Chapter 46

46.287(2)(a)1m. 1m. Except as provided in subd. 2., a client may contest any of the following adverse benefit determinations by filing, within 90 days of the failure of a care management organization to act on a contested adverse benefit determination within the time frames specified by rule by the department or within 90 days after receipt of notice of a decision upholding the adverse benefit determination, a written request for a hearing under s. 227.44 to the division of hearings and appeals created under s. 15.103 (1):

46.287(2)(a)1m.a. a. Denial of functional eligibility under s. 46.286 (1) 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.

46.287(2)(a)1m.b. b. Failure to provide timely services and support items that are included in the plan of care.

46.287(2)(a)1m.c. c. 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.

46.287(2)(a)1m.d. d. 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.

46.287(2)(a)1m.e. e. Denial, in whole or in part, of payment for a service.

46.287(2)(a)1m.f. f. The failure of a care management organization to act within the time frames provided in 42 CFR 438.408 (b) (1) and (2) regarding the standard resolution of grievances and appeals.

46.287(2)(a)1m.g. g. Denial of an enrollee’s request to dispute financial liability, including copayments, premiums, deductibles, coinsurance, other cost sharing, and other member financial liabilities.

46.287(2)(a)1m.h. h. Denial of an enrollee, who is a resident of a rural area with only one care management organization, to obtain services outside the care management organization’s network of contracted providers.

46.287(2)(a)1m.i. i. Development of a plan of care that is unacceptable to the enrollee because the plan of care requires the enrollee to live in a place that is unacceptable to the enrollee; the plan of care does not provide sufficient care, treatment, or support to meet the enrollee’s needs and support the enrollee’s identified outcomes; or the plan of care requires the enrollee to accept care, treatment, or support that is unnecessarily restrictive or unwanted by the enrollee.

46.287(2)(a)1m.j. j. Involuntary disenrollment from the care management organization.

46.287(2)(a)2. 2. An applicant for or recipient of medical assistance is not entitled to a hearing concerning the identical dispute or matter under both this section and 42 CFR 431.200 to 431.246.

46.287(2)(b) (b) An enrollee may contest a decision, omission or action of a care management organization other than those specified in par. (a) 1m. by filing a grievance with the care management organization. If the grievance is not resolved to the satisfaction of the enrollee, he or she may request that the department review the decision of the care management organization.

46.287(2)(c) (c) Information regarding the availability of advocacy services and notice of adverse actions taken and appeal rights shall be provided to a client by the resource center or care management organization in a form and manner that is prescribed by the department by rule.

46.287 History History: 1999 a. 9; 2003 a. 33; 2013 a. 20; 2019 a. 9.

46.288 46.288 Rule-making. The department shall promulgate as rules all of the following:

46.288(1) (1) Standards for performance by resource centers and for certification of care management organizations, including requirements for maintaining quality assurance and quality improvement.

46.288(2) (2) Criteria and procedures for determining functional eligibility under s. 46.286 (1) (a), financial eligibility under s. 46.286 (1) (b), and cost sharing under s. 46.286 (2) (a).

46.288(3) (3) Procedures and standards for procedures for s. 46.287 (2), including time frames for action by a resource center or a care management organization on a contested matter.

46.288 History History: 1999 a. 9; 2007 a. 20; 2009 a. 28; 2019 a. 9.

46.2895 46.2895 Long-term care district.

46.2895(1) (1) Creation.

46.2895(1)(a) (a) A county, a tribe or band, or any combination of counties or tribes or bands, may create a special purpose district that is termed a “long-term care district”, that is a local unit of government, that is separate and distinct from, and independent of, the state and the county or tribe or band that created it, and that has the powers and duties specified in this section, if each county or tribe or band that participates in creating the district does all of the following:

46.2895(1)(a)1. 1. Adopts an enabling resolution that does all of the following:

46.2895(1)(a)1.a. a. Declares the need for establishing the long-term care district.

46.2895(1)(a)1.b. b. Specifies the long-term care district’s primary purpose, which shall be to operate, under contract with the department, a resource center under s. 46.283, a care management organization under s. 46.284, or a program described under s. 46.2805 (1) (a) or (b).

46.2895(1)(a)1.c. c. Specifies the number of individuals who shall be appointed as members of the long-term care district board, the length of their terms, and, if the long-term care district is created by more than one county or tribe or band, how many members shall be appointed by each county or tribe or band.

46.2895(1)(a)2. 2. Files copies of the enabling resolution with the secretary of administration, the secretary of health services and the secretary of revenue.

46.2895(1)(c) (c) A long-term care district may not operate a care management organization under s. 46.284 or a program described under s. 46.2805 (1) (a) or (b) if the district operates a resource center under s. 46.283.

46.2895(1)(d) (d) A county or tribe or band may create more than one long-term care district.

46.2895(1)(e) (e) A long-term care district may change its primary purpose specified under par. (a) 1. b. if all the counties or tribes or bands that created the district and that have not withdrawn or been removed from the district under sub. (14), adopt a resolution approving the change in primary purpose and if the change in purpose does not violate par. (c) or any provision of a contract between the department and the district.

46.2895(2) (2) Jurisdiction.

46.2895(2)(a) (a) Except as provided in par. (b) or (c), a long-term care district’s jurisdiction is the geographical area of the county or counties that created the long-term care district and the geographic area of the reservation of, or lands held in trust for, any tribe or band that created the long-term care district.

46.2895(2)(b) (b) A long-term care district may apply to the department for a contract to operate a care management organization under s. 46.284 in an area outside the geographic boundary of the county or counties that created the long-term care district.

46.2895(2)(c) (c) If the department awards a contract to a long-term care district to operate a care management organization outside the geographic area of the counties that created the long-term care district, any county that is newly served by the care management organization and is outside the geographic area of the counties that created the long-term care district may join the existing long-term care district at the discretion of the long-term care district’s board, provided the newly served county adopts a resolution that authorizes the county to join the long-term care district. A county served by a care management organization operated by a long-term care district to which the county does not belong shall cooperate with and may not impede the operation of the care management organization.

46.2895(3) (3) Long-term care district board.

46.2895(3)(a) (a) The county board of supervisors of a county or, in a county with a county administrator or county executive, the county administrator or county executive shall appoint the long-term care district board members whom the county is allotted, by resolutions adopted under sub. (1) (a) 1. c., to appoint.

46.2895(3)(b) (b)

46.2895(3)(b)1. 1. At least one-fourth of the members of a long-term care district board shall be representative of the client group or groups whom it is the long-term care district’s primary purpose to serve or those clients’ family members, guardians, or other advocates.

46.2895(3)(b)3. 3. Membership of a long-term care district board shall reflect the ethnic and economic diversity in the jurisdiction of the long-term care district.

46.2895(3)(b)4. 4. No member of a long-term care district board may have a private financial interest in or profit directly or indirectly from any contract or other business of the long-term care district.

46.2895(3)(b)5. 5. Only individuals who reside within the area served by a long-term care district may serve as members of the long-term care district board.

46.2895(3)(d) (d) As soon as possible after the appointment of the initial members of the long-term care district board, the board shall organize for the transaction of business and elect a chairperson and other necessary officers. Each chairperson shall be elected by the board from time to time for the term of that chairperson’s office as a member of the board or for the term of 3 years, whichever is shorter, and shall be eligible for reelection. A majority of the board shall constitute a quorum. Unless specified otherwise in a bylaw adopted by the board, the board may act based on the affirmative vote of a majority of a quorum.

46.2895(3)(e) (e) Notwithstanding sub. (1) (a) 1. c., if a long-term care district is awarded a contract with the department to operate a care management organization outside the geographic area of the county or counties that created the long-term care district, the long-term care district board may add members to the long-term care district board to represent the counties or areas newly served by the long-term care district. The long-term care district board shall file notice of the change of the long-term care district board’s composition with the secretary of administration, the secretary of health services, and the secretary of revenue.

46.2895(4) (4) Powers. Subject to sub. (1) (c), a long-term care district has all the powers necessary or convenient to carry out the purposes and provisions of ss. 46.2805 to 46.2895. In addition to all these powers, a long-term care district may do all of the following:

46.2895(4)(a) (a) Adopt and alter, at pleasure, an official seal.

46.2895(4)(b) (b) Adopt bylaws and policies and procedures for the regulation of its affairs and the conduct of its business. The bylaws, policies and procedures shall be consistent with ss. 46.2805 to 46.2895 and, if the long-term care district contracts with the department under par. (d) or (dm), with the terms of that contract.

46.2895(4)(c) (c) Sue and be sued.

46.2895(4)(d) (d) Negotiate and enter into leases or contracts, including a contract with the department to operate either a resource center or a portion of its functions under s. 46.283 or a care management organization under s. 46.284, but not both a resource center or its functions and a care management organization.

46.2895(4)(dm) (dm) Subject to sub. (1) (c), enter into a contract with the department to operate a program described under s. 46.2805 (1) (a) or (b) and provide services related to the contracted services.

46.2895(4)(e) (e) Provide services related to services available under the family care benefit, to older persons and persons with disabilities, in addition to the services funded under the contract with the department that is specified under par. (d).

46.2895(4)(f) (f) Acquire, construct, equip, maintain, improve or manage a resource center under s. 46.283 or a care management organization under s. 46.284, but not both.

46.2895(4)(g) (g) Subject to sub. (8), employ any agent, employee, or special adviser that the long-term care district finds necessary, fix and regulate his or her compensation and provide, either directly or subject to an agreement under s. 66.0301 as a participant in a benefit plan of another governmental entity, any employee benefits, including an employee pension plan.

46.2895(4)(h) (h) Mortgage, pledge or otherwise encumber the long-term care district’s property or funds.

46.2895(4)(i) (i) Buy, sell or lease property, including real estate, and maintain or dispose of the property.

46.2895(4)(j) (j) Invest any funds not required for immediate disbursement in any of the following:

46.2895(4)(j)1. 1. An interest-bearing escrow account with a financial institution, as defined in s. 69.30 (1) (b).

46.2895(4)(j)2. 2. Time deposits in any financial institution, as defined in s. 69.30 (1) (b), if the time deposits mature in not more than 2 years.

46.2895(4)(j)3. 3. Bonds or securities issued or guaranteed as to principal and interest by the federal government or by a commission, board or other instrumentality of the federal government.

46.2895(4)(k) (k) Create a risk reserve or other special reserve as the long-term care district board desires or as the department requires under the contract with the department that is specified under par. (d).

46.2895(4)(L) (L) Accept aid, including loans, to accomplish the purpose of the long-term care district from any local, state or federal governmental agency or accept gifts, loans, grants or bequests from individuals or entities, if the conditions under which the aid, loan, gift, grant or bequest is furnished are not in conflict with this section.

46.2895(4)(m) (m) Make and execute other instruments necessary or convenient to exercise the powers of the long-term care district.

46.2895(4)(n) (n) In accordance with state law, operate a health maintenance organization.

46.2895(4)(o) (o) If awarded a contract by the department as described in sub. (2) (b) or (c), operate a care management organization outside the geographic boundary of the long-term care district.

46.2895(4)(p) (p) If awarded a contract by the department to operate a care management organization outside its geographic boundaries as described in sub. (2) (b) or (c), determine whether to add new counties, tribes, or bands into the long-term care district.

46.2895(4)(q) (q) Notwithstanding subs. (1) to (3), create a nonstock, nonprofit corporation under ch. 181 or a service insurance corporation under ch. 613 that may succeed the long-term care district and survive the district’s dissolution under sub. (13). Before creating a nonstock, nonprofit corporation or a service insurance corporation that will provide services under the family care benefit, the long-term care district shall submit to the department the proposed articles of incorporation for review and approval. If the department does not disapprove the articles of incorporation within 30 days of the date of submission to the department, the articles of incorporation are considered approved. If the department disapproves the articles of incorporation, the department shall provide specific reasons for the disapproval and recommendations regarding how the articles may be amended to cure the defect.

46.2895(4)(r) (r) With approval of the department and office of the commissioner of insurance, assign the following to a corporation created under par. (q):

46.2895(4)(r)1. 1. The long-term care district’s assets and liabilities, including operating capital funds, risk reserve funds, solvency funds, or other special reserve funds required by the department or the office of the commissioner of insurance.

46.2895(4)(r)2. 2. A contract with the department as described in sub. (2) (b) or (c).

46.2895(4)(r)3. 3. A permit issued by the office of the commissioner of insurance under ch. 648.

46.2895(4)(r)4. 4. A certification by the department under s. 46.284 (3).

46.2895(4r) (4r) Transfer of enrollees. Upon approval of the department and the commissioner of insurance under sub. (4) (r), the department shall notify enrollees of the care management organization operated by the long-term care district regarding the transfer of the contract to the corporation created under sub. (4) (q) and shall inform enrollees of their rights and responsibilities in accordance with any requirements of the federal department of health and human services.

46.2895(5) (5) Limitation on powers. A long-term care district may not issue bonds or levy a tax or assessment.

46.2895(6) (6) Duties. The long-term care district board shall do all of the following:

46.2895(6)(a) (a) Appoint a director, who shall hold office at the pleasure of the board.

46.2895(6)(b) (b) Subject to sub. (8), develop and implement a personnel structure and other employment policies for employees of the long-term care district.

46.2895(6)(c) (c) Assure compliance with the terms of any contract with the department under sub. (4) (d) or (dm).

46.2895(6)(cm) (cm) Determine whether to authorize the long-term care district director to apply to the department for a contract to operate a care management organization outside the geographic boundary of the long-term care district.

46.2895(6)(d) (d) Establish a fiscal operating year and annually adopt a budget for the long-term care district.

46.2895(6)(e) (e) Contract for any legal services required for the long-term care district.

46.2895(6)(f) (f) Subject to sub. (8), procure liability insurance covering its officers, employees, and agents, insurance against any loss in connection with its property and other assets and other necessary insurance; establish and administer a plan of self-insurance; or, subject to an agreement under s. 66.0301, participate in a governmental plan of insurance or self-insurance.

46.2895(7) (7) Director; duties. The director appointed under sub. (6) (a) shall do all of the following:

46.2895(7)(a) (a) Manage the property and business of the long-term care district and manage the employees of the district, subject to the general control of the long-term care district board.

46.2895(7)(b) (b) Comply with the bylaws and direct enforcement of all policies and procedures adopted by the long-term care district board.

46.2895(7)(c) (c) Perform duties in addition to those specified in pars. (a) and (b) as are prescribed by the long-term care district board.

46.2895(8) (8) Employment and employee benefits of certain employees.

46.2895(8)(a) (a) A long-term care district board that is created at least in part by a county shall do all of the following:

46.2895(8)(a)1. 1. If the long-term care district offers employment to any individual who was previously employed by a county, which participated in creating the district and at the time of the offer had not withdrawn or been removed from the district under sub. (14), and who while employed by the county performed duties relating to the same or a substantially similar function for which the individual is offered employment by the district and whose wages were established in a collective bargaining agreement with the county under subch. IV of ch. 111 that is in effect on the date that the individual commences employment with the district, with respect to that individual, abide by the terms of the collective bargaining agreement concerning the individual’s wages until the time of the expiration of that collective bargaining agreement or adoption of a collective bargaining agreement with the district under subch. IV of ch. 111 covering the individual as an employee of the district, whichever occurs first.

46.2895(8)(a)3. 3. If the long-term care district offers employment to any individual who was previously employed by a county, which participated in creating the district and at the time of the offer had not withdrawn or been removed from the district under sub. (14), and who while employed by the county performed duties relating to the same or a substantially similar function for which the individual is offered employment by the district, with respect to that individual, recognize all years of service with the county for any benefit provided or program operated by the district for which an employee’s years of service may affect the provision of the benefit or the operation of the program.