Chapter DHS 73

Chapter DHS 73

SELECTED FISCAL MANAGEMENT PROCEDURES AND STANDARDS UNDER THE MEDICAL ASSISTANCE HOME AND COMMUNITY-BASED SERVICES WAIVER

DHS 73.01   Authority and purpose.

DHS 73.02   Applicability.

DHS 73.03   Definitions.

DHS 73.04   Assessment and case plan.

DHS 73.06   Development of service agreements.

DHS 73.08   Supervisory review of payment decisions.

DHS 73.09   Documentation that services have been provided.

DHS 73.10   Individual hardship exceptions to limits on funding for CBRF care.

DHS 73.11   Criteria for determination of the infeasibility of in-home services.

Ch. DHS 73 Note Note: Chapter HSS 73 was renumbered chapter HFS 73 under s. 13.93 (2m) (b) 1., Stats., and corrections were made under s. 13.93 (2m) (b) 6. and 7., Stats., Register, July, 2000, No. 535. Chapter HFS 73 was renumbered to chapter DHS 73 under s. 13.92 (4) (b) 1., Stats., and corrections made under s. 13.92 (4) (b) 7., Stats., Register November 2008 No. 635.

DHS 73.01 DHS 73.01 Authority and purpose. This chapter is promulgated under the authority of ss. 46.277 (5) (d) 1n. b. and (5r), and 227.11 (2) (a), Stats., to establish certain standards and procedures related to assessments, case plans, service agreements, participant payment of service providers and verification that services have been received for county administration of home and community-based services waivers from medical assistance requirements that the department receives from the secretary of the U.S. department of health and human services under 42 USC 1396n (c), to establish conditions of hardship under which the department may grant exceptions in individual cases to limits on spending by counties for care provided in CBRFs and to establish criteria for county agency determination of the infeasibility of in-home services as a condition for paying for services provided to a program participant residing in a CBRF.

DHS 73.01 History History: Cr. Register, January, 1993, No. 445, eff. 2-1-93; emerg. am. eff. 1-1-96; am. Register, May, 1996, No. 485, eff. 6-1-96; CR 00-056: am. Register August 2001 No. 548, eff. 9-1-01; CR 22-026: am. Register May 2023 No. 809, eff. 6-1-23.

DHS 73.02 DHS 73.02 Applicability. This chapter applies to county departments and private non-profit agencies with which the department contracts to provide home and community-based services through a medical assistance waiver, and to vendors providing assessments, case plans or supportive home care services funded under a medical assistance waiver.

DHS 73.02 History History: Cr. Register, January, 1993, No. 445, eff. 2-1-93; CR 22-026: am. Register May 2023 No. 809, eff. 6-1-23.

DHS 73.03 DHS 73.03 Definitions. In this chapter:

DHS 73.03(1) (1) “Assessment” means a process for determining a person’s functional abilities and disabilities and the person’s need for and preferences in regard to medical and social long-term community support services.

DHS 73.03(2) (2) “Case manager” means an employee of a county department or vendor agency responsible for locating, managing, coordinating and monitoring the services and informal community supports identified in a participant’s case plan.

DHS 73.03(3) (3) “Case plan” means a comprehensive community services plan specifying the types and amounts of services to be provided, the methods of service delivery and the coordination with informal community supports.

DHS 73.03(3m) (3m) “CBRF” or “community-based residential facility” has the meaning specified in s. 50.01 (1g), Stats.

DHS 73.03(5) (5) “County department” means a county department established under s. 46.215, 46.22, 46.23, 46.272, 51.42, or 51.437, Stats., which provides home and community-based services under a medical assistance waiver or a private non-profit agency designated by the department to provide services under a medical assistance waiver.

DHS 73.03(6) (6) “Department” means the Wisconsin department of health services.

DHS 73.03(7) (7) “Home and community-based services” means services that are provided under a medical assistance waiver as an alternative to institutional care.

DHS 73.03(8) (8) “Household care” means household tasks and home maintenance activities that do not change the physical structure of the home, including shopping, meal preparation, cleaning, laundry, bed-making, simple home repairs, errands and seasonal chores.

DHS 73.03(8m) (8m) “Initially applies for services” means applies for the first time for services in addition to an assessment or care plan under the community integration program under s. 46.277, Stats., and has not previously received the services.

DHS 73.03(9) (9) “Medical assistance” means the assistance program operated by the department under ss. 49.43 to 49.497, Stats.

DHS 73.03(10) (10) “Medical assistance waiver” means a waiver granted to the department by the secretary of the U.S. department of health and human services under 42 USC 1396n (c), authorizing the department to provide home and community-based services as part of the medical assistance program.

DHS 73.03(11) (11) “Participant” means a person receiving an assessment, case plan or supportive home care services funded under a medical assistance waiver.

DHS 73.03(12) (12) “Participant’s representative” means a person designated in writing by the participant to act on behalf of the participant in making decisions about or directing the provision of services received by the participant.

DHS 73.03(13) (13) “Primary caregiver” means the person providing the majority of unpaid, informal care to the participant.

DHS 73.03(14) (14) “Private non-profit agency” means a nonprofit corporation, as defined in s. 181.0103 (17), Stats., that provides a program of all-inclusive care for the elderly under 42 USC 1395eee or 1396u-4.

DHS 73.03(15) (15) “Respite care” means care and supervision to a participant in a homelike environment for purposes of giving the primary caregiver temporary relief, relieving the primary caregiver of the stress of giving continuous support.

DHS 73.03(16) (16) “Service provider” means an individual employed to provide supportive home care services to a participant, whether that individual is employed by the participant, the participant’s representative, a county department or a vendor agency.

DHS 73.03(17) (17) “Supportive home care” means the provision of services except nursing care that are intended to maintain participants in independent or supervised living in the participant’s own home or the home of the participant’s friends or relatives, which help the participant meet his or her daily living needs, address the participant’s needs for social contact, ensure the participant’s well being, and reduce the likelihood that the participant will have to move to a nursing home or other alternate living arrangement.

DHS 73.03(17m) (17m) “Terminally ill” means a medical prognosis that an individual’s life expectancy is less than 12 months.

DHS 73.03(18) (18) “Vendor agency” means an agency from which a county department purchases supportive home care services for participants.

DHS 73.03 History History: Cr. Register, January, 1993, No. 445, eff. 2-1-93; emerg. cr. (3m) and (8m), eff. 1-1-96; cr. (3m), (8m) and (17m), Register, May, 1996, No. 485, eff. 6-1-96; correction in (6) made under s. 13.92 (4) (b) 6., Stats., Register November 2008 No. 635; CR 22-026: r. (4), am. (5), (8m), (11), (14) Register May 2023 No. 809, eff. 6-1-23; correction in (14) made under s. 35.17, Stats., Register May 2023 No. 809.

DHS 73.04 DHS 73.04 Assessment and case plan.

DHS 73.04(1) (1) Assessment. Within the limits of state and federal funds, a county department shall carry out an assessment of any person residing in a nursing home who wants to be assessed for eligibility to receive support services within the community rather than within the nursing home, any person seeking admission to or about to be admitted to a nursing home for whom community services represent an alternative to nursing home residence or any person whom the county department judges would otherwise require nursing home care in the absence of comprehensive community services. The assessment shall include a face-to-face discussion with the person or the person’s guardian and any appropriate family members and caregivers. The assessment shall result in an outline of what would be required to enable the person to live at home or in a homelike setting integrated with the community and to meet the person’s preferences for location, type and manner of services provided.

DHS 73.04(2) (2) Case plan. The county department shall develop a case plan for non-institutional community services for a person who is assessed and for whom services are feasible, can be financed with available state and federal funds and are preferred to nursing home care by the person or the person’s guardian. The case plan shall specify the types and amounts of services to be provided, the manner of service delivery and the assistance to be provided by informal community supports and shall incorporate the participant’s preferences to the maximum extent possible.

DHS 73.04 History History: Cr. Register, January, 1993, No. 445, eff. 2-1-93; correction in (1) made under s. 13.93 (2m) (b) 7., Stats., Register August 2001 No. 548; CR 22-026: am. (1) Register May 2023 No. 809, eff. 6-1-23.

DHS 73.06 DHS 73.06 Development of service agreements.

DHS 73.06(1) (1) Requirement for negotiated agreement. Except when a county department expects services to be provided for less than 30 days, after an assessment and case plan have been completed and within 2 weeks after the initiation of service by the service provider, an agreement or agreements on services to be provided the participant shall be negotiated.

DHS 73.06(2) (2) Participant employment of service provider. If the service provider is employed by the participant or participant’s representative, there shall be 2 service agreements unless the county department and the participant or participant’s representative decide that a single agreement is preferable. A single agreement involving the county department, participant or participant’s representative and service provider shall cover all required items in the 2 agreements. If there are 2 agreements, they shall be the following:

DHS 73.06(2)(a) (a) A signed agreement between the county department and the participant or participant’s representative, which shall set out in writing:

DHS 73.06(2)(a)1. 1. The specific services that will be provided;

DHS 73.06(2)(a)2. 2. The amount of funds the county department will provide;

DHS 73.06(2)(a)3. 3. Procedures for transfer of funds by the county department;

DHS 73.06(2)(a)4. 4. A requirement that any service provider employed by the participant or participant’s representative shall be qualified on the basis of experience, training or both to perform required tasks, and that any training needed by the service provider shall be completed within 6 months after beginning employment or after February 1, 1993 whichever is later; and

DHS 73.06(2)(a)5. 5. That the county department or a vendor for the county department shall act as fiscal agent for the participant or participant’s representative for the purpose of performing the tasks required to comply with wage, benefit and tax laws applicable to the employer, unless the participant or participant’s representative makes an informed, knowing and voluntary waiver of the use of a fiscal agent; and

DHS 73.06(2)(b) (b) Except as provided in sub. (3), a signed agreement between the participant or participant’s representative and the service provider, which shall set out in writing:

DHS 73.06(2)(b)1. 1. The services the service provider will perform;

DHS 73.06(2)(b)2. 2. The service provider’s normal schedule of work or a specification of how scheduling will be accomplished;

DHS 73.06(2)(b)3. 3. When and how any training needed by the service provider will be furnished and completed;

DHS 73.06(2)(b)4. 4. The service provider’s rate of compensation; and

DHS 73.06(2)(b)5. 5. Verification and payment procedures to be followed consistent with s. DHS 73.09 (1) to (3).

