DHS 10.11(6) (6) Provides for the recovery of correctly and incorrectly paid family care benefits.

DHS 10.11(7) (7) Establishes requirements for the provision of information about the family care program to prospective residents of long-term care facilities and for referrals to resource centers by long-term care facilities.

DHS 10.11 History History: 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 10.12 DHS 10.12 Applicability. This chapter applies to all of the following:

DHS 10.12(1) (1) The department and its agents.

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 History History: 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 10.13 DHS 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)(a)1. 1. Denial of eligibility under s. DHS 10.31 (5) or 10.32 (4).

DHS 10.13(1)(a)2. 2. Determination of cost sharing requirements under s. DHS 10.34.

DHS 10.13(1)(a)3. 3. Determination of entitlement under s. DHS 10.36.

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)3. 3. The denial, in whole or in part, of payment for a service.

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)7. 7. Involuntary disenrollment from a CMO.

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.