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46.27(6)(a)2. 2. Subdivision 1. does not apply to:
46.27(6)(a)2.a. a. Any person or facility that is excluded because of gradual implementation of the program under sub. (3) (c).
46.27(6)(a)2.b. b. Emergency admissions, as determined by a physician, but shall be applied within 10 days of admission.
46.27(6)(a)2.c. c. Private pay patients seeking admission to or about to be admitted to a facility under subd. 1. who are informed about the program but waive the assessment, unless the patient will be eligible for medical assistance within 6 months of assessment.
46.27(6)(a)2.cm. cm. Persons under subd. 1. seeking admission to or about to be admitted to a Wisconsin veterans home operated by the department of veterans affairs under s. 45.50 who are informed about the program but waive the assessment.
46.27(6)(a)2.d. d. Any person who is readmitted to a nursing home from a hospital within 6 months after being assessed.
46.27(6)(a)2.e. e. Current residents of a nursing home who are eligible for an assessment under sub. (5) (e) and subd. 3., but who waive the assessment.
46.27(6)(a)2.f. f. A person who enters a nursing home for recuperative care.
46.27(6)(a)2.g. g. A person who enters a nursing home for respite care.
46.27(6)(a)2.h. h. A person who is admitted to a nursing home from another nursing home, unless the person requests an assessment and funds allocated for assessments under sub. (7) (am) are available to the county.
46.27(6)(a)3. 3. In each participating county, except in counties in which the department has contracted with an entity under s. 46.284 (2), assessments shall be conducted for those persons and in accordance with the procedures described in the county's community options plan. The county may elect to establish assessment priorities for persons in target groups identified by the county in its plan regarding gradual implementation. If a person who is already admitted to a nursing home requests an assessment and if funds allocated for assessments under sub. (7) (am) are available, the county shall conduct the assessment.
46.27(6)(b) (b) Within the limits of state and federal funds allocated under sub. (7) and within the limits of fees collected unless prohibited, a community services case plan shall be developed for any person with chronic disabilities:
46.27(6)(b)1. 1. Who is assessed under par. (a); and
46.27(6)(b)2. 2. For whom noninstitutional community services are feasible, financially viable and preferred by the person or the person's guardian. In this subdivision, noninstitutional community services are financially viable if they can be financed by state or federal funds allocated under sub. (7).
46.27(6)(c) (c) The amount of any fee charged for conduct of an assessment under par. (a) or for development of a case plan under par. (b) shall be in accordance with a sliding scale formula established by the department by rule under sub. (12) (c). A fee may not be charged if prohibited under 42 USC 1396 to 1396v or under regulations under 42 USC 1396 to 1396v.
46.27(6)(d) (d) If the county, through an assessment, determines that a community arrangement is not feasible, the county department or aging unit administering the program shall explain the reasons to the person and his or her family or guardian. The county department or aging unit administering the program shall maintain records sufficient to provide the county long-term support planning committee and the department with a periodic review of the reasons community arrangements were not feasible in order to assist future program planning.
46.27(6)(e) (e) The department shall encourage counties to use public health nurses who meet the requirements of s. 250.06 (1) to conduct assessments under this subsection.
46.27(6d) (6d)Care management requirements.
46.27(6d)(a) (a) The department, after consulting with representatives of counties, hospitals, and individuals who receive services under this section, shall do all of the following:
46.27(6d)(a)1. 1. Establish minimum requirements for the provision of care management services, as defined by the department, including standards for care, times for performance of duties, and size of caseloads.
46.27(6d)(a)2. 2. Specify a reasonable schedule for phasing in the requirements established under subd. 1.
46.27(6d)(a)3. 3. Provide technical consultation and assistance to the administrator of the program, as designated under sub. (3) (b), with respect to the requirements established under subd. 1.
46.27(6d)(b) (b) The department need not promulgate as rules under ch. 227 the requirements under par. (a) 1. or the schedule under par. (a) 2.
46.27(6g) (6g)Fiscal responsibility. Except as provided in s. 51.40, and within the limitations under sub. (7) (b), the fiscal responsibility of a county for an assessment, unless the assessment is performed by an entity under a contract as specified under s. 46.284 (2), case plan, or services provided to a person under this section is as follows:
46.27(6g)(a) (a) For a person seeking admission to or about to be admitted to a nursing home, the county in which the person has residence is the county of fiscal responsibility.