DHS 73.06(3) (3) Exemptions. The service agreement between the participant or participant’s representative and service provider under sub. (2) (b) is not required when:

DHS 73.06(3)(a) (a) The services provided are limited to household care;

DHS 73.06(3)(b) (b) The services are provided by the spouse of the participant or by the parent of a minor participant; or

DHS 73.06(3)(c) (c) The services are for the purpose of providing respite care.

DHS 73.06(4) (4) County department or vendor agency employment of service provider.

DHS 73.06(4)(a) (a) If the service provider is employed by the county department or a vendor agency, there shall be either a single signed agreement among the participant or participant’s representative, the county department and, where applicable, the vendor agency, or separate signed agreements, one between the participant or participant’s representative and the county department and the other between the participant or participant’s representative and the vendor agency.

DHS 73.06(4)(b) (b) The agreement or agreements required under par. (a) shall contain at least the content specified in sub. (2) (a) 1. to 4. and (b), except that verification and payment procedures under sub. (2) (b) 5. and training arrangements under sub. (2) (b) 3. may be omitted if these do not directly involve the participant and are covered elsewhere either in written policy of the county department or in its contract with the vendor agency.

DHS 73.06 History History: Cr. Register, January, 1993, No. 445, eff. 2-1-93.

DHS 73.08 DHS 73.08 Supervisory review of payment decisions.

DHS 73.08(1) (1) The county department shall develop and implement written procedures for supervisory review of staff decisions regarding the competence of a participant to receive funds to pay a service provider and appropriateness of the levels of funds based upon the needs identified in the participant’s assessment and services authorized in the case plan for the participant.

DHS 73.08(2) (2) In conducting a review of a case in which a participant or participant’s representative receives funds, the supervisor shall examine:

DHS 73.08(2)(a) (a) The capability of the participant or participant’s representative to manage funds and act as employer of the service provider;

DHS 73.08(2)(b) (b) The adequacy of the funds provided compared to the level of need identified in the participant’s assessment; and

DHS 73.08(2)(c) (c) The adequacy of any training provided to the participant or the participant’s representative to enable the participant or participant’s representative to manage funds and serve as an employer.

DHS 73.08(3) (3) The supervisor’s review shall occur within 3 months after the initial disbursement of funds to a participant who receives funds for the first time on or after February 1, 1993 and within 9 months after February 1, 1993 for a participant who was receiving payments prior to February 1, 1993, and thereafter whenever there is a substantial change to the participant’s condition or need for services. Alternatively, the county department may conduct a supervisor’s review on a random sample of at least 10% of cases or 25 cases, whichever is greater, in which a participant receives funds. County departments with fewer that 25 cases shall review all cases. This review shall be completed within 12 months after February 1, 1993 and within every 12 months thereafter.

DHS 73.08(4) (4) A county department may contract with a third party for supervisory review under this section.

DHS 73.08 History History: Cr. Register, January, 1993, No. 445, eff. 2-1-93.

DHS 73.09 DHS 73.09 Documentation that services have been provided.

DHS 73.09(1) (1) If a participant or the participant’s representative employs a service provider, the county department shall verify the type and amount of service for which reimbursement is sought. A verification form developed and available from the county department shall either be submitted to the county department by the participant or participant’s representative or be reviewed by the case manager at the participant’s residence at least every 6 months.

DHS 73.09(2) (2) The completed verification form shall include the following information:

DHS 73.09(2)(a) (a) The type or types of services provided;

DHS 73.09(2)(b) (b) The number of hours of service provided in the past month or, if the service provider lives in the residence of the participant, the number of days of service provided in the past month;

DHS 73.09(2)(c) (c) The total dollar amount paid for the services;

DHS 73.09(2)(d) (d) The month in which the services were provided;

DHS 73.09(2)(e) (e) The dated signature of the participant or participant’s representative; and

DHS 73.09(2)(f) (f) The dated signature of the service provider.

DHS 73.09(3) (3) The county department may provide in the form under sub. (2) that the information in sub. (2) (b) does not have to be maintained or reported if:

DHS 73.09(3)(a) (a) The services provided are limited to household care;

DHS 73.09(3)(b) (b) The services are for the purpose of providing respite care; or