Chapter DHS 10

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

DHS 10.24(1) (1) Monitoring. The department shall monitor the performance and operations of the resource center in all of the following areas:

DHS 10.24(1)(a) (a) Providing information about long-term care options to persons who could benefit from the information and linking persons to needed services, including family care, when eligible.

DHS 10.24(1)(b) (b) Respecting individuals’ rights and dignity and giving consumers a strong role in program and policy development.

DHS 10.24(1)(c) (c) Providing early intervention and prevention services.

DHS 10.24(2) (2) Indicators. In order to monitor the performance of the resource center, the department shall develop and use indicators to measure and assess the performance of the resource center in the areas specified in sub. (1). The department shall use indicators to compare performance both within and across resource centers and against other programs in order to enable resource centers to improve the quality of their services. Where possible, the department shall measure indicators against available or created benchmarks and evaluate the resource centers’ performance.

DHS 10.24(3) (3) Measurement indicators. The department shall measure at least the following indicators:

DHS 10.24(3)(a) (a) Information and assistance contacts and follow-ups:

DHS 10.24(3)(b) (b) Persons who have received enrollment counseling who subsequently enroll in family care or who subsequently receive non-family care medical assistance-funded long-term care services.

DHS 10.24(3)(c) (c) Referrals for, and timeliness of, pre-admission consultation under s. 46.283 (4) (g), Stats., and the functional screening.

DHS 10.24(3)(d) (d) Referrals for medical assistance, supplemental security income, including the increased or exceptional payments, and food stamps.

DHS 10.24(3)(e) (e) Referrals for emergency help, protective services, and other long-term care services.

DHS 10.24(3)(f) (f) Grievances, appeals and fair hearings and their disposition.

DHS 10.24(4) (4) Assessment indicators. The department shall use the following indicators to assess the performance of the resource center:

DHS 10.24(4)(a) (a) Fair treatment.

DHS 10.24(4)(b) (b) Consumer satisfaction.

DHS 10.24(4)(c) (c) Consumer involvement in the planning and governance of the resource center.

DHS 10.24(4)(d) (d) Collaborative arrangements with community agencies whose services are focused on preventing loss of health or the capacity to function independently in performing activities of daily living.

DHS 10.24(5) (5) Cost-effectiveness. The department shall measure resource center cost-effectiveness in carrying out its program responsibilities.

DHS 10.24(6) (6) Required referrals. The department shall measure compliance with requirements for referrals to the resource center under subch. VII.

DHS 10.24(7) (7) Functional screening accuracy and reliability. The department shall measure the accuracy and reliability of functional screenings, including whether screens result in payment of appropriate rates to CMOs.

DHS 10.24 History History: Cr. Register, October, 2000, No. 538, eff. 11-1-00; CR 04-040: am. (3) (c) and (f) and (7) Register November 2004 No. 587, eff. 12-1-04.

subch. III of ch. DHS 10 Subchapter III — Access to the Family Care Benefit

DHS 10.31 DHS 10.31 Application and eligibility determination.

DHS 10.31(1) (1) Definition. In this section, “agency” means any county agency, or any resource center that is not a county agency, that is responsible for all or part of determination of functional, financial, and other conditions of eligibility for the family care benefit.

DHS 10.31(2) (2) General requirement. Application for the family care benefit shall be made and reviewed in accordance with the provisions of this chapter.

DHS 10.31(3) (3) Access to information. The agency shall provide information to persons inquiring about or applying for the family care benefit as required under s. DHS 10.23 (2) (c) and (h).

DHS 10.31(4) (4) Application.

DHS 10.31(4)(a) (a) Making application. Any person in the target population served by resource centers may apply for a family care benefit. Application for the family care benefit requires that a person apply for financial, non-financial and functional eligibility. Financial and non-financial eligibility determination shall be made by the income maintenance agency serving the county or tribe in which the person resides. Functional eligibility determination shall be made by the resource center serving the county or tribe in which the person resides.

DHS 10.31(4)(b) (b) Signing the financial and non-financial eligibility application. The applicant or the applicant’s legal guardian, authorized representative or, where the applicant is incapacitated, someone acting responsibly for the applicant, shall sign each application form. The signatures of 2 witnesses are required when the applicant signs the application with a mark.

DHS 10.31 Note Note: This provision allows anyone acting responsibly for a person who is incapacitated to begin the application process for financial assistance with the costs of long-term care services. Other decisions regarding receipt of health or long-term care services, including placement in a long-term care facility, require consent of the individual or authorization by a person or court with the specific authority to make treatment or placement decisions.

DHS 10.31(5) (5) Verification of information. A financial and non-financial eligibility application for the family care benefit shall be denied when the applicant or enrollee is able to produce required verifications but refuses or fails to do so. If the applicant or enrollee is not able to produce verifications or requires assistance to do so, the agency taking the application may not deny assistance but shall proceed immediately to assist the person to secure necessary verifications.

DHS 10.31(6) (6) Eligibility determination.

DHS 10.31(6)(a) (a) Decision date for financial and non-financial eligibility. Except as provided in par. (b), as soon as practicable, but not later than 30 days from the date the agency receives a financial and non-financial eligibility application that includes at least the applicant’s name, address, unless the applicant is homeless, and signature, the agency shall determine the applicant’s financial and non-financial eligibility and cost sharing requirements for the family care benefit. If the applicant is the spouse of a family care member, the agency shall notify both spouses in accordance with the requirements of s. 49.455 (7), Stats.

DHS 10.31(6)(am) (am) Decision date for functional eligibility. Except as provided in par. (b), as soon as practicable, but not later than 30 days from the date the resource center receives verbal acceptance from the applicant to proceed with the functional screen, the resource center will determine the applicant’s functional eligibility for the family care benefit.

DHS 10.31(6)(b) (b) Notice. The agency shall notify the applicant in writing of its determination. If a delay in processing the financial and non-financial eligibility application or determining functional eligibility occurs because of a delay in securing necessary information, the agency shall notify the applicant that there is a delay in processing the application. Communications with the applicant, either orally or in writing, in the attempt to obtain the missing information shall serve as notice of the delay. If the delay is not resolved within 30 days following this notice to the applicant of the missing information, the agency shall notify the applicant in writing of the delay in completing the determination, specify the reason for the delay, and inform the applicant of their right to appeal the delay by requesting a fair hearing under s. DHS 10.55.

DHS 10.31(7) (7) Enrollment. The agency shall complete and transmit, as directed by the department, all enrollment forms and materials required to enroll persons who are eligible and who choose to enroll in a care management organization.

DHS 10.31(8) (8) Fraud. When the agency director or designee has reason to believe that an applicant or enrollee, or the representative of an applicant or enrollee, has committed fraud, the agency director or designee shall refer the case to the district attorney.

DHS 10.31 History History: Cr. Register, October, 2000, No. 538, eff. 11-1-00; CR 04-040: am. (6) (a) Register November 2004 No. 587, eff. 12-1-04; EmR2121: emerg. am. (4) (b), eff. 8-5-21; CR 21-081: am. (4) (b) Register May 2022 No. 797, eff. 6-1-22, am. (4) (b) eff. upon the termination of the Appendix K: Emergency Preparedness and Response and COVID-19 Addendum to the 1915 (c) Family Care program waiver; CR 22-026: am. (4) (a), (b), (5), (6) (a), cr. (6) (am), am. (6) (b) Register May 2023 No. 809, eff. 6-1-23.

DHS 10.32 DHS 10.32 General conditions of eligibility.

DHS 10.32(1) (1) Conditions. To be eligible for the family care benefit, a person shall meet all of the following conditions:

DHS 10.32(1)(a) (a) Age. The person is at least 18 years of age at the time of application.

