Wisconsin Legislature: subch. I of ch. DHS 10

DHS 10.32 General conditions of eligibility.

DHS 10.33 Conditions of functional eligibility.

DHS 10.34 Financial eligibility and cost sharing.

DHS 10.35 Protections against spousal impoverishment.

DHS 10.36 Eligibility and entitlement.

DHS 10.37 Private pay individuals.

Subchapter IV — Family Care Benefit; Delivery Through Care Management Organizations (CMOs)

DHS 10.41 Family care services.

DHS 10.42 Certification and contracting.

DHS 10.43 CMO certification standards.

DHS 10.44 Standards for performance by CMOs.

DHS 10.45 Operational requirements for CMOs.

DHS 10.46 Department responsibilities for monitoring CMO quality and operations.

Subchapter V — Protection of Applicant, Eligible Person and Enrollee Rights

DHS 10.51 Client rights.

DHS 10.52 Required notifications.

DHS 10.53 Grievances and appeals.

DHS 10.54 Department reviews.

DHS 10.55 Fair hearing.

DHS 10.56 Continuation of services.

DHS 10.57 Cooperation with advocates.

Subchapter VI — Recovery of Paid Benefits

DHS 10.61 Recovery of incorrectly paid benefits.

DHS 10.62 Recovery of correctly paid benefits.

Subchapter VII — Assuring Timely Long-term Care Consultation

DHS 10.73 Information and referral requirements for long-term care facilities.

DHS 10.74 Requirements for resource centers.

Note: Chapter HFS 10 was created as an emergency rule effective February 1, 2000. Chapter HFS 10 was renumbered to chapter DHS 10 under s. 13.92 (4) (b) 1., Stats., and corrections made under s. 13.92 (4) (b) 7., Stats., Register November 2008 No. 635.

Subchapter I — General Provisions

DHS 10.11 Authority and purpose. This chapter is promulgated under the authority of ss. 46.281 (1n) (b) 1., 46.286 (4) to (7), 46.287 (2) (a) 1. (intro.), 46.288, 50.02 (2) (d), and 227.11 (2) (a), Stats., to implement a program called family care that is designed to help families arrange for appropriate long-term care services for older family members and for adults with physical or developmental disabilities. The chapter does all the following:

(1) Establishes functional eligibility criteria for the family care benefit.

(1m) Establishes financial eligibility criteria, entitlement criteria and cost sharing requirements for the family care benefit, including divestment of assets, treatment of trusts and spousal impoverishment protections.

(2) Establishes the procedures for applying for the family care benefit.

(3) Establishes standards for the performance of aging and disability resource centers.

(4) Establishes certification standards and standards for performance by care management organizations.

(5) Provides for the protection of applicants for the family care benefit and enrollees in care management organizations through appeal, grievance and fair hearing procedures.

(6) Provides for the recovery of correctly and incorrectly paid family care benefits.

(7) Establishes requirements for the provision of information about the family care program to prospective residents of long-term care facilities and for referrals to resource centers by long-term care facilities.

History: Cr. Register, October, 2000, No. 538, eff. 11-1-00; correction in (intro.) made under s. 13.92 (4) (b) 7., Stats., Register November 2008 No. 635; CR 22-026: am. (5) Register May 2023 No. 809, eff. 6-1-23; CR 23-046: am. (intro.), (1), cr. (1m), am. (7) Register April 2024 No. 820, eff. 5-1-24.

DHS 10.12 Applicability. This chapter applies to all of the following:

(1) The department and its agents.

(2) County agencies designated by the department to determine financial eligibility for the family care benefit.

(3) All organizations seeking or holding contracts with the department to operate an aging and disability resource center or a care management organization.

(4) All persons applying to receive the family care benefit.

(5) All persons found eligible to receive the family care benefit.

(6) All enrollees in a care management organization.

(7) Certain private pay individuals who may purchase certain services from a care management organization.

(8) Nursing homes, community-based residential facilities, residential care apartment complexes and adult family homes that are required to provide information to patients, residents and prospective residents and make certain referrals to an aging and disability resource center.

History: Cr. Register, October, 2000, No. 538, eff. 11-1-00; CR 23-046: am. (8) Register April 2024 No. 820, eff. 5-1-24.

DHS 10.13 Definitions. In this chapter:

(1) “Adverse benefit determination” means any of the following:

(a) Any of the following acts taken by an aging and disability resource center or county economic support unit:

1. Denial of eligibility under s. DHS 10.31 (5) or 10.32 (4).

2. Determination of cost sharing requirements under s. DHS 10.34.

3. Determination of entitlement under s. DHS 10.36.

(b) Any of the following acts taken by a care management organization:

1. The denial or limited authorization of a requested service, including determinations based on type or level of service, requirements or medical necessity, appropriateness, setting, or effectiveness of a covered benefit.

2. The reduction, suspension, or termination of a previously authorized service, unless the service was only authorized for a limited amount or duration and that amount or duration has been completed.

3. The denial, in whole or in part, of payment for a service.

6. The development of an individualized service plan that is unacceptable to the member because any of the following apply:

a. The plan is contrary to an enrollee’s wishes insofar as it requires the enrollee to live in a place that is unacceptable to the enrollee.

b. The plan does not provide sufficient care, treatment, or support to meet the enrollee’s needs and identified family care outcomes.

c. The plan requires the enrollee to accept care, treatment or support items that are unnecessarily restrictive or unwanted by the enrollee.

7. Involuntary disenrollment from a CMO.

8. The denial of functional eligibility under s. DHS 10.33 as a result of the care management organization’s administration of the long-term care functional screen, including a change from a nursing home level of care to a non-nursing home level of care.

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.

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.

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.

2. The failure to act in a timely manner as specified in subch. V of this chapter to resolve grievances or appeals.

(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.

(2) “Adult family home” or “AFH” has the meaning specified in s. 50.01 (1), Stats.

(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.

(3m) “Appeal” means a request for review of an adverse benefit determination.

(4) “Applicant” means a person who directly or through a representative makes application for the family care benefit.

(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.

(6) “Assistance” means cueing, supervision or partial or complete hands-on assistance from another person.

(7) “At risk of losing independence or functional capacity” means having the conditions or needs described in s. DHS 10.33 (2) (d).

(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.

(8m) “Choice counseling” means information and services designed to assist eligible applicants in making enrollment decisions.

(9) “Client” means a person applying for eligibility for the family care benefit, an eligible person or an enrollee.

(10) “Community-based residential facility” or “CBRF” has the meaning specified in s. 50.01 (1g), Stats.

(11) “Community spouse” means an individual who is legally married as recognized under state law to a family care spouse.

(13) “Countable assets” means assets that are used in calculating financial eligibility and cost sharing requirements for the family care benefit.

(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.

(14m) “Day” means calendar day, unless otherwise indicated.

(14s) “Degenerative brain disorder” has the meaning given in s. 55.01 (1v), Stats.

(15) “Department” means the Wisconsin department of health services.