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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.
46.27(7)(d) (d) The department may release funds to counties acting jointly, if the counties sign a contract approved by the secretary that explains the plans for joint sponsorship.
46.27(7)(e) (e) No county may use funds received under this section to purchase land or construct buildings.
46.27(7)(f) (f) If the department determines that a county demonstrates a pattern of failure to serve clients whose cost of care significantly exceeds the average cost of care for long-term community support services provided under this section, the department may require that county to reserve a portion of funds allocated under this subsection for provision of service to those clients.
46.27(7)(fm) (fm) The department shall, at the request of a county, carry forward up to 5 percent of the amount allocated under this subsection to the county for a calendar year if up to 5 percent of the amount so allocated has not been spent or encumbered by the county by December 31 of that year, for use by the county in the following calendar year, except that the amount carried forward shall be reduced by the amount of funds that the county has notified the department that the county wishes to place in a risk reserve under par. (fr). The department may transfer funds within s. 20.435 (4) (bd) to accomplish this purpose. An allocation under this paragraph does not affect a county's base allocation under this subsection and shall lapse to the general fund unless expended within the calendar year to which the funds are carried forward. A county may not expend funds carried forward under this paragraph for administrative or staff costs, except administrative or staff costs that are associated with implementation of the waiver under sub. (11) and approved by the department.
46.27(7)(fr)1.1. Notwithstanding s. 46.036 (3) and (5m), a county may place in a risk reserve funds that are allocated under par. (am) or (b) or sub. (11) (c) 3. and are not expended or encumbered for services under this subsection or sub. (11). The county shall notify the department of this decision and of the amount to be placed in the risk reserve. The county shall maintain the risk reserve in an interest-bearing escrow account with a financial institution, as defined in s. 69.30 (1) (b), if the department has approved the terms of the escrow. All interest from the principal shall be reinvested in the escrow account.
46.27(7)(fr)2. 2. The annual amount of a county's expenditure for a risk reserve, as specified in subd. 1., may not exceed 10 percent of the county's most recent allocation under pars. (am) and (b) and sub. (11) (c) 3. or $750,000, whichever is less. The total amount of the risk reserve, including interest, may not exceed 15 percent of the county's most recent allocation under this subsection.
46.27(7)(fr)3. 3. A county may expend funds maintained in a risk reserve, as specified in subd. 1., for any of the following purposes:
46.27(7)(fr)3.a. a. To defray costs of long-term community support services under this section.
46.27(7)(fr)3.b. b. To meet requirements under any contract that the county has with the department to operate a care management organization under s. 46.284.
46.27(7)(fr)3.c. c. If approved by a resolution of the county board of supervisors, to transfer funds to a long-term care district.
46.27(7)(fr)3.d. d. If approved by the department, for administrative or staff costs under this section.
46.27(7)(fr)4. 4. A county that maintains a risk reserve, as specified in subd. 1., shall annually, on a form prescribed by the department, submit to the department a record of the status of the risk reserve, including revenues and disbursements.
46.27(7)(g) (g) The department may carry forward to the next state fiscal year funds allocated under this subsection and not encumbered by counties by December 31 or carried forward under par. (fm). The department may transfer moneys within s. 20.435 (4) (bd) to accomplish this purpose. An allocation under this paragraph shall not affect a county's base allocation for the program. The department may allocate these transferred moneys during the next fiscal year to counties for planning and implementation of resource centers under s. 46.283 or care management organizations under s. 46.284 and for the improvement or expansion of long-term community support services for clients whose cost of care significantly exceeds the average cost of care provided under this section, including any of the following:
46.27(7)(g)1. 1. Specialized training for providers of services under this section.
46.27(7)(g)2. 2. Start-up costs for developing needed services.
46.27(7)(g)3. 3. Home modifications.
46.27(7)(g)4. 4. Purchase of medical equipment or other specially adapted equipment.
46.27(7g) (7g)Recovery of costs of care.
46.27(7g)(a)(a) In this subsection:
46.27(7g)(a)1. 1. “Client" means a person who receives or received long-term community support services that are funded under sub. (7).
46.27(7g)(a)1m. 1m. “Decedent" means a deceased client or a deceased nonclient surviving spouse, whichever is applicable.
46.27(7g)(a)2. 2. “Disabled" has the meaning given in s. 49.468 (1) (a) 1.
46.27(7g)(a)3. 3. “Home" means property in which a person has an ownership interest consisting of the person's dwelling and the land used and operated in connection with the dwelling.
46.27(7g)(a)4. 4. “Nonclient surviving spouse" means any person who was married to a client while the client was receiving services for which the cost may be recovered under par. (c) 1. and who survived the client.
46.27(7g)(a)5. 5. “Property of a decedent" means all real and personal property to which the client held any legal title or in which the client had any legal interest immediately before death, to the extent of that title or interest, including assets transferred to a survivor, heir, or assignee through joint tenancy, tenancy in common, survivorship, life estate, revocable trust, or any other arrangement, excluding an irrevocable trust.
46.27(7g)(c)1.1. Except as provided in subd. 4., the department shall file a claim against the estate of a client, and against the estate of a nonclient surviving spouse, for the amount of long-term community support services funded under sub. (7) paid on behalf of the client after the client attained 55 years of age, unless already recovered by the department under this subsection.
46.27(7g)(c)2. 2. The affidavit of a person designated by the secretary to administer this paragraph is evidence of the amount of the claim.
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