The department may contract with counties, long-term 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 subdivision shall be solicited under a competitive sealed proposal process under s. 16.75 (2m)
and the department shall evaluate the proposals primarily as to the quality of care that is proposed to be provided, certify those applicants that meet the requirements specified in sub. (3) (a)
, select certified applicants for contract and contract with the selected applicants.
The department may contract with a county or long-term care district to operate a care management organization outside the geographic area of that county or long-term care district.
The department may award contracts under this paragraph to one or more entities certified under sub. (3)
to operate a care management organization within a county or geographic area.
The department shall require, as a term of any contract with a care management organization under this section, that the care management organization contract for the provision of services that are covered under the family care benefit with any community-based residential facility under s. 50.01 (1g)
, residential care apartment complex under s. 50.01 (6d)
, nursing home under s. 50.01 (3)
, intermediate care facility for persons with an intellectual disability under s. 50.14 (1) (b)
, community rehabilitation program, home health agency under s. 50.49 (1) (a)
, provider of day services, or provider of personal care, as defined in s. 50.01 (4o)
, that agrees to accept the reimbursement rate that the care management organization pays under contract to similar providers for the same service and that satisfies any applicable quality of care, utilization, or other criteria that the care management organization requires of other providers with which it contracts to provide the same service.
As a term of a contract with a care management organization under this section, the department shall prohibit a care management organization from including a provision that requires a provider to return any funding for residential services, prevocational services, or supported employment services that exceeds the cost of those services to the care management organization in a contract for services covered by the family care benefit.
If an entity meets the requirements under par. (b)
and applicable rules of the department and submits to the department an application for initial certification or certification renewal, the department shall certify that the entity meets the requirements for a care management organization.
To be certified as a care management organization, an applicant shall demonstrate or ensure all of the following:
Adequate availability of providers with the expertise and ability to provide services that are responsive to the disabilities or conditions of all of the applicant's proposed enrollees and sufficient representation of programmatic philosophies and cultural orientations to accommodate a variety of enrollee preferences and needs.
Adequate availability of providers that can meet the preferences and needs of its proposed service recipients for services at various times, including evenings, weekends and, when applicable, on a 24-hour basis.
Adequate availability of providers that are able and willing to perform all of the tasks that are likely to be identified in proposed enrollees' service and care plans.
Adequate availability of residential and day services that are geographically accessible to proposed enrollees' homes, families or friends.
Adequate supported living arrangements of the types and sizes that meet proposed enrollees' preference and needs.
Expertise in determining and meeting the needs of every target population that the applicant proposes to serve and connections to the appropriate service providers.
Thorough knowledge of local long-term care and other community resources.
The ability to manage and deliver, either directly or through subcontracts or partnerships with other organizations, the full range of benefits to be included in the monthly payment amount.
Thorough knowledge of methods for maximizing informal caregivers and community resources and integrating them into a service or care plan.
Coverage for a geographic area specified by the department.
The ability to develop strong linkages with systems and services that are not directly within the scope of the applicant's responsibility but that are important to the target group that it proposes to serve, including primary and acute health care services.
Adequate and competent staffing by qualified personnel to perform all of the functions that the applicant proposes to undertake.
A care management organization shall, in addition to meeting all contract requirements, do all of the following:
Accept requested enrollment of any person who is entitled to the family care benefit and of any person who is eligible for the family care benefit and for whom funding is available. No care management organization may disenroll any enrollee, except under circumstances specified by the department by contract. No care management organization may encourage any enrollee to disenroll in order to obtain long-term care services under the medical assistance fee-for-service system. No involuntary disenrollment is effective unless the department has reviewed and approved it.
Conduct a comprehensive assessment for each enrollee, including an in-person interview with the enrollee, using a standard format developed by the department.
With the enrollee and the enrollee's family or guardian, if appropriate, develop a comprehensive care plan that reflects the enrollee's values and preferences.
Provide or contract for the provision of necessary services and monitor the provided or contracted services.
