DHS 10.34(2)(2) Individuals eligible for medical assistance. A person who is eligible for medical assistance under ch. 49, Stats., and chs. DHS 101 to 108 is financially eligible for the family care benefit. Cost sharing requirements for the family care benefit for a medical assistance-eligible person are those that apply under ch. 49, Stats., and chs. DHS 101 to 108. DHS 10.34(3)(3) Individuals not eligible for medical assistance. DHS 10.34(3)(a)(a) Conditions of financial eligibility. Eligibility under this subsection is effective beginning July 1, 2000. For persons who are not eligible for medical assistance, financial eligibility and cost sharing requirements for the family care benefit shall be determined pursuant to applicable provisions of s. 46.286 (1) (b) and (2), Stats., and this chapter. The maximum cost-sharing requirement for a non-MA-eligible person shall be determined by a county agency using a uniform financial eligibility and cost-sharing screening prescribed by the department. A non-MA-eligible person is financially eligible for the family care benefit if the projected cost of the person’s care plan exceeds the person’s maximum cost-sharing requirement. DHS 10.34(3)(b)(b) Calculation of maximum cost share requirement at initial determination and annual re-determination of eligibility. A non-MA-eligible family care enrollee shall contribute to the cost of his or her care an amount that is calculated as provided under this section. Treatment of assets, including assets in trusts, and income shall be as provided under ss. 49.454 and 49.47, Stats., and ss. DHS 103.06 and 103.07 unless specified otherwise in this section. All dollar amounts specified in this section shall be updated annually based on changes in the consumer price index. The following calculation shall determine the applicant’s or enrollee’s maximum cost-sharing requirement: DHS 10.34(3)(b)1.1. Determine total countable assets according to ss. 49.454 and 49.47, Stats., and s. DHS 103.06. If the applicant or enrollee is legally married, include the countable assets of both members of the couple. DHS 10.34(3)(b)2.2. Determine monthly net countable assets by subtracting from total countable assets the following allowances, as applicable, and dividing the result by 12: DHS 10.34(3)(b)2.a.a. Subject to subd. 6., if the applicant or enrollee is a family care spouse, the amount of the community spouse resource allowance under s. 49.455 (6) (b), Stats. DHS 10.34(3)(b)2.b.b. If the person resides in a nursing home, community-based residential facility or adult family home, an allowance of $9,000. DHS 10.34(3)(b)2.c.c. If the person resides in his or her own home, including a residential care apartment complex or in the private home of a relative or other person, an allowance of $12,000. DHS 10.34(3)(b)3.3. Determine countable monthly income by adding together all of the following: DHS 10.34(3)(b)3.a.a. Monthly unearned income less a $20 disregard from unearned income, or if the person has less than $20 of unearned income, the remainder from earned income. DHS 10.34(3)(b)3.b.b. Total monthly earned income, less the first $200, and then less two-thirds of any remaining earned income. DHS 10.34(3)(b)4.4. Add together the monthly net countable assets and the countable monthly income. DHS 10.34(3)(b)5.c.c. If the person resides in a nursing home, community-based residential facility or adult family home, a personal maintenance allowance of $65. DHS 10.34(3)(b)5.d.d. If the person resides in his or her own home, including a residential care apartment complex or the home of another person, a personal maintenance allowance equal to the greater of the combined benefit amount available under 42 USC 1381 to 1383 and s. 49.77 (3s), Stats., or actual maintenance costs, as defined under sub. (1) (a), up to the maximum personal maintenance allowance for persons receiving home and community-based waiver services funded under 42 USC 1396 (b) or (c). DHS 10.34(3)(b)5.e.e. If the person resides in a medical institution, the monthly cost of maintaining a homestead property when the applicant or enrollee can reasonably be expected to return within 6 months or the anticipated absence of the applicant or enrollee from the home is for more than 6 months but there is a realistic expectation, as verified by a physician, that the person will return to the home. The monthly cost shall not exceed the SSI payment level for one person living in that person’s own household. DHS 10.34(3)(b)5.f.f. The average monthly out-of-pocket cost of necessary medical or remedial care, including health insurance premiums and cost-sharing requirements for other state or federal programs. DHS 10.34(3)(b)5.g.g. An allowance for dependents who live in the home of the person or the person’s community spouse equal to the allowance payable under s. 49.455 (4) (a) 3., Stats. DHS 10.34(3)(b)6.6. If both members of a married couple are family care spouses, the community spouse resource allowance under subd. 2. a. and the community spouse monthly income allowance under subd. 5. a. may be included in the calculation of cost share for either spouse, but not for both. DHS 10.34(3)(c)(c) Recalculation of maximum cost-sharing requirement during a certification period. When changes in income, assets or cost of care necessitate a re-determination of a person’s maximum cost-sharing requirement during a certification period as described in par. (f), the calculation for the remainder of the certification period shall be the same as under par. (b) except that the amount already incurred and paid by the person from countable assets during the certification period shall be added to the amount under par. (b) 4. DHS 10.34(3)(d)(d) Treatment of assets. In determining financial eligibility and cost sharing requirements for the family care benefit, the department or the county agency shall treat assets, including assets in trusts, according to ss. 49.454 and 49.47 (4) (b), Stats., and s. DHS 103.06, except as follows: DHS 10.34(3)(d)1.1. All funds in an independence account shall be considered as an exempt asset. In this subdivision, “independence account” means one or more separate accounts at a financial institution, approved by the department, that are in the sole ownership of the client, and that consist solely of savings, and dividends or other gains derived from those savings, from earned income received after application for the family care benefit. DHS 10.34(3)(e)(e) Treatment of income. In determining financial eligibility and cost sharing requirements for the family care benefit, the department or the county agency shall treat income according to applicable provisions of s. 49.47 (4) (c), Stats., and s. DHS 103.07 except that worker’s compensation cash benefits under ch. 104, Stats., and unemployment insurance benefits received under ch. 108, Stats., shall be treated as earned income for purposes of par. (b) 3. b. DHS 10.34(3)(f)(f) Certification period. Cost sharing requirements as determined under this section shall be in effect for a full 12-month certification period except as follows: DHS 10.34(3)(f)1.1. An enrollee shall report, within 10 days of the change, increases in assets that exceed a total of at least $1000 in a calendar month. DHS 10.34(3)(f)2.2. At any time, an enrollee may report decreases of any amount in assets other than decreases resulting from payment of required cost sharing under this section. DHS 10.34(3)(f)3.3. An enrollee shall report any change in income within 10 days of the change. DHS 10.34(3)(f)4.4. Cost-sharing requirements shall be re-determined whenever any of the following occurs: DHS 10.34(3)(f)4.a.a. Reported changes in income, assets, or both, would result in a lower cost-sharing requirement. DHS 10.34(4)(a)(a) Except as provided in par. (b), a person who is required to contribute to the cost of his or her care but who fails to make the required contributions is ineligible for the family care benefit. DHS 10.34(4)(b)(b) If the department or its designee determines that the person or his or her family would incur an undue financial hardship as a result of making the payment, the department may waive or reduce the requirement. Any reduction or waiver of cost share shall be subject to review at least every 12 months. A reduction or waiver under this paragraph shall meet all of the following conditions: DHS 10.34(4)(b)1.1. The hardship is documented by financial information beyond that normally collected for eligibility and cost-sharing determination purposes and is based on total financial resources and total obligations. DHS 10.34(4)(b)2.2. Sufficient relief cannot be provided through an extended or deferred payment plan. DHS 10.34(4)(b)3.3. The person is notified in writing of approval or denial within 30 days of providing necessary information to the department or its designee. DHS 10.34 NoteNote: The forced sale of a family residence or cessation of an education program for a person or his or her family member are examples of genuine hardships under this provision. Reductions or waivers of cost sharing requirements are generally restricted to situations where services are provided for a relatively long term, when deferred payments will not provide sufficient relief.
DHS 10.34(4)(c)(c) A CMO shall collect or monitor the collection of its enrollees’ cost sharing payments. If an enrollee does not meet his or her cost sharing obligations, the CMO shall notify the resource center in the county in which the enrollee resides. The resource center, directly or through arrangement with the county agency, shall notify the enrollee that he or she will be ineligible on a specified date unless cost sharing obligations are met. If the client has not paid the cost share amount due by the date specified, the county agency shall determine the person to be ineligible and disenroll the person from the CMO. DHS 10.34(4)(d)(d) Until an enrollee is disenrolled, a CMO remains responsible for provision of services in the enrollee’s plan of care and for payment to providers for those services. DHS 10.34 HistoryHistory: 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 (1) (d), (e), (2), (3) (b) (intro.), 1., (d) (intro.) and (e) made under s. 13.92 (4) (b) 7., Stats., Register November 2008 No. 635; EmR2121: emerg. r. (4) (a), eff. 8-5-21; CR 21-081: am. (4) (a) Register May 2022 No. 797, eff. 6-1-22, am. (4) (a) eff. the first day of the month after the emergency period, as defined in section 1135 (g) (1) (b) of the Social Security Act, 42 USC 1320b-5 (g) (1) (B) and declared in response to the COVID-19 pandemic, end; correction in (4) (a) made under s. 35.17, Stats., Register May 2022 No. 797. DHS 10.35DHS 10.35 Protections against spousal impoverishment. The provisions related to spousal impoverishment under s. 49.455, Stats., and s. DHS 103.075 apply to all family care spouses, regardless of their eligibility for medical assistance. DHS 10.35 HistoryHistory: Cr. Register, October, 2000, No. 538, eff. 11-1-00; correction made under s. 13.92 (4) (b) 7., Stats., Register November 2008 No. 635. DHS 10.36DHS 10.36 Eligibility and entitlement. DHS 10.36(1)(1) Entitlement. Except as provided in sub. (2), a person who meets all of the conditions of eligibility under s. DHS 10.32 is entitled to enroll in a care management organization and to receive the family care benefit if any of the following apply: DHS 10.36(1)(b)(b) The person meets the conditions of functional eligibility at the non-nursing home level under s. DHS 10.33 (2) (d) and at least one of the following applies: DHS 10.36(2)(a)(a) Effective date. Except as provided in pars. (b) and (c), within each county and for each CMO target population, entitlement to the family care benefit first applies on the effective date of a contract under which a CMO accepts a per person per month payment to provide services under the family care benefit to eligible persons in that target population in the county. DHS 10.36(2)(c)(c) Phase-in of capacity. To provide time for a newly established care management organization to develop sufficient capacity to serve all individuals who meet the conditions of entitlement, a care management organization may limit enrollment. If enrollment is limited during this phase-in period, a resource center may place persons otherwise entitled under sub. (1) on a waiting list until a CMO can accept the enrollment. Any waiting list created under this paragraph shall conform to department requirements. DHS 10.36(3)(3) Eligibility without entitlement. A person who is found eligible but who does not meet any of the conditions of sub. (1) (a) to (c) is not entitled to the family care benefit. The person may be placed on a waiting list to receive the family care benefit when funds are available. The county agency shall inform the person of his or her right to receive a new functional screening or financial eligibility and cost-sharing screening if the person’s circumstances change. Waiting lists under this subsection shall conform to criteria established by the department. While waiting for enrollment, a person who has been found eligible but not entitled may purchase services from a CMO as provided under s. DHS 10.37. DHS 10.36 HistoryHistory: Cr. Register, October, 2000, No. 538, eff. 11-1-00; CR 04-040: am. (2) (b) and (3) Register November 2004 No. 587, eff. 12-1-04; correction in (1) (b) 1. made under s. 13.93 (2m) (b) 7., Stats., Register November 2004 No. 587; correction in (1) (b) 1. made under s. 13.92 (4) (b) 7., Stats., Register November 2009 No. 647; CR 23-046: am. (1) (a), (b) (intro.), r. (2) (b) Register April 2024 No. 820, eff. 5-1-24. DHS 10.37(1)(a)(a) “Case management” means assessment, care planning, assistance in arranging and coordinating services in the care plan, assistance in filing grievances and appeals and obtaining advocacy services, and periodic reassessment and updates to the person’s care plan. DHS 10.37(1)(b)1.1. A person who is a member of a CMO’s target population and who does not qualify financially for the family care benefit under s. DHS 10.34. DHS 10.37(2)(2) Case management available for purchase. A care management organization shall offer case management services, at rates approved by the department, to private pay individuals who wish to purchase the services. A private pay individual may purchase from the CMO any types and amounts of case management. The types and amounts of case management and the cost of the services shall be specified in a written agreement signed by the authorized representative of the CMO and the individual purchasing the service or the person’s authorized representative. DHS 10.37(3)(a)(a) A private pay individual may not enroll in a care management organization, but, subject to pars. (b) and (c), may purchase services other than case management services, on a fee-for-service basis, from a care management organization. DHS 10.37(3)(b)(b) An individual who meets the definition under sub. (1) (b) 1. may purchase any service that the CMO provides directly and offers to the general public, at prices normally charged to the public. DHS 10.37(3)(c)(c) An individual who meets the definition under sub. (1) (b) 2. or 3. may purchase any service purchased or provided by the CMO for its members. DHS 10.37 HistoryHistory: Cr. Register, October, 2000, No. 538, eff. 11-1-00; CR 04-040: am. (1) (a) Register November 2004 No. 587, eff. 12-1-04. DHS 10.41(1)(1) Enrollment required. The family care benefit is available to eligible persons only through enrollment in a care management organization (CMO) under contract with the department. DHS 10.41(2)(2) Services. Services provided under the family care benefit shall be determined through individual assessment of enrollee needs and values and detailed in an individual service plan unique to each enrollee. As appropriate to its target population and as specified in the department’s contract, each CMO shall have available at least the services and support items covered under the home and community-based waivers under 42 USC 1396n (c) and ss. 46.275, 46.277, and 46.278, Stats., the long-term support community options program under s. 46.27, Stats., and specified services and support items under the state’s plan for medical assistance. In addition, a CMO may provide other services that substitute for or augment the specified services if these services are cost-effective and meet the needs of enrollees as identified through the individual assessment and service plan. When providing applicable services, CMOs shall comply with EVV requirements. DHS 10.41 NoteNote: The services that typically will be required to be available include adaptive aids; adult day care; assessment and case planning; case management; communication aids and interpreter services; counseling and therapeutic resources; daily living skills training; day services and treatment; home health services; home modification; home delivered and congregate meal services; nursing services; nursing home services, including care in an intermediate care facility for individuals with intellectual disabilities or in an institution for mental diseases; personal care services; personal emergency response system services; prevocational services; protective payment and guardianship services; residential services in an RCAC, CBRF or AFH; respite care; durable medical equipment and specialized medical supplies; outpatient speech; physical and occupational therapy; supported employment; supportive home care; transportation services; mental health and alcohol or other drug abuse services; and community support program services.
DHS 10.41(3)(3) Payment mechanisms. Payment to a care management organization shall be on a per enrollee per month basis. Any contractual agreements for shared financial risk between the department and a CMO shall meet applicable federal requirements. DHS 10.41 HistoryHistory: Cr. Register, October, 2000, No. 538, eff. 11-1-00; CR 22-026: am. (2) Register May 2023 No. 809, eff. 6-1-23; EmR2306: emerg. am. (2), eff. 5-1-23; CR 23-045: am. (2) Register January 2024 No. 817, eff. 2-1-24; correction in (2) made under s. 35.17, Stats., Register January 2024 No. 817. DHS 10.42DHS 10.42 Certification and contracting. DHS 10.42(1)(1) No entity may receive payment of funds for the family care benefit as a care management organization unless it is certified by the department as meeting all of the requirements of s. 46.284, Stats., and this chapter and is under contract with the department. DHS 10.42(2)(a)(a) To obtain and retain certification, an organization shall submit all information and documentation required by the department, in a format prescribed by the department, including comments it has obtained from each regional long-term care advisory committee in the area it proposes to serve. The department shall review and make a determination on the application within 90 calendar days of receipt of a complete application containing complete and accurate supporting documentation that the organization meets the standards under s. DHS 10.43. The department may conduct any necessary investigation to verify that the information submitted by the organization is accurate. The organization shall consent to disclosure by any third party of information the department determines is necessary to review the application. DHS 10.42(2)(am)(am) For initial certifications, or when a currently certified organization will provide or arrange for the provision of services to new eligibility groups, the organization shall submit to an onsite readiness review which will assess all of the following:
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