46.27(6g)(b) (b) For a person residing in a nursing home, except a state-operated long-term care facility, the county in which the nursing home is located is the county of fiscal responsibility.
46.27(6g)(c) (c) For a person living in a nursing home, except a state-operated long-term care facility, whose legal residence is established in another county, the county in which the legal residence is established is the county of fiscal responsibility.
46.27(6g)(d) (d) For a person residing in a state-operated long-term care facility, or for a person protectively placed under ch. 55, the county in which the person has residence before he or she enters the state-operated long-term care facility or is protectively placed is the county of fiscal responsibility.
46.27(6r) (6r)Eligibility. No county may use funds received under sub. (7) (b) to pay for long-term community support services provided to any of the following:
46.27(6r)(a) (a) A person who is initially eligible for services under sub. (7) (b), for whom home and community-based services are available under sub. (11) or s. 46.275, 46.277, 46.278, or 46.2785 that require less total expenditure of state funds than do comparable services under sub. (7) (b) and who is eligible for and offered the home and community-based services under sub. (11) or s. 46.275, 46.277, 46.278, or 46.2785, but who declines the offer, except that a county may use funds received under sub. (7) (b) to pay for long-term community support services for the person for a period of up to 90 days during which an application for services under sub. (11) or s. 46.275, 46.277, 46.278, or 46.2785 for the person is processed.
46.27(6r)(b) (b) A person who initially receives services under this section after December 31, 1985, unless one of the following applies:
46.27(6r)(b)1. 1. The person meets the level of care requirements under s. 49.45 (6m) (i) for reimbursement of nursing home care under the medical assistance program.
46.27(6r)(b)1m. 1m. The person meets the requirements under any of the following for receipt of care in an institution for mental diseases:
46.27(6r)(b)1m.a. a. A person who resided in the facility on the date of the finding that a skilled nursing facility or intermediate care facility that provides care to Medical Assistance recipients is an institution for mental diseases whose care in the facility is disallowed for federal financial participation under Medical Assistance.
46.27(6r)(b)1m.b. b. A person who is aged 21 to 64, who has a primary diagnosis of mental illness, who would meet the level of care requirements for Medical Assistance reimbursement in a skilled nursing facility or intermediate care facility but for a finding that the facility is an institution for mental diseases, and for whom services would be provided in place of a person specified in subd. 1m. a. who discontinues services.
46.27(6r)(b)2. 2. The person has serious and persistent mental illness, as defined under s. 51.01 (14t), affecting mental health to the extent that long-term or repeated hospitalization is likely unless the person receives long-term community support services.
46.27(6r)(b)3. 3. The person receives medical assistance, resides in a nursing home immediately prior to receiving services under this section and is identified through the inspection of patient care under 42 USC 1396a (a) (31) as a person for whom community care is appropriate.
46.27(6r)(b)4. 4. The person has been diagnosed by a physician as having Alzheimer's disease and requires a level of care equivalent to either of the following:
46.27(6r)(b)4.a. a. Noninstitutional personal care, including personal assistance, supervision and protection, and periodic medical services and consultation with a registered nurse, or periodic observation and consultation for physical, emotional, social or restorative needs, but not regular nursing care.
46.27(6r)(b)4.b. b. Care, including social services and activity therapy, in a residential facility under the daily supervision of a licensed nurse with consultation from a registered nurse at least 4 hours per week.
46.27(6r)(c) (c) A person who resides or intends to reside in a community-based residential facility and who is initially applying for long-term community support services, if the projected cost of services for the person, plus the cost of services for existing participants, would cause the county to exceed the limitation under sub. (3) (f), unless the department grants an exception to the requirement under this paragraph, under the conditions specified by rule, to avoid hardship to the person.
46.27(6r)(e) (e) A person who has not resided in this state for at least 180 consecutive days before applying for or receiving long-term community support services that are funded under sub. (7) (b).
46.27(6r)(f) (f) A person who has attained the age of 18 but has not attained the age of 65 unless that person is engaged in gainful employment or participating in a program that is certified by the department to provide health and employment services that are aimed at helping the individual achieve employment goals. The department may waive this paragraph for any individual for whom its application would cause undue hardship.
46.27(6u) (6u)Financial eligibility and cost-sharing requirements.
46.27(6u)(a)(a) In this subsection, “assets" has the meaning given in s. 49.453 (1) (a).
46.27(6u)(b) (b) The county department or aging unit selected to administer the program shall require all persons applying for long-term community support services that are funded under sub. (7) or (11) and, annually, all persons receiving the services to provide the following information:
46.27(6u)(b)1. 1. For persons applying for or receiving services under sub. (7), a declaration of assets, on a form prescribed by the department. The declaration shall include any assets that the person applying for or receiving the services, or his or her spouse, has, after August 12, 1993, transferred to another for less than fair market value at any time within the 36-month period, or with respect to payments from a trust or portions of a trust that would be treated as assets transferred by an individual under s. 49.454 (2) (c) or (3) (b), within the 60-month period, immediately before the date of the declaration.
46.27(6u)(b)2. 2. For persons applying for or receiving services under sub. (11), a declaration of income, on a form prescribed by the department.
46.27(6u)(c) (c) From the information obtained under par. (b), the county department or aging unit shall:
46.27(6u)(c)1. 1. Determine the financial eligibility of the applicant or recipient of services to receive assistance for long-term community support services under the program. A person is financially eligible under this subdivision if he or she is one of the following:
46.27(6u)(c)1.a. a. Eligible for medical assistance under s. 49.46, 49.468, 49.47, or 49.471 (4) (a).
46.27(6u)(c)1.b. b. A person whom the county department or aging unit finds is likely to become medically indigent within 6 months by spending excess assets for medical or remedial care.
46.27(6u)(c)2. 2. For a person who is determined to be financially eligible under subd. 1. calculate, by use of the uniform fee system under s. 46.03 (18), the amount of cost sharing required for receipt of long-term community support services provided under sub. (5) (b). The county department or aging unit shall require payment by the person of 100 percent of the amount calculated under this subdivision, unless the person is a recipient of medical assistance under s. 49.472. If the person is a recipient of medical assistance under s. 49.472, the county department or aging unit may not require any payment from the person under this subdivision.
46.27(6u)(c)3. 3. Bill persons not determined under subd. 1. to be financially eligible for the full cost of long-term community support services received.
46.27(6u)(c)4. 4. Use funds received under subds. 2. and 3. to pay for long-term community support services for persons who are eligible under sub. (6) (b).
46.27(6u)(d) (d) In determining financial eligibility under par. (c) 1. and in calculating the amount under par. (c) 2., the county department or aging unit shall include as the assets for any person, except those persons who are eligible for medical assistance under s. 49.46, 49.468, 49.47, or 49.471 (4) (a), any portion of assets that the person or the person's spouse has, after August 12, 1993, transferred to another as specified in par. (b), unless one of the following conditions applies:
46.27(6u)(d)1. 1. The transferred asset has no current value.
46.27(6u)(d)2. 2. The county department or aging unit determines that undue hardship would result to the person or to his or her family from a denial of financial eligibility or from including all or a portion of a transferred asset in the calculation of the amount of cost sharing required.
46.27(7) (7)Funding.
46.27(7)(am) (am) From the appropriation under s. 20.435 (4) (bd), the department shall allocate funds to each county or private nonprofit agency with which the department contracts to pay assessment and case plan costs under sub. (6) not otherwise paid by fee or under s. 49.45 or 49.78 (2). The department shall reimburse multicounty consortia for the cost of assessing persons eligible for medical assistance under s. 49.46, 49.468, 49.47, or 49.471 (4) (a) as part of the administrative services of medical assistance, payable under s. 49.45 (3) (a). Counties may use unspent funds allocated under this paragraph to pay the cost of long-term community support services and for a risk reserve under par. (fr).
46.27(7)(b) (b) From the appropriations under s. 20.435 (4) (bd) and (im), the department shall allocate funds to each county to pay the cost of providing long-term community support services under sub. (5) (b) not otherwise paid under s. 49.45 to persons eligible for medical assistance under s. 49.46, 49.47, or 49.471 (4) (a) or to persons whom the county department or aging unit administering the program finds likely to become medically indigent within 6 months by spending excess income or assets for medical or remedial care. The average per person reimbursement under this paragraph may not exceed the state share of the average per person payment rate the department expects under s. 49.45 (6m). The county department or aging unit administering the program may spend funds received under this paragraph only in accordance with the case plan and service contract created for each person receiving long-term community support services. Counties may use unspent funds allocated under this paragraph from the appropriation under s. 20.435 (4) (bd) for a risk reserve under par. (fr).