Provide, within guidelines established by the department, a mechanism by which an enrollee may arrange for, manage, and monitor his or her family care benefit directly or with the assistance of another person chosen by the enrollee. The care management organization shall provide each enrollee with a form on which the enrollee shall indicate whether he or she has been offered the option under this paragraph and whether he or she has accepted or declined the option. If the enrollee accepts the option, the care management organization shall monitor the enrollee's use of a fixed budget for purchase of services or support items from any qualified provider, monitor the health and safety of the enrollee, and provide assistance in management of the enrollee's budget and services at a level tailored to the enrollee's need and desire for the assistance.
Provide, on a fee-for-service basis, case management services to persons who are functionally eligible but not financially eligible for the family care benefit.
Meet all performance standards required by the federal government or promulgated by the department by rule.
Submit to the department reports and data required or requested by the department.
Implement internal quality improvement and assurance processes that meet standards prescribed by the department by rule.
Cooperate with external quality assurance reviews.
Meet departmental requirements for protection of solvency.
Annually submit to the department an independent financial audit that meets federal requirements.
In this subsection, “governmental entity" means a political subdivision, as defined in s. 16.99 (3d)
, or a subunit of a political subdivision.
A governmental entity that has a contract under sub. (2)
may do all of the following:
Create a nonstock, nonprofit corporation under ch. 181
or a service insurance corporation under ch. 613
. Before creating a nonstock, nonprofit corporation or a service insurance corporation that will provide services under the family care benefit, the governmental entity shall submit to the department the proposed articles of incorporation for review and approval. If the department does not disapprove the articles of incorporation within 30 days of the date of submission to the department, the articles of incorporation are considered approved. If the department disapproves the articles of incorporation, the department shall provide specific reasons for the disapproval and recommendations regarding how the articles may be amended to cure the defect.
With approval of the department and office of the commissioner of insurance, assign any of the following to a corporation created under subd. 1.
The governmental entity's assets and liabilities relating to providing the family care benefit, including operating capital funds, risk reserve funds, solvency funds, or other special reserve funds required by the department or the office of the commissioner of insurance.
Upon approval of the department and the commissioner of insurance under par. (b) 2.
, the department shall notify enrollees of the care management organization regarding the transfer of the contract to the corporation created under par. (b) 1.
and shall inform enrollees of their rights and responsibilities in accordance with any requirements of the federal department of health and human services.
From the appropriation accounts under s. 20.435 (4) (b)
, and (w)
and (7) (b)
, the department shall provide funding on a capitated payment basis for the provision of services under this section. Notwithstanding s. 46.036 (3)
, a care management organization that is under contract with the department may expend the funds, consistent with this section, including providing payment, on a capitated basis, to providers of services under the family care benefit.
If the expenditures by a care management organization under par. (a)
exceed payments received from the department under par. (a)
, as determined by the department by contract, the department may share the loss with the care management organization, within the limits prescribed under the contract with the department.
If the payments received from the department under par. (a)
exceed the expenditures by a care management organization under par. (a)
, as determined by the department by contract, the care management organization may retain a portion of the excess payments, within the limits prescribed under the contract with the department, and shall return the remainder to the department.
The department may, by contract, impose solvency protections that the department determines are reasonable and necessary to retain federal financial participation. These protections may include all of the following:
The requirement that a care management organization segregate a risk reserve from other funds of the care management organization or the authorizing body for the care management organization.
The requirement that interest accruing to the risk reserve remain in the escrow account for the risk reserve.
Limitations on the distribution of funds from the risk reserve.
The requirement that a care management organization place funds in a risk reserve and maintain the risk reserve in an interest-bearing escrow account with a financial institution, as defined in s. 69.30 (1) (b)
, or invest funds as specified in s. 46.2895 (4) (j) 2.
Moneys in the risk reserve or invested as specified in this subdivision may be expended only for the provision of services under this section. If a care management organization ceases participation under this section, the funds in the risk reserve or invested as specified in this subdivision, minus any contribution of moneys other than those specified in par. (c)
, shall be returned to the department. The department shall expend the moneys for the payment of outstanding debts to providers of family care benefit services and for the continuation of family care benefit services to enrollees.
Subject to subd. 2.
, a care management organization may enter into contracts with providers of family care benefit services and may limit profits of the providers under the contracts.
The department shall review the contracts in subd. 1.
