DHS 10.35 HistoryHistory: Cr. Register, October, 2000, No. 538, eff. 11-1-00; correction made under s. 13.92 (4) (b) 7., Stats., Register November 2008 No. 635.
DHS 10.36DHS 10.36Eligibility and entitlement.
DHS 10.36(1)(1)Entitlement. Except as provided in sub. (2), a person who meets all of the conditions of eligibility under s. DHS 10.32 is entitled to enroll in a care management organization and to receive the family care benefit if any of the following apply:
DHS 10.36(1)(a)(a) The person meets the conditions of functional eligibility at the nursing home level under s. DHS 10.33 (2) (c).
DHS 10.36(1)(b)(b) The person meets the conditions of functional eligibility at the non-nursing home level under s. DHS 10.33 (2) (d) and at least one of the following applies:
DHS 10.36(1)(b)1.1. The person is in need of adult protective services as substantiated by a county agency under s. 46.90 (2), Stats., or specified in s. 55.01 (1f), Stats.
DHS 10.36(1)(b)2.2. The person is eligible for medical assistance.
DHS 10.36(1)(c)(c) The person meets the criteria under s. DHS 10.33 (3).
DHS 10.36(2)(2)Phase-in of entitlement.
DHS 10.36(2)(a)(a) Effective date. Except as provided in pars. (b) and (c), within each county and for each CMO target population, entitlement to the family care benefit first applies on the effective date of a contract under which a CMO accepts a per person per month payment to provide services under the family care benefit to eligible persons in that target population in the county.
DHS 10.36(2)(c)(c) Phase-in of capacity. To provide time for a newly established care management organization to develop sufficient capacity to serve all individuals who meet the conditions of entitlement, a care management organization may limit enrollment. If enrollment is limited during this phase-in period, a resource center may place persons otherwise entitled under sub. (1) on a waiting list until a CMO can accept the enrollment. Any waiting list created under this paragraph shall conform to department requirements.
DHS 10.36(3)(3)Eligibility without entitlement. A person who is found eligible but who does not meet any of the conditions of sub. (1) (a) to (c) is not entitled to the family care benefit. The person may be placed on a waiting list to receive the family care benefit when funds are available. The county agency shall inform the person of his or her right to receive a new functional screening or financial eligibility and cost-sharing screening if the person’s circumstances change. Waiting lists under this subsection shall conform to criteria established by the department. While waiting for enrollment, a person who has been found eligible but not entitled may purchase services from a CMO as provided under s. DHS 10.37.
DHS 10.36 HistoryHistory: Cr. Register, October, 2000, No. 538, eff. 11-1-00; CR 04-040: am. (2) (b) and (3) Register November 2004 No. 587, eff. 12-1-04; correction in (1) (b) 1. made under s. 13.93 (2m) (b) 7., Stats., Register November 2004 No. 587; correction in (1) (b) 1. made under s. 13.92 (4) (b) 7., Stats., Register November 2009 No. 647; CR 23-046: am. (1) (a), (b) (intro.), r. (2) (b) Register April 2024 No. 820, eff. 5-1-24.
DHS 10.37DHS 10.37Private pay individuals.
DHS 10.37(1)(1)Definitions. In this section:
DHS 10.37(1)(a)(a) “Case management” means assessment, care planning, assistance in arranging and coordinating services in the care plan, assistance in filing grievances and appeals and obtaining advocacy services, and periodic reassessment and updates to the person’s care plan.
DHS 10.37(1)(b)(b) “Private pay individual” means any of the following:
DHS 10.37(1)(b)1.1. A person who is a member of a CMO’s target population and who does not qualify financially for the family care benefit under s. DHS 10.34.
DHS 10.37(1)(b)2.2. A person who is eligible for the family care benefit under s. DHS 10.32, but who is not entitled to receive the benefit immediately as specified in s. DHS 10.36 (3).
DHS 10.37(1)(b)3.3. A person who meets the entitlement conditions specified in s. DHS 10.36 (1), but who is waiting for enrollment in a CMO under the phase-in provisions of s. DHS 10.36 (2).
DHS 10.37(2)(2)Case management available for purchase. A care management organization shall offer case management services, at rates approved by the department, to private pay individuals who wish to purchase the services. A private pay individual may purchase from the CMO any types and amounts of case management. The types and amounts of case management and the cost of the services shall be specified in a written agreement signed by the authorized representative of the CMO and the individual purchasing the service or the person’s authorized representative.
DHS 10.37(3)(3)Limitations on purchase of other services.
DHS 10.37(3)(a)(a) A private pay individual may not enroll in a care management organization, but, subject to pars. (b) and (c), may purchase services other than case management services, on a fee-for-service basis, from a care management organization.
DHS 10.37(3)(b)(b) An individual who meets the definition under sub. (1) (b) 1. may purchase any service that the CMO provides directly and offers to the general public, at prices normally charged to the public.
DHS 10.37(3)(c)(c) An individual who meets the definition under sub. (1) (b) 2. or 3. may purchase any service purchased or provided by the CMO for its members.
DHS 10.37 HistoryHistory: Cr. Register, October, 2000, No. 538, eff. 11-1-00; CR 04-040: am. (1) (a) Register November 2004 No. 587, eff. 12-1-04.
subch. IV of ch. DHS 10Subchapter IV — Family Care Benefit; Delivery Through Care Management Organizations (CMOs)
DHS 10.41DHS 10.41Family care services.
DHS 10.41(1)(1)Enrollment required. The family care benefit is available to eligible persons only through enrollment in a care management organization (CMO) under contract with the department.