Chapter DHS 10

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.

DHS 10.13(1)(c)2. 2. The failure to act in a timely manner as specified in subch. V of this chapter to resolve grievances or appeals.

DHS 10.13(1m) (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.

DHS 10.13(2) (2) “Adult family home” or “AFH” has the meaning specified in s. 50.01 (1), Stats.

DHS 10.13(3) (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.

DHS 10.13(3m) (3m) Appeal” means a request for review of an adverse benefit determination.

DHS 10.13(4) (4) “Applicant” means a person who directly or through a representative makes application for the family care benefit.

DHS 10.13(5) (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.

DHS 10.13(6) (6) “Assistance” means cueing, supervision or partial or complete hands-on assistance from another person.

DHS 10.13(7) (7) “At risk of losing independence or functional capacity” means having the conditions or needs described in s. DHS 10.33 (2) (d).

DHS 10.13(8) (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.

DHS 10.13(8m) (8m) “Choice counseling” means information and services designed to assist eligible applicants in making enrollment decisions.

DHS 10.13(9) (9) “Client” means a person applying for eligibility for the family care benefit, an eligible person or an enrollee.

DHS 10.13(10) (10) “Community-based residential facility” or “CBRF” has the meaning specified in s. 50.01 (1g), Stats.

DHS 10.13(11) (11) “Community spouse” means an individual who is legally married as recognized under state law to a family care spouse.

DHS 10.13(13) (13) “Countable assets” means assets that are used in calculating financial eligibility and cost sharing requirements for the family care benefit.

DHS 10.13(14) (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.

DHS 10.13(14m) (14m) “Day” means calendar day, unless otherwise indicated.

DHS 10.13(14s) (14s) “Degenerative brain disorder” has the meaning given in s. 55.01 (1v), Stats.

DHS 10.13(15) (15) “Department” means the Wisconsin department of health services.

DHS 10.13(16) (16) “Developmental disability” has the meaning provided in s. 51.01 (5) (a), Stats.

DHS 10.13(16m) (16m) “Disability benefit specialist” means a person providing services to individuals ages 18 to 59 under s. DHS 10.23 (2) (d).

DHS 10.13(16p) (16p) “Electronic visit verification” or “EVV” means, with respect to personal care services or home health care services as defined and required in Section 12006 of the 21st Century Cures Act, 42 USC 1396b (l), a system under which in-home visits conducted as part of such services are electronically verified.

DHS 10.13(16r) (16r) “EVV record” means the information or data related to an electronically verified visit which contains all of the following:

DHS 10.13(16r)(a) (a) The type of service performed.

DHS 10.13(16r)(b) (b) The individual receiving the service.

DHS 10.13(16r)(c) (c) The date of the service.

DHS 10.13(16r)(d) (d) The location of service delivery.

DHS 10.13(16r)(e) (e) The individual providing the service.

DHS 10.13(16r)(f) (f) The time the service begins and ends.

DHS 10.13(17) (17) “Eligible person” means a person who has been determined under ss. DHS 10.31 and 10.32 to meet all eligibility criteria under s. 46.286 (1), Stats., and this chapter.

DHS 10.13(18) (18) “Enrollee” means a person who is enrolled in a care management organization to receive the family care benefit.

DHS 10.13(19) (19) “Exceptional payments” means the state supplement to federal supplemental security income authorized under s. 49.77 (3s), Stats.

DHS 10.13(20) (20) “Fair hearing” means a de novo proceeding under ch. HA 3 before an impartial administrative law judge in which the petitioner or the petitioner’s representative presents the reasons why an administrative action under s. HA 3.03 or inaction by the department, a county agency, a resource center or a CMO in the petitioner’s case should be corrected.

DHS 10.13(21) (21) “Family care benefit” has the meaning given in s. 46.2805 (4), Stats., namely, financial assistance for long-term care and support items for an enrollee.

DHS 10.13(22) (22) “Family care district” means a special purpose district created under s. 46.2895 (1), Stats.

DHS 10.13(23) (23) “Family care spouse” means an individual who is a family care applicant or enrollee and is legally married as recognized under state law to an individual who does not reside in a medical institution or a nursing facility.

DHS 10.13(24) (24) “Financial eligibility and cost-sharing screening” means a uniform screening tool prescribed by the department that is used to determine financial eligibility and cost-sharing under s. 46.286 (1) (b) and (2), Stats., and ss. DHS 10.32 and 10.34.