Wisconsin Legislature: DHS 10.23(6)(e)5.

d. How to contact the resource center for assistance.

e. The services of available advocacy services external to the resource center, including services under s. 16.009 (2) (p), Stats., and how to access these services.

f. The requirements and performance of available care management organizations as set forth in 42 CFR 438.66.

g. Any cost-sharing that will be imposed on members.

(b) Community needs identification. Implement a process for identifying unmet needs of its target population in the geographic area it serves. The process shall include input from members of the target populations and their representatives, and local government and service agencies including the care management organization, if any. The process shall include a systematic review of the needs of populations residing in public and private long-term care facilities, populations in need of public or private long-term care services, members of minority groups and people in rural areas. A resource center shall target its outreach, education, prevention and service development efforts based on the results of the needs identification process.

(c) Grievance process. Implement a process for reviewing and resolving client grievances as required under s. DHS 10.53 (1).

(d) Reporting and records.

1. Except as provided in this par. and sub. (7), collect data about its operations as required by the department by contract. No data collection effort shall interfere with a person’s right to receive information anonymously or require personally identifiable information unless the person has authorized the resource center to have or share that information.

2. Report information as the department determines necessary, including information needed for doing all of the following:

a. Determining whether the resource center is meeting minimum quality standards and other requirements of its contract with the department.

b. Determining the extent to which the resource center is improving its performance on measurable indicators identified by the resource center in its current quality improvement plan.

c. Evaluating the effects of providing long-term care options counseling and choice counseling under this section.

d. Evaluating the effects for enrollees and cost-effectiveness of providing the family care benefit.

3. Submit to the department all reports and data required or requested by the department, in the format and timeframe specified by the department.

(e) Internal quality assurance and quality improvement. Implement an internal quality assurance and quality improvement program that meets the requirements of its contract with the department. As part of the program, the resource center shall do all of the following:

1. Develop and implement a written quality assurance and quality improvement plan designed to ensure and improve outcomes for its target population. The plan shall be approved by the department and shall include at least all of the following components:

a. Identification of performance goals, specific to the needs of the resource center’s customers, including any goals specified by the department.

b. Identification of objective and measurable indicators of whether the identified goals are being achieved, including any indicators specified by the department.

c. Identification of timelines within which goals will be achieved.

d. Description of the process that the resource center will use to gather feedback from the resource center’s customers and staff and other sources on the quality and effectiveness of the resource center’s performance.

e. Description of the process the resource center will use to monitor and act on the results and feedback received.

f. A process for regularly updating the plan, including a description of the process the resource center will use for annually assessing the effectiveness of the quality assurance and quality improvement plan and the impact of its implementation on outcomes.

2. Measure resource center performance, using standard measures as required by its contract with the department, and report its findings on these measurements to the department.

3. Achieve minimum performance levels and performance improvement levels, as demonstrated by standardized measures agreed to in its contract with the department.

4. Initiate performance improvement projects that examine aspects of services related to improving resource center quality. These projects shall include all of the following:

a. Measuring performance.

b. Implementing system interventions.

c. Evaluating the effectiveness of the interventions.

d. Planning for sustained or increased improvement in performance based on the findings of the evaluation.

5. Comply with quality standards for services included in the resource center’s contract with the department in all of the following areas:

a. Timeliness and accuracy of the functional screen and financial eligibility and cost-sharing screen.

b. Timely and accurate eligibility determination and enrollment procedures.

c. Information and assistance services and long-term care options counseling.

d. Protection of applicant rights.

e. Effective processes for reviewing and resolving appeals and grievances of applicants and other persons who use resource center services.

f. Services to minority, rural and institutionalized populations.

6. Report all data required by the department related to standardized measures of performance, in the timeframes and format specified by the department.

7. Cooperate with the department in evaluating outcomes and in developing and implementing plans to sustain and improve performance.

(f) Cooperation with external reviews. Cooperate with any review of resource center activities by the department, another state agency or the federal government.

(7) Confidentiality and exchange of information. No record, as defined in s. 19.32 (2), Stats., of a resource center that contains personally identifiable information, as defined in s. 19.62 (5), Stats., concerning an individual who receives services from the resource center may be disclosed by the resource center without the individual’s informed consent, except as follows:

(a) A resource center shall provide information as required to comply with s. 16.009 (2) (p) or 49.45 (4), Stats., or as necessary for the department to administer the family care program under ss. 46.2805 to 46.2895, Stats.