, including rates for the provision of service, to ensure that the contract terms protect services access by enrollees and financial viability of the care management organization, and may require contract revision.
(6) Governing board.
A care management organization shall have a governing board that reflects the ethnic and economic diversity of the geographic area served by the care management organization. At least one-fourth of the members of the governing board shall be representative of the client group or groups whom the care management organization is contracted to serve or those clients' family members, guardians, or other advocates.
(7) Confidentiality; exchange of information.
No record, as defined in s. 19.32 (2)
, of a care management organization that contains personally identifiable information, as defined in s. 19.62 (5)
, concerning an individual who receives services from the care management organization may be disclosed by the care management organization without the individual's informed consent, except as follows:
Notwithstanding ss. 48.78 (2) (a)
, 49.45 (4)
, 51.45 (14) (a)
, 55.22 (3)
, 252.11 (7)
, 253.07 (3) (c)
and 938.78 (2) (a)
, a care management organization acting under this section may exchange confidential information about a client, as defined in s. 46.287 (1)
, without the informed consent of the client, under s. 46.21 (2m) (c)
, 46.215 (1m)
, 46.22 (1) (dm)
, 46.23 (3) (e)
, 46.283 (7)
, 46.2895 (10)
, 51.42 (3) (e)
or 51.437 (4r) (b)
in the county of the care management organization, if necessary to enable the care management organization to perform its duties or to coordinate the delivery of services to the client.
A long-term care district is governed by s. 46.2895 (2) and is limited to the counties that are members of the district. Before a district may provide care management organization services to a county beyond its jurisdiction, that county must become a member of the district. New counties joining a district, like the original creating members, are entitled to representation on the district's governing board. OAG 3-15
Operation of resource center and care management organization.
In order to meet federal requirements and assure federal financial participation in funding of the family care benefit, a county, a tribe or band, a long-term care district or an organization, including a private, nonprofit corporation, may not directly operate both a resource center and a care management organization.
Family care benefit. 46.286(1)(1)
A person is eligible for, but not necessarily entitled to, the family care benefit if the person is at least 18 years of age; has a physical disability, as defined in s. 15.197 (4) (a) 2.
, or a developmental disability, as defined in s. 51.01 (5) (a)
, or is a frail elder; and meets all of the following criteria:
A person is functionally eligible if the person's level of care need, as determined by the department or its designee, is either of the following:
The nursing home level, if the person has a long-term or irreversible condition, expected to last at least 90 days or result in death within one year of the date of application, and requires ongoing care, assistance or supervision.
The non-nursing home level, if the person has a condition that is expected to last at least 90 days or result in death within 12 months after the date of application, and is at risk of losing his or her independence or functional capacity unless he or she receives assistance from others.
A person is financially eligible if any of the following apply:
The person is eligible under ch. 49
for medical assistance and, unless he or she is exempt from acceptance under rules promulgated by the department, accepts medical assistance.
The person was receiving the family care benefit on October 27, 2007, the person would qualify for medical assistance except for financial or disability criteria, and the projected cost of the person's care plan, as calculated by the department or its designee, exceeds the person's gross monthly income, plus one-twelfth of his or her countable assets, less deductions and allowances permitted by rule by the department.
A person who is determined to be financially eligible under sub. (1) (b)
shall contribute to the cost of his or her care an amount that is calculated by the department or its designee after subtracting from the person's gross income, plus one-twelfth of countable assets, the deductions and allowances permitted by the department by rule.
Funds received under par. (a)
shall be used by a care management organization to pay for services under the family care benefit.
A person who is required to contribute to the cost of his or her care but who fails to make the required contributions is ineligible for the family care benefit unless he or she is exempt from the requirement under rules promulgated by the department.
Subject to par. (c)
, a person is entitled to and may receive the family care benefit through enrollment in a care management organization if all of the following apply:
An entitled individual who is enrolled in a care management organization may not be involuntarily disenrolled except as follows:
If the contract between the care management organization and the department is canceled or not renewed. If this circumstance occurs, the department shall assure that enrollees continue to receive needed services through another care management organization or through the medical assistance fee-for-service system or any of the following programs: