DHS 10.11 HistoryHistory: 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 10.12DHS 10.12 Applicability. This chapter applies to all of the following: 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 HistoryHistory: 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 10.13DHS 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)(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)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)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(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(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(15)(15) “Department” means the Wisconsin department of health services. 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(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(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. DHS 10.13(25m)(25m) “Frail elder” means an individual aged 65 or older who has a physical disability, or an irreversible dementia, that restricts the individual’s ability to perform normal daily tasks or that threatens the capacity of the individual to live independently. DHS 10.13(26)(26) “Functional capacity” means the skill to perform activities in an acceptable manner. DHS 10.13(27)(27) “Functional screening” means a uniform screening tool prescribed by the department that is used to determine functional eligibility under s. 46.286 (1) (a), Stats., and ss. DHS 10.32 and 10.33. DHS 10.13(28)(28) “Grievance” means an expression of dissatisfaction about any matter that is not an adverse benefit determination. DHS 10.13(29)(29) “Home” means a place of abode and lands used or operated in connection with the place of abode. DHS 10.13 NoteNote: Note: In urban situations the home usually consists of a house and lot. There will be situations where the home will consist of a house and more than one lot. As long as the lots adjoin one another, they are considered part of the home. In farm situations, the home consists of the house and building together with the total acreage property upon which they are located and which is considered a part of the farm. There will be farms where the land is on both sides of a road, in which case the land on both sides is considered part of the homestead.
DHS 10.13(32)(32) “Instrumental activities of daily living” or “IADLs” means management of medications and treatments, meal preparation and nutrition, money management, using the telephone, arranging and using transportation and the ability to function at a job site. DHS 10.13(34)(34) “Long-term care facility” means a nursing home, adult family home, community-based residential facility or residential care apartment complex. DHS 10.13(36)(36) “Medical institution” means a facility that meets all of the following conditions: DHS 10.13(36)(a)(a) Is organized to provide medical care, including nursing and convalescent care. DHS 10.13(36)(b)(b) Has the necessary professional personnel, equipment and facilities to manage the medical, nursing and other health care needs of patients on a continuing basis in accordance with accepted professional standards. DHS 10.13(36)(d)(d) Is staffed by professional personnel who are responsible for professional medical and nursing services. The professional medical and nursing services include adequate and continual medical care and supervision by a physician, registered nurse or licensed practical nurse supervision and services and nurses’ aide services sufficient to meet nursing care needs and a physician’s guidance on the professional aspects of operating the institution. DHS 10.13(38)(38) “Older person” means a person who is at least 65 years of age. DHS 10.13(40)(40) “Physical disability” means a physical condition, including an anatomical loss or musculoskeletal, neurological, respiratory or cardiovascular impairment, that results from injury, disease or congenital disorder and that significantly interferes with or significantly limits at least one major life activity of a person. In the context of physical disability, “major life activity” means self-care, performance of manual tasks unrelated to gainful employment, walking, receptive and expressive language, breathing, working, participating in educational programs, mobility other than walking and capacity for independent living.
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