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".
46.288(3)
(3) Procedures and standards for procedures for
s. 46.287 (2), including time frames for action by a resource center or a care management organization on a contested matter.
46.288 History
History: 1999 a. 9;
2007 a. 20;
2009 a. 28.
46.2895
46.2895
Long-term care district. 46.2895(1)(a)(a) A county, a tribe or band, or any combination of counties or tribes or bands, may create a special purpose district that is termed a "long-term care district", that is a local unit of government, that is separate and distinct from, and independent of, the state and the county or tribe or band that created it, and that has the powers and duties specified in this section, if each county or tribe or band that participates in creating the district does all of the following:
46.2895(1)(a)1.
1. Adopts an enabling resolution that does all of the following:
46.2895(1)(a)1.b.
b. Specifies the long-term care district's primary purpose, which shall be to operate, under contract with the department, a resource center under
s. 46.283, a care management organization under
s. 46.284, or a program described under
s. 46.2805 (1) (a) or
(b).
46.2895(1)(a)1.c.
c. Specifies the number of individuals who shall be appointed as members of the long-term care district board, the length of their terms, and, if the long-term care district is created by more than one county or tribe or band, how many members shall be appointed by each county or tribe or band.
46.2895(1)(a)2.
2. Files copies of the enabling resolution with the secretary of administration, the secretary of health services and the secretary of revenue.
46.2895(1)(c)
(c) A long-term care district may not operate a care management organization under
s. 46.284 or a program described under
s. 46.2805 (1) (a) or
(b) if the district operates a resource center under
s. 46.283.
46.2895(1)(d)
(d) A county or tribe or band may create more than one long-term care district.
46.2895(1)(e)
(e) A long-term care district may change its primary purpose specified under
par. (a) 1. b. if all the counties or tribes or bands that created the district and that have not withdrawn or been removed from the district under
sub. (14), adopt a resolution approving the change in primary purpose and if the change in purpose does not violate
par. (c) or any provision of a contract between the department and the district.
