DHS 10.13(1)(b)9.
9. The denial of an enrollee's request to dispute a financial liability, including copayments, premiums, deductibles, coinsurance, other cost sharing, and other member financial liabilities.
DHS 10.13(1)(b)10.
10. The denial of an enrollee, who is a resident of a rural area with only one care management organization, to obtain services outside of the care management organization's network of contracted providers.
DHS 10.13(1)(c)
(c) Any of the following failures on the part of a care management organization:
DHS 10.13(1)(c)1.
1. The failure to provide services and support items included in the individualized service plan in a timely manner, as defined in the department's contract with care management organizations.
DHS 10.13(1)(c)2.
2. The failure to act in a timely manner as specified in subch.
V of this chapter to resolve grievances or appeals.
DHS 10.13(1m)
(1m) “Activities of daily living" or “ADLs" means bathing, dressing, eating, mobility, transferring from one surface to another such as bed to chair and using the toilet.
DHS 10.13(3)
(3) “Adult protective services" means protective services for individuals with intellectual disabilities and other developmental disabilities, for individuals with degenerative brain disorder, for individuals with chronic mental illness, and for individuals with other like incapacities incurred at any age as defined in s.
55.02, Stats.
DHS 10.13(3m)
(3m) Appeal" means a request for review of an adverse benefit determination.
DHS 10.13(4)
(4) “Applicant" means a person who directly or through a representative makes application for the family care benefit.
DHS 10.13(5)
(5) “Assets" means any interest in real or personal property that can be used for support and maintenance. “Assets" includes motor vehicles, cash on hand, amounts in checking and savings accounts, certificates of deposit, money market accounts, marketable securities, other financial instruments and cash value of life insurance.
DHS 10.13(6)
(6) “Assistance" means cueing, supervision or partial or complete hands-on assistance from another person.
DHS 10.13(8)
(8) “Care management organization" or “CMO" means an entity that is certified as meeting the requirements for a care management organization under s.
46.284 (3), Stats., and this chapter and that has a contract under s.
46.284 (2), Stats., and s.
DHS 10.42. “Care management organization" does not include an entity that contracts with the department to operate a PACE or Wisconsin partnership program.
DHS 10.13(8m)
(8m) “
Choice counseling” means information and services designed to assist eligible applicants in making enrollment decisions.
DHS 10.13(9)
(9) “Client" means a person applying for eligibility for the family care benefit, an eligible person or an enrollee.
DHS 10.13(10)
(10) “Community-based residential facility" or “CBRF" has the meaning specified in s.
50.01 (1g), Stats.
DHS 10.13(11)
(11) “Community spouse" means an individual who is legally married as recognized under state law to a family care spouse.
DHS 10.13(13)
(13) “Countable assets" means assets that are used in calculating financial eligibility and cost sharing requirements for the family care benefit.
DHS 10.13(14)
(14) “County agency” means a county department of aging, multicounty consortium, social services or human services, an aging and disability resource center, a family care district or a tribal agency, that has been designated by the department to determine financial eligibility and cost sharing requirements for the family care benefit.
DHS 10.13(14m)
(14m) “Day” means calendar day, unless otherwise indicated.
DHS 10.13(15)
(15) “Department" means the Wisconsin department of health services.
DHS 10.13(16p)
(16p) “Electronic visit verification" or “EVV” means, with respect to personal care services or home health care services as defined and required in Section 12006 of the 21st Century Cures Act,
42 USC 1396b (l), a system under which in-home visits conducted as part of such services are electronically verified.
DHS 10.13(16r)
(16r) “EVV record” means the information or data related to an electronically verified visit which contains all of the following:
DHS 10.13(17)
(17) “Eligible person" means a person who has been determined under ss.
DHS 10.31 and
10.32 to meet all eligibility criteria under s.
46.286 (1), Stats., and this chapter.
DHS 10.13(18)
(18) “Enrollee" means a person who is enrolled in a care management organization to receive the family care benefit.
DHS 10.13(19)
(19) “Exceptional payments" means the state supplement to federal supplemental security income authorized under s.
49.77 (3s), Stats.
DHS 10.13(20)
(20) “Fair hearing” means a de novo proceeding under ch.
HA 3 before an impartial administrative law judge in which the petitioner or the petitioner's representative presents the reasons why an administrative action under s.