DHS 10.32(1)(b) (b) Residency. The person is a resident of a county, family care district or service area of a tribe in which the family care benefit is available through a care management organization. This requirement does not apply to a person who is either of the following:

DHS 10.32(1)(b)1. 1. An enrollee who was a resident of the county, family care district or tribal area when he or she enrolled in family care, but currently resides in a long-term care facility outside the service area of the CMO under a plan of care approved by the CMO.

DHS 10.32(1)(b)2. 2. An applicant who, on the date that the family care benefit first became available in the county, was receiving services in a long-term care facility funded under any of the programs specified under s. DHS 10.33 (3) (c) administered by that county.

DHS 10.32(1)(c) (c) Family care target group. The person has a physical disability, is a frail elder, or has a developmental disability.

DHS 10.32(1)(d) (d) Functional eligibility. The person meets the functional eligibility conditions under s. DHS 10.33.

DHS 10.32(1)(e) (e) Financial eligibility. The person meets the financial eligibility conditions under s. DHS 10.34.

DHS 10.32(1)(f) (f) Cost sharing. The person pays any cost sharing obligations as required under s. DHS 10.34 (4).

DHS 10.32(1)(g) (g) Acceptance of medical assistance if eligible. If the person is eligible for medical assistance, he or she applies for and accepts the medical assistance.

DHS 10.32(1)(h) (h) Other non-financial conditions. The person meets the nonfinancial conditions of eligibility for medical assistance under s. DHS 103.03 (2) to (9).

DHS 10.32(1)(i) (i) Divestment. The person is not currently ineligible for the family care benefit, under the provisions of ss. 49.453 and 49.454 (2) (c) and (3) (b), Stats., and s. DHS 103.065 because he or she divested assets. The divestment provisions of ss. 49.453, 49.454 (2) (c) and (3) (b), Stats., and s. DHS 103.065 apply to all family care applicants and enrollees, regardless of whether they are eligible for medical assistance.

DHS 10.32(2) (2) Provision of necessary information. A client or person acting on behalf of a client shall provide full, correct and truthful information necessary to determine family care eligibility, entitlement status and cost sharing requirements, including the following:

DHS 10.32(2)(a) (a) A declaration of assets on a form prescribed by the department.

DHS 10.32(2)(b) (b) A declaration of income on a form prescribed by the department.

DHS 10.32(2)(c) (c) Information related to the person’s health and functional status, as required by the department.

DHS 10.32(3) (3) Reporting of changes required. An enrollee shall report to the county agency any change in circumstances that would affect his or her eligibility under this section, including income and asset changes that would affect cost sharing obligations, as specified under s. DHS 10.34 (3) (f).

DHS 10.32(4) (4) Review of eligibility. Enrollees’ eligibility for the family care benefit shall be re-determined annually or more often when a county agency has information indicating that a change has occurred in an enrollee’s circumstances that would affect his or her eligibility or cost sharing requirements.

DHS 10.32 History History: Cr. Register, October, 2000, No. 538, eff. 11-1-00; CR 04-040: am. (1) (b) 2. and (c) Register November 2004 No. 587, eff. 12-1-04; corrections in (1) (h) and (i) made under s. 13.92 (4) (b) 7., Stats., Register November 2008 No. 635; EmR2121: emerg. r. (4), eff. 8-5-21; CR 21-081: am. (4) Register May 2022 No. 797, eff. 6-1-22, am. (4) 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, ends; correction in (4) made under s. 35.17, Stats., Register May 2022 No. 797; CR 23-046: am. (1) (a) Register April 2024 No. 820, eff. 5-1-24.

DHS 10.33 DHS 10.33 Conditions of functional eligibility.

DHS 10.33(1) (1) Definitions. In this section:

DHS 10.33(1)(a) (a) “ADL” means activities of daily living.

DHS 10.33(1)(b) (b) “IADL” means instrumental activities of daily living.

DHS 10.33(1)(c) (c) “Appropriately” means suitable in terms of time and place.

DHS 10.33(1)(d) (d) “Long-term or irreversible condition” means a physical or cognitive impairment that is expected to last for more than 90 days or result in death within one year.

DHS 10.33(1)(e) (e) “Requires ongoing care, assistance or supervision” means a person cannot safely or appropriately perform one or more ADLs or IADLs, as is evidenced by findings from functional screening.

DHS 10.33(1)(f) (f) “Safely” means without significant risk of harm to oneself or others.

DHS 10.33(2) (2) Determination of functional eligibility.

DHS 10.33(2)(a) (a) Determination. Functional eligibility for the family care benefit shall be determined pursuant to s. 46.286 (1), Stats., and this chapter, using a uniform functional screening prescribed by the department. To have functional eligibility for the family care benefit, the functional eligibility condition under par. (b) shall be met and, except as provided under sub. (3), the functional capacity level under par. (c) or (d) shall be met.

DHS 10.33(2)(b) (b) Long-term condition. The person shall have a long-term or irreversible condition.

DHS 10.33(2)(c) (c) Nursing home level. A person is functionally eligible at the nursing home level if the person requires ongoing care, assistance or supervision from another person, as is evidenced by any of the following findings from application of the functional screening:

DHS 10.33(2)(c)1. 1. The person cannot safely or appropriately perform 3 or more activities of daily living.

DHS 10.33(2)(c)2. 2. The person cannot safely or appropriately perform 2 or more ADLs and one or more instrumental activities of daily living.

DHS 10.33(2)(c)3. 3. The person cannot safely or appropriately perform 5 or more IADLs.

DHS 10.33(2)(c)4. 4. The person cannot safely or appropriately perform one or more ADL and 3 or more IADLs and has cognitive impairment.

DHS 10.33(2)(c)5. 5. The person cannot safely or appropriately perform 4 or more IADLs and has cognitive impairment.

DHS 10.33(2)(c)6. 6. The person has a complicating condition that limits the person’s ability to independently meet his or her needs as evidenced by meeting both of the following conditions:

DHS 10.33(2)(c)6.a. a. The person requires frequent medical or social intervention to safely maintain an acceptable health or developmental status; or requires frequent changes in service due to intermittent or unpredictable changes in his or her condition; or requires a range of medical or social interventions due to a multiplicity of conditions.

DHS 10.33(2)(c)6.b. b. The person has a developmental disability that requires specialized services; or has impaired cognition exhibited by memory deficits or disorientation to person, place or time; or has impaired decision making ability exhibited by wandering, physical abuse of self or others, self neglect or resistance to needed care.

DHS 10.33(2)(d) (d) Non-nursing home level. A person is functionally eligible at the non-nursing home level if the person is at risk of losing his or her independence or functional capacity unless he or she receives assistance from others, as is evidenced by a finding from application of the functional screening that the person needs assistance to safely or appropriately perform either of the following:

DHS 10.33(2)(d)1. 1. One or more ADL.

DHS 10.33(2)(d)2. 2. One or more of the following critical IADLs:

DHS 10.33(2)(d)2.a. a. Management of medications and treatments.

DHS 10.33(2)(d)2.b. b. Meal preparation and nutrition.

DHS 10.33(2)(d)2.c. c. Money management.

DHS 10.33 History History: Cr. Register, October, 2000, No. 538, eff. 11-1-00; CR 04-040: am. (1) (c) and (2) (a), (c) and (d) Register November 2004 No. 587, eff. 12-1-04; CR 22-026: r. (3) Register May 2023 No. 809, eff. 6-1-23; CR 23-046: renum. (1) (a) to (d) to be (1) (c) to (f), cr. (1) (a), (b), am. (2) (c) (intro.), (d) (intro.) Register April 2024 No. 820, eff. 5-1-24.

DHS 10.34 DHS 10.34 Financial eligibility and cost sharing.

DHS 10.34(1) (1) Definitions. In this section:

DHS 10.34(1)(a) (a) “Actual maintenance costs” means the sum of the following: