reglab/statecodes huggingface dataset:
Wisconsin Administrative Code › Department of Health Services › DHS 1-19 - Management and Technology and Strategic Finance › Chapter DHS 10 - Family Care › Subchapter I - General Provisions › Section DHS 10.12 - Applicability

Current through June 24, 2024
This chapter applies to all of the following:
(1) The department and its agents.
(2) County agencies designated by the
				  department to determine financial eligibility for the family care
				  benefit.
(3) All organizations
				  seeking or holding contracts with the department to operate an aging and
				  disability resource center or a care management organization.
(4) All persons applying to receive the
				  family care benefit.
(5) All
				  persons found eligible to receive the family care benefit.
(6) All enrollees in a care management
				  organization.
(7) Certain private
				  pay individuals who may purchase certain services from a care management
				  organization.
(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.
Wisconsin Administrative Code › Department of Health Services › DHS 1-19 - Management and Technology and Strategic Finance › Chapter DHS 10 - Family Care › Subchapter I - General Provisions › Section DHS 10.13 - Definitions

Current through June 24, 2024
In this chapter:
(1) "Adverse benefit determination" means any
				  of the following:
(a) Any of the following
				  acts taken by an aging and disability resource center or county economic
				  support unit:
1. Denial of eligibility under
				  s.
				  DHS 10.31
				  (5) or
				  10.32
				  (4).
2. Determination of cost sharing requirements
				  under s.
				  DHS
				  10.34.
3.
				  Determination of entitlement under s.
				  DHS
				  10.36.
Wisconsin Administrative Code › Department of Health Services › DHS 1-19 - Management and Technology and Strategic Finance › Chapter DHS 10 - Family Care › Subchapter II - Aging and Disability Resource Centers › Section DHS 10.21 - Contracting

Current through June 24, 2024
(1) The department may contract for resource
				  center operation only with entities that do all of the following:
(a) Comply with the general requirements
				  specified in s. 46.283, Stats., and s.
				  DHS
				  10.22.
(b)
				  Meet the standards for performance by resource centers specified in s.
				  DHS
				  10.23.
Wisconsin Administrative Code › Department of Health Services › DHS 1-19 - Management and Technology and Strategic Finance › Chapter DHS 10 - Family Care › Subchapter II - Aging and Disability Resource Centers › Section DHS 10.22 - General requirements

Current through June 24, 2024
(1) TARGET POPULATION. Each contract for
				  operation of a resource center shall specify the target population that the
				  resource center will serve. The target population to be served by the resource
				  center includes all members of the specified group who reside in the geographic
				  area served by the resource center regardless of whether they need or are
				  seeking family care or other long-term care services or programs.
(2) NAME.
(a) A resource center shall have a name that
				  is appropriate to its target population and includes any of the following
				  phrases:
1. "Aging and disability resource
				  center."
2. "Aging resource
				  center."
3. "Disability resource
				  center."
4. "Developmental
				  disabilities resource center."
Wisconsin Administrative Code › Department of Health Services › DHS 1-19 - Management and Technology and Strategic Finance › Chapter DHS 10 - Family Care › Subchapter II - Aging and Disability Resource Centers › Section DHS 10.23 - Standards for performance by resource centers

Current through June 24, 2024
(1) COMPLIANCE. An
				  aging and disability resource center shall comply with all applicable statutes,
				  all of the standards in this section and all requirements of its contract with
				  the department.
(2) SERVICES. A
				  resource center shall ensure that the following services, meeting the standards
				  specified, are available to its target population:
(a)
Information and referral services
				  and other assistance.
A resource center shall provide information,
				  referral and assistance at hours that are convenient to the public and
				  consistent with requirements of this chapter and its contract with the
				  department, using a telephone number that is toll-free to all callers in its
				  service area. The resource center shall be physically accessible and be able to
				  provide information and assistance services in a private and confidential
				  manner. The resource center shall be able to provide information and assistance
				  services in a language that a person contacting the resource center can
				  understand. Information and referral services include all of the following:
1. Current information on a wide variety of
				  topics related to aging, physical and developmental disabilities, chronic
				  illness and long-term care, as specified by the department and appropriate to
				  the resource center's target population.
2. Referrals to and assistance in accessing
				  an array of voluntary, purchased and public resources to help older people and
				  people with disabilities secure needed services or benefits, live with dignity
				  and security, and achieve maximum independence and quality of life. Referral
				  and assistance includes all the following:
a.
				  Professional advice and counseling to assist consumers in identifying needs,
				  capacities and personal preferences.
b. Educating consumers regarding available
				  service options and resources.
c.
				  Identifying service providers capable of meeting the person's needs.
d. Actively assisting the consumer in
				  accessing services when necessary.
3. Continued contact with people, as needed,
				  to determine the outcomes of previous contacts and to offer additional
				  assistance in locating or using services as necessary.
Wisconsin Administrative Code › Department of Health Services › DHS 1-19 - Management and Technology and Strategic Finance › Chapter DHS 10 - Family Care › Subchapter II - Aging and Disability Resource Centers › Section DHS 10.24 - Department responsibilities for monitoring resource center quality and operations