(b) Notwithstanding ss. 48.78 (2) (a), 49.45 (4), 49.83, 51.30, 51.45 (14) (a), 55.22, 146.82, 252.11 (7), 253.07 (3) (c) and 938.78 (2) (a), Stats., and except as provided in sub. (2) (d) 2., a resource center may exchange confidential information about a client without the informed consent of the client, in the county of the resource center, if the exchange of information is necessary to enable the resource center to perform its duties or to coordinate the delivery of services to the client, as authorized under s. 46.21 (2m) (c), 46.215 (1m), 46.22 (1) (dm), 46.23 (3) (e), 46.284 (7), 46.2895 (10), 51.42 (3) (e) or 51.437 (4r) (b), Stats.

History: Cr. Register, October, 2000, No. 538, eff. 11-1-00; CR 04-040: am. (2) (d) 1., (3) (a) 2. (intro.) Register November 2004 No. 587, eff. 12-1-04; correction in (7) (b) made under s. 13.92 (4) (b) 7., Stats., Register November 2008 No. 635; EmR0834: emerg. am. (2) (d) 2., eff. 11-3-08; CR 08-109: am. (2) (d) 2. Register June 2009 No. 642, eff. 7-1-09; correction in (6) (b) made under s. 13.92 (4) (b) 6., Stats., Register November 2009 No. 647; CR 22-026: am. (2) (d) 3., (e), (h), (j) 2., r. (2) (k), am. (3) (intro.), (a) 2. (intro.), c., 3., (6) (b), (c), (e) 5. e. Register May 2023 No. 809, eff. 6-1-23; correction in (2) (h) made under s. 35.17, Stats., Register May 2023 No. 809; CR 23-046: am. (3) (a) 2. c., (6) (a) 2. (intro.), a., cr. (6) (a) 2. f., g. Register April 2024 No. 820, eff. 5-1-24; merger of (3) (a) 2. c. treatments by CR 22-026 and CR 23-046 made under s. 13.92 (4) (bm), Stats., Register April 2024 No. 820.

DHS 10.24 Department responsibilities for monitoring resource center quality and operations.

(1) Monitoring. The department shall monitor the performance and operations of the resource center in all of the following areas:

(a) Providing information about long-term care options to persons who could benefit from the information and linking persons to needed services, including family care, when eligible.

(b) Respecting individuals’ rights and dignity and giving consumers a strong role in program and policy development.

(2) Indicators. In order to monitor the performance of the resource center, the department shall develop and use indicators to measure and assess the performance of the resource center in the areas specified in sub. (1). The department shall use indicators to compare performance both within and across resource centers and against other programs in order to enable resource centers to improve the quality of their services. Where possible, the department shall measure indicators against available or created benchmarks and evaluate the resource centers’ performance.

(3) Measurement indicators. The department shall measure at least the following indicators:

(a) Information and assistance contacts and follow-ups:

(b) Persons who have received enrollment counseling who subsequently enroll in family care or who subsequently receive non-family care medical assistance-funded long-term care services.

(c) Referrals for, and timeliness of, pre-admission consultation under s. 46.283 (4) (g), Stats., and the functional screening.

(d) Referrals for medical assistance, supplemental security income, including the increased or exceptional payments, and food stamps.

(e) Referrals for emergency help, protective services, and other long-term care services.

(f) Grievances, appeals and fair hearings and their disposition.

(4) Assessment indicators. The department shall use the following indicators to assess the performance of the resource center:

(a) Fair treatment.

(b) Consumer satisfaction.

(d) Collaborative arrangements with community agencies whose services are focused on preventing loss of health or the capacity to function independently in performing activities of daily living.

(5) Cost-effectiveness. The department shall measure resource center cost-effectiveness in carrying out its program responsibilities.

(6) Required referrals. The department shall measure compliance with requirements for referrals to the resource center under subch. VII.

(7) Functional screening accuracy and reliability. The department shall measure the accuracy and reliability of functional screenings, including whether screens result in payment of appropriate rates to CMOs.

History: Cr. Register, October, 2000, No. 538, eff. 11-1-00; CR 04-040: am. (3) (c) and (f) and (7) Register November 2004 No. 587, eff. 12-1-04.

Subchapter III — Access to the Family Care Benefit

DHS 10.31 Application and eligibility determination.

(1) Definition. In this section, “agency” means any county agency, or any resource center that is not a county agency, that is responsible for all or part of determination of functional, financial, and other conditions of eligibility for the family care benefit.

(2) General requirement. Application for the family care benefit shall be made and reviewed in accordance with the provisions of this chapter.

(3) Access to information. The agency shall provide information to persons inquiring about or applying for the family care benefit as required under s. DHS 10.23 (2) (c) and (h).

(4) Application.

(a) Making application. Any person in the target population served by resource centers may apply for a family care benefit. Application for the family care benefit requires that a person apply for financial, non-financial and functional eligibility. Financial and non-financial eligibility determination shall be made by the income maintenance agency serving the county or tribe in which the person resides. Functional eligibility determination shall be made by the resource center serving the county or tribe in which the person resides.

(b) Signing the financial and non-financial eligibility application. The applicant or the applicant’s legal guardian, authorized representative or, where the applicant is incapacitated, someone acting responsibly for the applicant, shall sign each application form. The signatures of 2 witnesses are required when the applicant signs the application with a mark.

Note: This provision allows anyone acting responsibly for a person who is incapacitated to begin the application process for financial assistance with the costs of long-term care services. Other decisions regarding receipt of health or long-term care services, including placement in a long-term care facility, require consent of the individual or authorization by a person or court with the specific authority to make treatment or placement decisions.

(5) Verification of information. A financial and non-financial eligibility application for the family care benefit shall be denied when the applicant or enrollee is able to produce required verifications but refuses or fails to do so. If the applicant or enrollee is not able to produce verifications or requires assistance to do so, the agency taking the application may not deny assistance but shall proceed immediately to assist the person to secure necessary verifications.

(6) Eligibility determination.

(a) Decision date for financial and non-financial eligibility. Except as provided in par. (b), as soon as practicable, but not later than 30 days from the date the agency receives a financial and non-financial eligibility application that includes at least the applicant’s name, address, unless the applicant is homeless, and signature, the agency shall determine the applicant’s financial and non-financial eligibility and cost sharing requirements for the family care benefit. If the applicant is the spouse of a family care member, the agency shall notify both spouses in accordance with the requirements of s. 49.455 (7), Stats.

(am) Decision date for functional eligibility. Except as provided in par. (b), as soon as practicable, but not later than 30 days from the date the resource center receives verbal acceptance from the applicant to proceed with the functional screen, the resource center will determine the applicant’s functional eligibility for the family care benefit.

(b) Notice. The agency shall notify the applicant in writing of its determination. If a delay in processing the financial and non-financial eligibility application or determining functional eligibility occurs because of a delay in securing necessary information, the agency shall notify the applicant that there is a delay in processing the application. Communications with the applicant, either orally or in writing, in the attempt to obtain the missing information shall serve as notice of the delay. If the delay is not resolved within 30 days following this notice to the applicant of the missing information, the agency shall notify the applicant in writing of the delay in completing the determination, specify the reason for the delay, and inform the applicant of their right to appeal the delay by requesting a fair hearing under s. DHS 10.55.

(7) Enrollment. The agency shall complete and transmit, as directed by the department, all enrollment forms and materials required to enroll persons who are eligible and who choose to enroll in a care management organization.

(8) Fraud. When the agency director or designee has reason to believe that an applicant or enrollee, or the representative of an applicant or enrollee, has committed fraud, the agency director or designee shall refer the case to the district attorney.

History: Cr. Register, October, 2000, No. 538, eff. 11-1-00; CR 04-040: am. (6) (a) Register November 2004 No. 587, eff. 12-1-04; EmR2121: emerg. am. (4) (b), eff. 8-5-21; CR 21-081: am. (4) (b) Register May 2022 No. 797, eff. 6-1-22, am. (4) (b) eff. upon the termination of the Appendix K: Emergency Preparedness and Response and COVID-19 Addendum to the 1915 (c) Family Care program waiver; CR 22-026: am. (4) (a), (b), (5), (6) (a), cr. (6) (am), am. (6) (b) Register May 2023 No. 809, eff. 6-1-23.

DHS 10.32 General conditions of eligibility.

(1) Conditions. To be eligible for the family care benefit, a person shall meet all of the following conditions:

(a) Age. The person is at least 18 years of age at the time of application.

(b) Residency. The person is a resident of a county, family care district or service area of a tribe in which the family care benefit is available through a care management organization. This requirement does not apply to a person who is either of the following:

1. An enrollee who was a resident of the county, family care district or tribal area when he or she enrolled in family care, but currently resides in a long-term care facility outside the service area of the CMO under a plan of care approved by the CMO.

2. An applicant who, on the date that the family care benefit first became available in the county, was receiving services in a long-term care facility funded under any of the programs specified under s. DHS 10.33 (3) (c) administered by that county.