Chapter DHS 10

Chapter DHS 10

FAMILY CARE

Subchapter I — General Provisions

DHS 10.11   Authority and purpose.

DHS 10.12   Applicability.

DHS 10.13   Definitions.

Subchapter II — Aging and Disability Resource Centers

DHS 10.21   Contracting.

DHS 10.22   General requirements.

DHS 10.23   Standards for performance by resource centers.

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

Subchapter III — Access to the Family Care Benefit

DHS 10.31   Application and eligibility determination.

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.

Ch. DHS 10 Note 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.

subch. I of ch. DHS 10 Subchapter I — General Provisions

DHS 10.11 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:

DHS 10.11(1) (1) Establishes functional eligibility criteria for the family care benefit.

DHS 10.11(1m) (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.

DHS 10.11(2) (2) Establishes the procedures for applying for the family care benefit.

DHS 10.11(3) (3) Establishes standards for the performance of aging and disability resource centers.

DHS 10.11(4) (4) Establishes certification standards and standards for performance by care management organizations.

DHS 10.11(5) (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.

DHS 10.11(6) (6) Provides for the recovery of correctly and incorrectly paid family care benefits.

DHS 10.11(7) (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.

DHS 10.11 History 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 DHS 10.12 Applicability. This chapter applies to all of the following:

DHS 10.12(1) (1) The department and its agents.

DHS 10.12(2) (2) County agencies designated by the department to determine financial eligibility for the family care benefit.

DHS 10.12(3) (3) All organizations seeking or holding contracts with the department to operate an aging and disability resource center or a care management organization.

DHS 10.12(4) (4) All persons applying to receive the family care benefit.

DHS 10.12(5) (5) All persons found eligible to receive the family care benefit.

DHS 10.12(6) (6) All enrollees in a care management organization.

DHS 10.12(7) (7) Certain private pay individuals who may purchase certain services from a care management organization.

DHS 10.12(8) (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.

DHS 10.12 History 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 DHS 10.13 Definitions. In this chapter:

DHS 10.13(1) (1) “Adverse benefit determination” means any of the following:

DHS 10.13(1)(a) (a) Any of the following acts taken by an aging and disability resource center or county economic support unit:

DHS 10.13(1)(a)1. 1. Denial of eligibility under s. DHS 10.31 (5) or 10.32 (4).

DHS 10.13(1)(a)2. 2. Determination of cost sharing requirements under s. DHS 10.34.

DHS 10.13(1)(a)3. 3. Determination of entitlement under s. DHS 10.36.

DHS 10.13(1)(b) (b) Any of the following acts taken by a care management organization:

DHS 10.13(1)(b)1. 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.

DHS 10.13(1)(b)2. 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.

DHS 10.13(1)(b)3. 3. The denial, in whole or in part, of payment for a service.

DHS 10.13(1)(b)6. 6. The development of an individualized service plan that is unacceptable to the member because any of the following apply:

DHS 10.13(1)(b)6.a. 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.

DHS 10.13(1)(b)6.b. b. The plan does not provide sufficient care, treatment, or support to meet the enrollee’s needs and identified family care outcomes.

DHS 10.13(1)(b)6.c. c. The plan requires the enrollee to accept care, treatment or support items that are unnecessarily restrictive or unwanted by the enrollee.

DHS 10.13(1)(b)7. 7. Involuntary disenrollment from a CMO.

DHS 10.13(1)(b)8. 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.

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.