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.
DHS 10.41(2)(2)Services. Services provided under the family care benefit shall be determined through individual assessment of enrollee needs and values and detailed in an individual service plan unique to each enrollee. As appropriate to its target population and as specified in the department’s contract, each CMO shall have available at least the services and support items covered under the home and community-based waivers under 42 USC 1396n (c) and ss. 46.27546.277, and 46.278, Stats., the long-term support community options program under s. 46.27, Stats., and specified services and support items under the state’s plan for medical assistance. In addition, a CMO may provide other services that substitute for or augment the specified services if these services are cost-effective and meet the needs of enrollees as identified through the individual assessment and service plan. When providing applicable services, CMOs shall comply with EVV requirements.
DHS 10.41 NoteNote: The services that typically will be required to be available include adaptive aids; adult day care; assessment and case planning; case management; communication aids and interpreter services; counseling and therapeutic resources; daily living skills training; day services and treatment; home health services; home modification; home delivered and congregate meal services; nursing services; nursing home services, including care in an intermediate care facility for individuals with intellectual disabilities or in an institution for mental diseases; personal care services; personal emergency response system services; prevocational services; protective payment and guardianship services; residential services in an RCAC, CBRF or AFH; respite care; durable medical equipment and specialized medical supplies; outpatient speech; physical and occupational therapy; supported employment; supportive home care; transportation services; mental health and alcohol or other drug abuse services; and community support program services.
DHS 10.41(3)(3)Payment mechanisms. Payment to a care management organization shall be on a per enrollee per month basis. Any contractual agreements for shared financial risk between the department and a CMO shall meet applicable federal requirements.
DHS 10.41 HistoryHistory: Cr. Register, October, 2000, No. 538, eff. 11-1-00; CR 22-026: am. (2) Register May 2023 No. 809, eff. 6-1-23; EmR2306: emerg. am. (2), eff. 5-1-23; CR 23-045: am. (2) Register January 2024 No. 817, eff. 2-1-24; correction in (2) made under s. 35.17, Stats., Register January 2024 No. 817.
DHS 10.42DHS 10.42Certification and contracting.
DHS 10.42(1)(1)No entity may receive payment of funds for the family care benefit as a care management organization unless it is certified by the department as meeting all of the requirements of s. 46.284, Stats., and this chapter and is under contract with the department.
DHS 10.42(2)(2)
DHS 10.42(2)(a)(a) To obtain and retain certification, an organization shall submit all information and documentation required by the department, in a format prescribed by the department. The department shall review and make a determination on the application within 90 calendar days of receipt of a complete application containing complete and accurate supporting documentation that the organization meets the standards under s. DHS 10.43. The department may conduct any necessary investigation to verify that the information submitted by the organization is accurate. The organization shall consent to disclosure by any third party of information the department determines is necessary to review the application.
DHS 10.42(2)(am)(am) For initial certifications, or when a currently certified organization will provide or arrange for the provision of services to new eligibility groups, the organization shall submit to an onsite readiness review which will assess all of the following:
DHS 10.42(2)(am)1.1. Operations and administration, including all of the following:
DHS 10.42(2)(am)1.a.a. Administrative staffing and resources.
DHS 10.42(2)(am)1.b.b. Delegation and oversight of entity responsibilities.
DHS 10.42(2)(am)1.c.c. Enrollee and provider communications.
DHS 10.42(2)(am)1.d.d. Grievance and appeals.
DHS 10.42(2)(am)1.e.e. Member services and outreach.
DHS 10.42(2)(am)1.f.f. Provider network management.
DHS 10.42(2)(am)1.g.g. Program integrity compliance.
DHS 10.42(2)(am)2.2. Service delivery, including all of the following: