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),
(gm),
(im),
(o), and
(w) and
(7) (b),
(bd), and
(g), 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 representative of the client group or groups whom the care management organization is contracted to serve or those clients' family members, guardians, or other advocates.
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),
55.22 (3),
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.
46.285
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 long-term care district or an organization, including a private, nonprofit corporation, may not directly operate both a resource center and a care management organization, except as follows:
46.285(1)
(1) For an entity with which the department has contracted under s.
46.281 (1) (e) 1., 2005 stats., provision of the services specified under
s. 46.283 (3) (b),
(e),
(f) and
(g) shall be structurally separate from the provision of services of the care management organization by January 1, 2001.
46.285(2)
(2) The department may approve separation of the functions of a resource center from those of a care management organization by a means other than creating a long-term care district under
s. 46.2895 to serve either as a resource center or as a care management organization.
46.286
46.286
Family care benefit. 46.286(1)
(1)
Eligibility. A person is eligible for, but not necessarily entitled to, the family care benefit if the person is at least 18 years of age; has a physical disability, as defined in
s. 15.197 (4) (a) 2., or a developmental disability, as defined in
s. 51.01 (5) (a), or is a frail elder; and meets all of the following criteria:
46.286(1)(a)
(a)
Functional eligibility. A person is functionally eligible if the person's level of care need, as determined by the department or its designee, is either of the following:
46.286(1)(a)1m.
1m. The nursing home 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)2m.
2m. The non-nursing home 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)(b)2m.
2m. A person is financially eligible if any of the following apply:
46.286(1)(b)2m.a.
a. The person is eligible under
ch. 49 for medical assistance and, unless he or she is exempt from acceptance under rules promulgated by the department, accepts medical assistance.
46.286(1)(b)2m.b.
b. The person was receiving the family care benefit on October 27, 2007, 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(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
par. (c), a person is entitled to and may receive the family care benefit through enrollment in a care management organization if all of the following apply:
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 following programs:
46.286(3)(b)2.d.
d. Community aids under
s. 46.40, if documented by the county under a method prescribed by the department.
46.286(3)(b)2.e.
e. County funding, if documented by the county under a method prescribed by the department.
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 36 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(3m)
(3m) Information about enrollees. The department shall obtain and share information about family care enrollees as provided in
s. 49.475.
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. The department shall apply to the recovery from persons who receive the family care benefit, including by liens and affidavits and from estates, of correctly paid family care benefits, the applicable provisions under
ss. 49.496 and
49.849.
46.286 Cross-reference
Cross-reference: See also ch.
DHS 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;
2013 a. 20.
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), and cost sharing under
s. 46.286 (2) (a). The rules for determining functional eligibility under
s. 46.286 (1) (a) 1m. 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".
