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(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 HistoryHistory: 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(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(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)(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 10.41(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 NoteNote: 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.