HA 3.03 or inaction by the department, a county agency, a resource center or a CMO in the petitioner's case should be corrected.
DHS 10.13(21)
(21) “Family care benefit" has the meaning given in s.
46.2805 (4), Stats., namely, financial assistance for long-term care and support items for an enrollee.
DHS 10.13(23)
(23) “Family care spouse" means an individual who is a family care applicant or enrollee and is legally married as recognized under state law to an individual who does not reside in a medical institution or a nursing facility.
DHS 10.13(24)
(24) “Financial eligibility and cost-sharing screening" means a uniform screening tool prescribed by the department that is used to determine financial eligibility and cost-sharing under s.
46.286 (1) (b) and
(2), Stats., and ss.
DHS 10.32 and
10.34.
DHS 10.13(25m)
(25m) “Frail elder" means an individual aged 65 or older who has a physical disability, or an irreversible dementia, that restricts the individual's ability to perform normal daily tasks or that threatens the capacity of the individual to live independently.
DHS 10.13(26)
(26) “Functional capacity" means the skill to perform activities in an acceptable manner.
DHS 10.13(27)
(27) “Functional screening" means a uniform screening tool prescribed by the department that is used to determine functional eligibility under s.
46.286 (1) (a), Stats., and ss.
DHS 10.32 and
10.33.
DHS 10.13(28)
(28) “Grievance" means an expression of dissatisfaction about any matter that is not an adverse benefit determination.
DHS 10.13(29)
(29) “Home" means a place of abode and lands used or operated in connection with the place of abode.
DHS 10.13 Note
Note: Note: In urban situations the home usually consists of a house and lot. There will be situations where the home will consist of a house and more than one lot. As long as the lots adjoin one another, they are considered part of the home. In farm situations, the home consists of the house and building together with the total acreage property upon which they are located and which is considered a part of the farm. There will be farms where the land is on both sides of a road, in which case the land on both sides is considered part of the homestead.
DHS 10.13(32)
(32) “Instrumental activities of daily living" or “IADLs" means management of medications and treatments, meal preparation and nutrition, money management, using the telephone, arranging and using transportation and
the ability to function at a job site.
DHS 10.13(34)
(34) “Long-term care facility" means a nursing home, adult family home, community-based residential facility or residential care apartment complex.
DHS 10.13(36)
(36) “Medical institution" means a facility that meets all of the following conditions:
DHS 10.13(36)(a)
(a) Is organized to provide medical care, including nursing and convalescent care.
DHS 10.13(36)(b)
(b) Has the necessary professional personnel, equipment and facilities to manage the medical, nursing and other health care needs of patients on a continuing basis in accordance with accepted professional standards.
DHS 10.13(36)(d)
(d) Is staffed by professional personnel who are responsible for professional medical and nursing services. The professional medical and nursing services include adequate and continual medical care and supervision by a physician, registered nurse or licensed practical nurse supervision and services and nurses' aide services sufficient to meet nursing care needs and a physician's guidance on the professional aspects of operating the institution.
DHS 10.13(38)
(38) “Older person" means a person who is at least 65 years of age.
DHS 10.13(40)
(40) “Physical disability" means a physical condition, including an anatomical loss or musculoskeletal, neurological, respiratory or cardiovascular impairment, that results from injury, disease or congenital disorder and that significantly interferes with or significantly limits at least one major life activity of a person. In the context of physical disability, “major life activity" means self-care, performance of manual tasks unrelated to gainful employment, walking, receptive and expressive language, breathing, working, participating in educational programs, mobility other than walking and capacity for independent living.
DHS 10.13(41)
(41) “Residential care apartment complex" or “RCAC" has the meaning specified in s.
50.01 (6d), Stats.
DHS 10.13(42)
(42) “Resource center" or “aging and disability resource center" means an entity that meets the standards for operation and is under contract with the department to provide services under s.
46.283 (3), Stats., and this chapter or, if under contract to provide a portion of the services specified under s.
46.283 (3), Stats., meets the standards for operation with respect to those services.
DHS 10.13(43)
(43) “Respite care" means temporary placement in a long-term care facility for maintenance of care, treatment or services, as established by the person's primary care provider, in addition to room and board, for no more than 28 consecutive days at a time.
DHS 10.13(44)
(44) “Secretary" means the secretary of the department.
DHS 10.13(45)
(45) “Supplemental security income" means the supplemental security income program authorized under
42 USC 1381.
DHS 10.13(46)
(46) “Target population" means any of the following groups that a resource center or a care management organization has contracted with the department to serve:
DHS 10.13(47)
(47) “Wisconsin partnership program" means a demonstration program known by this name under contract with the department to provide health and long-term care services under a federal waiver authorized under
42 USC 1315.
DHS 10.13 History
History: Cr.
Register, October, 2000, No. 538, eff. 11-1-00;
CR 04-040: renum. (1) to be (1m), cr. (1), (3m), and (25m), am. (24) and (27), r. and recr. (28), r. (31)
Register November 2004 No. 587, eff. 12-1-04; correction in (17) made under s. 13.93 (2m) (b) 7., Stats.,
Register November 2004 No. 587; corrections in (15) and (35) made under s. 13.92 (4) (b) 6. and 7., Stats.,
Register November 2008 No. 635;
CR 08-109: cr. (16m)
Register June 2009 No. 642, eff. 7-1-09; corrections and renum. of (33) to be (40m) made under s. 13.92 (4) (b) 1., 6. and 7., Stats.,
Register November 2009 No. 647; correction in (41) made under s. 13.92 (4) (b) 7., Stats.,
Register December 2013 No. 696;
2019 Wis. Act 1: am. (3), (16)
Register May 2019 No. 761, eff. 6-1-19;
CR 22-026: am. (1) (intro.), (b) 1., 2., r. (1) (b) 4., 5., am. (1) (b) 7., cr. (1) (b) 8. to 10., (c), am. (3m), cr. (8m), r. (12), am. (14), cr. (14m), am. (16), (20), (28), cr. (36m), r. (40m), am. (46)
Register May 2023 No. 809, eff. 6-1-23; correction in (1) (c) 2., (20) made under s. 35.17, Stats.,
Register May 2023 No. 809;
EmR2306: emerg. cr. (16g), (16r), eff. 5-1-23;
CR 23-045: cr. (16g), (16r)
Register January 2024 No. 817, eff. 2-1-24; renum. (16g) to (16p) under s. 13.92 (4) (b) 1., Stats.,
Register January 2024 No. 817;
CR 23-046: am. (3), cr. (14s), am. (16) Register April 2024 No. 820, eff. 5-1-24. DHS 10.21(1)(1)
The department may contract for resource center operation only with entities that do all of the following:
DHS 10.21(2)
(2) The department's contracts with organizations operating resource centers shall specify sanctions that may be taken if certain contract requirements are not met, including the withholding or deduction of funds.
DHS 10.21(3)
(3) The department shall use standard contract provisions for contracting with resource centers, except as provided in this subsection. The provisions of the standard contract shall comply with all applicable state and federal laws and may be modified only in accordance with those laws and after consideration of the advice of the secretary's council on long-term care.
DHS 10.21(4)
(4) The department shall annually provide to the members of the council on long-term care copies of the standard resource center contract the department proposes to use in the next contract period and seek the advice of the council regarding the contract's provisions.
DHS 10.21(6)
(6) Prior to receiving funds to operate a resource center, an organization shall agree to the terms of the standard contract.
DHS 10.21 History
History: Cr.
Register, October, 2000, No. 538, eff. 11-1-00;
CR 04-040: am. (3) (a)
Register November 2004 No. 587, eff. 12-1-04; corrections in (3) (b) and (5) made under s.
13.92 (4) (b) 6. and
7., Stats.,
Register November 2009 No. 647;
CR 22-026: cons. (3) (intro.) and (a) and renum. to (3) and am., r. (3) (b), am. (4), r. (5)
Register May 2023 No. 809, eff. 6-1-23;
CR 23-046: am. (1) (a) Register April 2024 No. 820, eff. 5-1-24. DHS 10.22(1)(1)
Target population. Each contract for operation of a resource center shall specify the target population that the resource center will serve. The target population to be served by the resource center includes all members of the specified group who reside in the geographic area served by the resource center regardless of whether they need or are seeking family care or other long-term care services or programs.
DHS 10.22(2)(a)(a) A resource center shall have a name that is appropriate to its target population and includes any of the following phrases:
