the following:
46.286(3m)(b)1.
1. Information that the department needs to identify enrollees of family care who satisfy any of the following:
46.286(3m)(b)1.b.
b. Would be eligible for benefits under a disability insurance policy if the enrollee were enrolled as a dependent of a person insured under the disability insurance policy.
46.286(3m)(b)2.
2. Information required for submittal of claims under the insurer's disability insurance policy.
46.286(3m)(b)3.
3. The types of benefits provided by the disability insurance policy.
46.286(3m)(c)
(c) Upon requesting an insurer to provide the information under
par. (b), the department shall enter into a written agreement with the insurer that satisfies all of the following:
46.286(3m)(c)2.
2. Includes provisions that adequately safeguard the confidentiality of the information to be disclosed.
46.286(3m)(d)1.1. An insurer shall provide the information requested under
par. (b) within 180 days after receiving the department's request if it is the first time that the department has requested the insurer to disclose information under this subsection.
46.286(3m)(d)2.
2. An insurer shall provide the information requested under
par. (b) within 30 days after receiving the department's request if the department has previously requested the insurer to disclose information under this subsection.
46.286(3m)(d)3.
3. If an insurer fails to comply with
subd. 1. or
2., the department may notify the commissioner of insurance, and the commissioner of insurance may initiate enforcement proceedings against the insurer under
s. 601.41 (4) (a).
46.286(4)
(4) Divestment; rules. The department shall promulgate rules relating to prohibitions on divestment of assets of persons who receive the family care benefit, that are substantially similar to applicable provisions under
s. 49.453.
46.286(5)
(5) Treatment of trust amounts; rules. The department shall promulgate rules relating to treatment of trust amounts of persons who receive the family care benefit, that are substantially similar to applicable provisions under
s. 49.454.
46.286(6)
(6) Protection of income and resources of couple for maintenance of community spouse; rules. The department shall promulgate rules relating to protection of income and resources of couples for the maintenance of the spouse in the community with regard to persons who receive the family care benefit, that are substantially similar to applicable provisions under
s. 49.455.
46.286(7)
(7) Recovery of family care benefit payments; rules. The department shall promulgate rules relating to the recovery from persons who receive the family care benefit, including by liens and from estates, of correctly and incorrectly paid family care benefits, that are substantially similar to applicable provisions under
ss. 49.496 and
49.497.
46.286 Cross-reference
Cross Reference: See also ch.
HFS 10, Wis. adm. code.
46.287(1)(1)
Definition. In this section, "client" means a person applying for eligibility for the family care benefit, an eligible person or an enrollee.
46.287(2)(a)1.1. Except as provided in
subd. 2., a client may contest any of the following applicable matters by filing, within 45 days of the failure of a resource center or care management organization to act on the contested matter within the time frames specified by rule by the department or within 45 days after receipt of notice of a decision in a contested matter, a written request for a hearing under
s. 227.44 to the division of hearings and appeals created under
s. 15.103 (1):
46.287(2)(a)1.d.
d. Failure to provide timely services and support items that are included in the plan of care.
46.287(2)(a)1.e.
e. Reduction of services or support items under the family care benefit.
46.287(2)(a)1.f.
f. Development of a plan of care that is unacceptable because the plan of care requires the enrollee to live in a place that is unacceptable to the enrollee or the plan of care provides care, treatment or support items that are insufficient to meet the enrollee's needs, are unnecessarily restrictive or are unwanted by the enrollee.
46.287(2)(a)2.
2. An applicant for or recipient of medical assistance is not entitled to a hearing concerning the identical dispute or matter under both this section and
42 CFR 431.200 to
431.246.
46.287(2)(b)
(b) An enrollee may contest a decision, omission or action of a care management organization other than those specified in
par. (a), or may contest the choice of service provider. In these instances, the enrollee shall first send a written request for review by the unit of the department that monitors care management organization contracts. This unit shall review and attempt to resolve the dispute. If the dispute is not resolved to the satisfaction of the enrollee, he or she may request a hearing under the procedures specified in
par. (a) 1. (intro.).
46.287(2)(c)
(c) Information regarding the availability of advocacy services and notice of adverse actions taken and appeal rights shall be provided to a client by the resource center or care management organization in a form and manner that is prescribed by the department by rule.
46.287 History
History: 1999 a. 9;
2003 a. 33.
46.288
46.288
Rule-making. The department shall promulgate as rules all of the following:
46.288(1)
(1) Standards for performance by resource centers and for certification of care management organizations, including requirements for maintaining quality assurance and quality improvement.
46.288(2)
(2) Criteria and procedures for determining functional eligibility under
s. 46.286 (1) (a), financial eligibility under
s. 46.286 (1) (b), cost sharing under
s. 46.286 (2) (a) and entitlement under
s. 46.286 (3). The rules for determining functional eligibility under
s. 46.286 (1) (a) 1. a. shall be substantially similar to eligibility criteria for receipt of the long-term support community options program under
s. 46.27. Rules under this subsection shall include definitions of the following terms applicable to
s. 46.286:
46.288(2)(e)
(e) "Requires ongoing care, assistance or supervision".
46.288(2)(f)
(f) "Condition that is expected to last at least 90 days or result in death within one year".
46.288(2)(g)
(g) "At risk of losing independence or functional capacity".
