Chapter DHS 10

DHS 10.34(4)(b) (b) If the department or its designee determines that the person or his or her family would incur an undue financial hardship as a result of making the payment, the department may waive or reduce the requirement. Any reduction or waiver of cost share shall be subject to review at least every 12 months. A reduction or waiver under this paragraph shall meet all of the following conditions:

DHS 10.34(4)(b)1. 1. The hardship is documented by financial information beyond that normally collected for eligibility and cost-sharing determination purposes and is based on total financial resources and total obligations.

DHS 10.34(4)(b)2. 2. Sufficient relief cannot be provided through an extended or deferred payment plan.

DHS 10.34(4)(b)3. 3. The person is notified in writing of approval or denial within 30 days of providing necessary information to the department or its designee.

DHS 10.34 Note Note: The forced sale of a family residence or cessation of an education program for a person or his or her family member are examples of genuine hardships under this provision. Reductions or waivers of cost sharing requirements are generally restricted to situations where services are provided for a relatively long term, when deferred payments will not provide sufficient relief.

DHS 10.34(4)(c) (c) A CMO shall collect or monitor the collection of its enrollees’ cost sharing payments. If an enrollee does not meet his or her cost sharing obligations, the CMO shall notify the resource center in the county in which the enrollee resides. The resource center, directly or through arrangement with the county agency, shall notify the enrollee that he or she will be ineligible on a specified date unless cost sharing obligations are met. If the client has not paid the cost share amount due by the date specified, the county agency shall determine the person to be ineligible and disenroll the person from the CMO.

DHS 10.34(4)(d) (d) Until an enrollee is disenrolled, a CMO remains responsible for provision of services in the enrollee’s plan of care and for payment to providers for those services.

DHS 10.34 History History: Cr. Register, October, 2000, No. 538, eff. 11-1-00; CR 04-040: am. (3) (a) Register November 2004 No. 587, eff. 12-1-04; corrections in (1) (d), (e), (2), (3) (b) (intro.), 1., (d) (intro.) and (e) made under s. 13.92 (4) (b) 7., Stats., Register November 2008 No. 635; EmR2121: emerg. r. (4) (a), eff. 8-5-21; CR 21-081: am. (4) (a) Register May 2022 No. 797, eff. 6-1-22, am. (4) (a) 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, end; correction in (4) (a) made under s. 35.17, Stats., Register May 2022 No. 797.

DHS 10.35 DHS 10.35 Protections against spousal impoverishment. The provisions related to spousal impoverishment under s. 49.455, Stats., and s. DHS 103.075 apply to all family care spouses, regardless of their eligibility for medical assistance.

DHS 10.35 History History: Cr. Register, October, 2000, No. 538, eff. 11-1-00; correction made under s. 13.92 (4) (b) 7., Stats., Register November 2008 No. 635.

DHS 10.36 DHS 10.36 Eligibility and entitlement.

DHS 10.36(1) (1) Entitlement. Except as provided in sub. (2), a person who meets all of the conditions of eligibility under s. DHS 10.32 is entitled to enroll in a care management organization and to receive the family care benefit if any of the following apply:

DHS 10.36(1)(a) (a) The person meets the conditions of functional eligibility at the nursing home level under s. DHS 10.33 (2) (c).

DHS 10.36(1)(b) (b) The person meets the conditions of functional eligibility at the non-nursing home level under s. DHS 10.33 (2) (d) and at least one of the following applies:

DHS 10.36(1)(b)1. 1. The person is in need of adult protective services as substantiated by a county agency under s. 46.90 (2), Stats., or specified in s. 55.01 (1f), Stats.

DHS 10.36(1)(b)2. 2. The person is eligible for medical assistance.

DHS 10.36(1)(c) (c) The person meets the criteria under s. DHS 10.33 (3).

DHS 10.36(2) (2) Phase-in of entitlement.

DHS 10.36(2)(a) (a) Effective date. Except as provided in pars. (b) and (c), within each county and for each CMO target population, entitlement to the family care benefit first applies on the effective date of a contract under which a CMO accepts a per person per month payment to provide services under the family care benefit to eligible persons in that target population in the county.

DHS 10.36(2)(c) (c) Phase-in of capacity. To provide time for a newly established care management organization to develop sufficient capacity to serve all individuals who meet the conditions of entitlement, a care management organization may limit enrollment. If enrollment is limited during this phase-in period, a resource center may place persons otherwise entitled under sub. (1) on a waiting list until a CMO can accept the enrollment. Any waiting list created under this paragraph shall conform to department requirements.

DHS 10.36(3) (3) Eligibility without entitlement. A person who is found eligible but who does not meet any of the conditions of sub. (1) (a) to (c) is not entitled to the family care benefit. The person may be placed on a waiting list to receive the family care benefit when funds are available. The county agency shall inform the person of his or her right to receive a new functional screening or financial eligibility and cost-sharing screening if the person’s circumstances change. Waiting lists under this subsection shall conform to criteria established by the department. While waiting for enrollment, a person who has been found eligible but not entitled may purchase services from a CMO as provided under s. DHS 10.37.

DHS 10.36 History History: Cr. Register, October, 2000, No. 538, eff. 11-1-00; CR 04-040: am. (2) (b) and (3) Register November 2004 No. 587, eff. 12-1-04; correction in (1) (b) 1. made under s. 13.93 (2m) (b) 7., Stats., Register November 2004 No. 587; correction in (1) (b) 1. made under s. 13.92 (4) (b) 7., Stats., Register November 2009 No. 647; CR 23-046: am. (1) (a), (b) (intro.), r. (2) (b) Register April 2024 No. 820, eff. 5-1-24.

DHS 10.37 DHS 10.37 Private pay individuals.

DHS 10.37(1) (1) Definitions. In this section:

DHS 10.37(1)(a) (a) “Case management” means assessment, care planning, assistance in arranging and coordinating services in the care plan, assistance in filing grievances and appeals and obtaining advocacy services, and periodic reassessment and updates to the person’s care plan.

DHS 10.37(1)(b) (b) “Private pay individual” means any of the following:

DHS 10.37(1)(b)1. 1. A person who is a member of a CMO’s target population and who does not qualify financially for the family care benefit under s. DHS 10.34.

DHS 10.37(1)(b)2. 2. A person who is eligible for the family care benefit under s. DHS 10.32, but who is not entitled to receive the benefit immediately as specified in s. DHS 10.36 (3).

DHS 10.37(1)(b)3. 3. A person who meets the entitlement conditions specified in s. DHS 10.36 (1), but who is waiting for enrollment in a CMO under the phase-in provisions of s. DHS 10.36 (2).

DHS 10.37(2) (2) Case management available for purchase. A care management organization shall offer case management services, at rates approved by the department, to private pay individuals who wish to purchase the services. A private pay individual may purchase from the CMO any types and amounts of case management. The types and amounts of case management and the cost of the services shall be specified in a written agreement signed by the authorized representative of the CMO and the individual purchasing the service or the person’s authorized representative.

DHS 10.37(3) (3) Limitations on purchase of other services.

DHS 10.37(3)(a) (a) A private pay individual may not enroll in a care management organization, but, subject to pars. (b) and (c), may purchase services other than case management services, on a fee-for-service basis, from a care management organization.

DHS 10.37(3)(b) (b) An individual who meets the definition under sub. (1) (b) 1. may purchase any service that the CMO provides directly and offers to the general public, at prices normally charged to the public.

DHS 10.37(3)(c) (c) An individual who meets the definition under sub. (1) (b) 2. or 3. may purchase any service purchased or provided by the CMO for its members.

DHS 10.37 History History: Cr. Register, October, 2000, No. 538, eff. 11-1-00; CR 04-040: am. (1) (a) Register November 2004 No. 587, eff. 12-1-04.

subch. IV of ch. DHS 10 Subchapter IV — Family Care Benefit; Delivery Through Care Management Organizations (CMOs)

DHS 10.41 DHS 10.41 Family care services.

DHS 10.41(1) (1) Enrollment required. The family care benefit is available to eligible persons only through enrollment in a care management organization (CMO) under contract with the department.

DHS 10.41(2) (2) Services. Services provided under the family care benefit shall be determined through individual assessment of enrollee needs and values and detailed in an individual service plan unique to each enrollee. As appropriate to its target population and as specified in the department’s contract, each CMO shall have available at least the services and support items covered under the home and community-based waivers under 42 USC 1396n (c) and ss. 46.275, 46.277, and 46.278, Stats., the long-term support community options program under s. 46.27, Stats., and specified services and support items under the state’s plan for medical assistance. In addition, a CMO may provide other services that substitute for or augment the specified services if these services are cost-effective and meet the needs of enrollees as identified through the individual assessment and service plan. When providing applicable services, CMOs shall comply with EVV requirements.

DHS 10.41 Note Note: The services that typically will be required to be available include adaptive aids; adult day care; assessment and case planning; case management; communication aids and interpreter services; counseling and therapeutic resources; daily living skills training; day services and treatment; home health services; home modification; home delivered and congregate meal services; nursing services; nursing home services, including care in an intermediate care facility for individuals with intellectual disabilities or in an institution for mental diseases; personal care services; personal emergency response system services; prevocational services; protective payment and guardianship services; residential services in an RCAC, CBRF or AFH; respite care; durable medical equipment and specialized medical supplies; outpatient speech; physical and occupational therapy; supported employment; supportive home care; transportation services; mental health and alcohol or other drug abuse services; and community support program services.

DHS 10.41(3) (3) Payment mechanisms. Payment to a care management organization shall be on a per enrollee per month basis. Any contractual agreements for shared financial risk between the department and a CMO shall meet applicable federal requirements.

DHS 10.41 History History: Cr. Register, October, 2000, No. 538, eff. 11-1-00; CR 22-026: am. (2) Register May 2023 No. 809, eff. 6-1-23; EmR2306: emerg. am. (2), eff. 5-1-23; CR 23-045: am. (2) Register January 2024 No. 817, eff. 2-1-24; correction in (2) made under s. 35.17, Stats., Register January 2024 No. 817.

DHS 10.42 DHS 10.42 Certification and contracting.

DHS 10.42(1) (1) No entity may receive payment of funds for the family care benefit as a care management organization unless it is certified by the department as meeting all of the requirements of s. 46.284, Stats., and this chapter and is under contract with the department.

DHS 10.42(2) (2) 

DHS 10.42(2)(a) (a) To obtain and retain certification, an organization shall submit all information and documentation required by the department, in a format prescribed by the department, including comments it has obtained from each regional long-term care advisory committee in the area it proposes to serve. The department shall review and make a determination on the application within 90 calendar days of receipt of a complete application containing complete and accurate supporting documentation that the organization meets the standards under s. DHS 10.43. The department may conduct any necessary investigation to verify that the information submitted by the organization is accurate. The organization shall consent to disclosure by any third party of information the department determines is necessary to review the application.

DHS 10.42(2)(am) (am) For initial certifications, or when a currently certified organization will provide or arrange for the provision of services to new eligibility groups, the organization shall submit to an onsite readiness review which will assess all of the following:

DHS 10.42(2)(am)1. 1. Operations and administration, including all of the following:

DHS 10.42(2)(am)1.a. a. Administrative staffing and resources.

DHS 10.42(2)(am)1.b. b. Delegation and oversight of entity responsibilities.

DHS 10.42(2)(am)1.c. c. Enrollee and provider communications.

DHS 10.42(2)(am)1.d. d. Grievance and appeals.

DHS 10.42(2)(am)1.e. e. Member services and outreach.

DHS 10.42(2)(am)1.f. f. Provider network management.

DHS 10.42(2)(am)1.g. g. Program integrity compliance.

DHS 10.42(2)(am)2. 2. Service delivery, including all of the following:

DHS 10.42(2)(am)2.a. a. Case management/care coordination/service planning.

DHS 10.42(2)(am)2.b. b. Quality improvement.

DHS 10.42(2)(am)2.c. c. Utilization review.

DHS 10.42(2)(am)3. 3. Financial management, including all of the following:

DHS 10.42(2)(am)3.a. a. Financial reporting and monitoring.

DHS 10.42(2)(am)3.b. b. Financial solvency.

DHS 10.42(2)(am)4. 4. Systems management, including all of the following:

DHS 10.42(2)(am)4.a. a. Claims management.

DHS 10.42(2)(am)4.b. b. Encounter data and enrollment information management.

DHS 10.42(2)(b) (b) If the department denies CMO certification for the organization, the department shall provide written notice to the organization that clearly states the reasons for the denial and describes the manner by which the organization may appeal the department’s decision.

DHS 10.42(3) (3) If an organization applying to operate a CMO meets standards for certification under s. 46.284 (2) and (3), Stats., and s. DHS 10.43, the department shall certify the organization as meeting the requirements. Certification by the department does not bind the department to contracting with the organization to operate a CMO. The department may contract with a certified organization to operate a CMO only if all of the following apply:

DHS 10.42(3)(b) (b) The regional long-term care advisory committee and individuals from the local target population that the organization proposes to serve have assisted the department in its review and evaluation of all applications of organizations proposing to serve a geographic area.

DHS 10.42(3)(c) (c) The department has determined, after considering the advice of the regional long-term care advisory committee for the geographic area, that the organization’s services are needed to provide sufficient access to the family care benefit for eligible individuals.

DHS 10.42(3)(d) (d) Before January 1, 2003, the organization is a county or a family care district, unless any of the following applies:

DHS 10.42(3)(d)1. 1. The county and the regional long-term care advisory committee agree in writing that at least one additional care management organization is necessary or desirable.

DHS 10.42(3)(d)2. 2. The governing body of a tribe or band or the Great Lakes inter–tribal council, inc., elects to operate a care management organization within the area and is certified under sub. (2).

DHS 10.42(3)(e) (e) After December 31, 2002, and before January 1, 2004, the organization is a county or a family care district unless any of the following applies:

DHS 10.42(3)(e)1. 1. Paragraph (d) 1. or 2. applies.

DHS 10.42(3)(e)2. 2. The county or family care district fails to meet requirements of s. DHS 10.43 or 10.44 or the requirements under its contract with the department.

DHS 10.42(3)(e)3. 3. The department determines that the county or family care district does not have the capacity to serve all county residents who are entitled to the family care benefit in the client group or groups that the county or family care district serves and cannot develop the capacity. If this subd. 3. applies, the department may contract with an organization in addition to the county.

DHS 10.42(4) (4) After December 31, 2003, the department may contract with counties, family care districts, the governing body of a tribe or band or the Great Lakes inter–tribal council, inc., or under a joint application of any of these, or with a private organization that has no significant connection to an entity that operates a resource center. Proposals for contracts under this subsection shall be solicited under a competitive sealed proposal process under s. 16.75 (2m), Stats., and, after consulting with the regional long-term care advisory committee for the county or counties, the department shall evaluate the proposals primarily as to the quality of care that is proposed to be provided and certify those applicants that meet the requirements specified in s. 46.284 (2) and (3), Stats., and s. DHS 10.43. The department may select certified applicants for contract and contract with the selected applicants.

DHS 10.42 Note Note: Until July 1, 2001, the Wisconsin Legislature has authorized the Department to establish Family Care pilots in areas of the state in which not more than 29% of the state’s eligible population lives. After that date, if specifically authorized and funded by the Legislature, the Department may contract with additional entities certified as meeting requirements for a CMO. The Department is required to submit, prior to November 1, 2000, a report to the Governor that describes the implementation and outcomes of the pilots and makes recommendations about further development of Family Care.

DHS 10.42(5) (5) The department’s contracts with CMOs shall specify a range of remedies that may be taken in the event of noncompliance by the CMO with contract requirements. The remedies may include the following:

DHS 10.42(5)(a) (a) Suspension of new enrollment.

DHS 10.42(5)(b) (b) Enrollment reductions.

DHS 10.42(5)(c) (c) Withholding or reduction of payments.

DHS 10.42(5)(d) (d) Imposition of damages.

DHS 10.42(5)(e) (e) Appointment of temporary management of the CMO.

DHS 10.42(5)(f) (f) Contract termination.

DHS 10.42(6) (6) Except as provided in this subsection, the department shall use standard contract provisions for contracting with CMOs. The provisions of the standard contract shall comply with all applicable state and federal laws and may be modified only in accordance with those laws and after consideration of the advice of the secretary’s council on long-term care.

DHS 10.42(7) (7) The department shall annually provide to the members of the secretary’s council on long-term care copies of the standard CMO contract the department proposes to use in the next contract period and seek the advice of the council regarding the contract’s provisions. The department shall consider any recommendations of the council and may make revisions, as appropriate, based on those recommendations. If the department proposes to modify the terms of the standard contract, including adding or deleting provisions, in contracting with one or more organizations, the department shall seek the advice of the council and consider any recommendations of the council before making the modifications.

DHS 10.42(8) (8) Whenever the department considers an application from an organization to be certified as meeting the standards for a CMO, the department shall provide a copy of the standard resource center contract to the regional long-term care advisory committee serving the area in which an organization operates, or proposes to operate, the CMO. If the department proposes to modify the contract, including adding or deleting provisions, the department shall seek the advice of the committee and consider any recommendations of the committee prior to signing the modified contract.

DHS 10.42(9) (9) Prior to receiving funds to provide the family care benefit, an organization shall agree to the terms of the standard CMO contract.