46.27(7)(c)2.2. Receipt of funds under this section is subject to s. 46.495 (2).
46.27(7)(c)3. 3. The department may not release funds under this section before approving the county's community options plan.
46.27(7)(cg) (cg) No county may use funds received under par. (b) to pay for long-term community support services provided any person who resides in a nursing home, unless the department waives this restriction on use of funds and the services are provided in accordance with a discharge plan.
46.27(7)(cj) (cj) No county may use funds received under par. (b) to provide services to a person who does not live in his or her own home or apartment unless, subject to the limitations under par. (cm), one of the following applies:
46.27(7)(cj)1. 1. The services are provided to the person in a community-based residential facility that entirely consists of independent apartments, each of which has an individual lockable independent entrance and exit and individual separate kitchen, bathroom, sleeping and living areas.
46.27(7)(cj)2. 2. The person suffers from Alzheimer's disease or related dementia and the services are provided to the person in a community-based residential facility that has a dementia care program.
46.27(7)(cj)3. 3. The services are provided to the person in a community-based residential facility and the county department or aging unit has determined that all of the following conditions have been met:
46.27(7)(cj)3.b. b. The county department or aging unit documents that the option of in-home services has been discussed with the person, thoroughly evaluated and found to be infeasible, as determined by the county department or aging unit in accordance with rules promulgated by the department of health services.
46.27(7)(cj)3.c. c. The county department or aging unit determines that the community-based residential facility is the person's preferred place of residence or is the setting preferred by the person's guardian.
46.27(7)(cj)3.d. d. The county department or aging unit determines that the community-based residential facility provides a quality environment and quality care services.
46.27(7)(cj)3.e. e. The county department or aging unit determines that placement in the community-based residential facility is cost-effective compared to other options, including home care and nursing home care.
46.27(7)(cj)5. 5. The services are provided to the person in an adult family home, as defined in s. 50.01 (1).
46.27(7)(ck)1.1. Subject to the approval of the department, a county may establish and implement more restrictive conditions than those imposed under par. (cj) on the use of funds received under par. (b) for the provision of services to a person in a community-based residential facility. A county that establishes more restrictive conditions under this subdivision shall include the conditions in its community options plan under sub. (3) (cm).
46.27(7)(ck)2. 2. If the department determines that a county has engaged in a pattern of inappropriate use of funds received under par. (b), the department may revoke its approval of the county's conditions established under subd. 1., if any, and may prohibit the county from using funds received under par. (b) to provide services under par. (cj) 3.
46.27(7)(cm)1.1. Beginning on January 1, 1996, no county, private nonprofit agency or aging unit may use funds received under par. (b) to provide services in any community-based residential facility that has more than 20 beds, unless one of the following applies:
46.27(7)(cm)1.a. a. The department approves the provision of services in a community-based residential facility that is licensed on July 29, 1995, and that meets standards established under subd. 2.
46.27(7)(cm)1.b. b. The department approves the provision of services in a community-based residential facility that entirely consists of independent apartments, each of which has an individual lockable entrance and exit and individual separate kitchen, bathroom, sleeping and living areas, to individuals who are provided services under sub. (5) (b) and are physically disabled or are at least 65 years of age.
46.27(7)(cm)1.c. c. The department approves the provision of services in a community-based residential facility that is initially licensed after July 29, 1995, that is licensed for more than 20 beds and that meets standards established under subd. 2.
46.27(7)(cm)2. 2. By January 1, 1996, the department shall establish standards for approvals made under subd. 1. a., including whether the proposed use of funds for residents at the community-based residential facility in question adequately provides for all of the following:
46.27(7)(cm)2.a. a. Sufficient responsiveness to individual resident needs.
46.27(7)(cm)2.b. b. Maintenance of approved levels of quality of care.
46.27(7)(cm)2.c. c. Cost effectiveness, in comparison with other feasible funding uses.
46.27(7)(cm)2.d. d. Sufficient consideration of care for facility residents with dementia or related conditions.
46.27(7)(cm)3. 3. The department need not promulgate as rules under ch. 227 the standards required to be established under subd. 2.
46.27(7)(cm)4. 4. This paragraph does not apply to individuals who are receiving services under this section that are funded under par. (b) and who are residing in community-based residential facilities with more than 8 beds on January 1, 1996.
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