Current through June 24, 2024
(1) MONITORING. The department shall monitor
				  the performance and operations of the resource center in all of the following
				  areas:
(a) Providing information about
				  long-term care options to persons who could benefit from the information and
				  linking persons to needed services, including family care, when
				  eligible.
(b) Respecting
				  individuals' rights and dignity and giving consumers a strong role in program
				  and policy development.
(c)
				  Providing early intervention and prevention services.
Wisconsin Administrative Code › Department of Health Services › DHS 1-19 - Management and Technology and Strategic Finance › Chapter DHS 10 - Family Care › Subchapter III - Access to the Family Care Benefit › Section DHS 10.31 - Application and eligibility determination

Current through June 24, 2024
(1) DEFINITION. In
				  this section, "agency" means any county agency, or any resource center that is
				  not a county agency, that is responsible for all or part of determination of
				  functional, financial, and other conditions of eligibility for the family care
				  benefit.
(2) GENERAL REQUIREMENT.
				  Application for the family care benefit shall be made and reviewed in
				  accordance with the provisions of this chapter.
(3) ACCESS TO INFORMATION. The agency shall
				  provide information to persons inquiring about or applying for the family care
				  benefit as required under s. DHS 10.23 (2) (c) and (h).
(4) APPLICATION.
(a)
Making application
. Any
				  person in the target population served by resource centers may apply for a
				  family care benefit. Application for the family care benefit requires that a
				  person apply for financial, non-financial and functional eligibility. Financial
				  and non-financial eligibility determination shall be made by the income
				  maintenance agency serving the county or tribe in which the person resides.
				  Functional eligibility determination shall be made by the resource center
				  serving the county or tribe in which the person resides.
(b)
Signing the application
.
				  The applicant or the applicant's legal guardian, authorized representative or,
				  where the applicant is incapacitated, someone acting responsibly for the
				  applicant, shall sign each application form. The signature may be provided
				  using electronic methods identified by the department as constituting a
				  signature.
Note: Par. (b) is amended by CR 21-081 and CR 22-026
					 effective upon the termination of the Appendix K: Emergency Preparedness and
					 Response and COVID-19 Addendum to the 1915 (c) Family Care program waiver, to
					 read:
(b)
Signing the
				  financial and non-financial eligibility application
. The
				  applicant or the applicant's legal guardian, authorized representative or,
				  where the applicant is incapacitated, someone acting responsibly for the
				  applicant, shall sign each application form. The signatures of 2 witnesses are
				  required when the applicant signs the application with a mark.
Note:
This provision allows anyone acting
					 responsibly for a person who is incapacitated to begin the application process
					 for financial assistance with the costs of long-term care services. Other
					 decisions regarding receipt of health or long-term care services, including
					 placement in a long-term care facility, require consent of the individual or
					 authorization by a person or court with the specific authority to make
					 treatment or placement decisions.
Wisconsin Administrative Code › Department of Health Services › DHS 1-19 - Management and Technology and Strategic Finance › Chapter DHS 10 - Family Care › Subchapter III - Access to the Family Care Benefit › Section DHS 10.32 - General conditions of eligibility

Current through June 24, 2024
(1) CONDITIONS. To
				  be eligible for the family care benefit, a person shall meet all of the
				  following conditions:
(a)
Age
. The person is at least 18 years of age at the time of
				  application.
(b)
Residency
. The person is a resident of a county, family care
				  district or service area of a tribe in which the family care benefit is
				  available through a care management organization. This requirement does not
				  apply to a person who is either of the following:
1. An enrollee who was a resident of the
				  county, family care district or tribal area when he or she enrolled in family
				  care, but currently resides in a long-term care facility outside the service
				  area of the CMO under a plan of care approved by the CMO.
2. An applicant who, on the date that the
				  family care benefit first became available in the county, was receiving
				  services in a long-term care facility funded under any of the programs
				  specified under s.
				  DHS 10.33 (3)
				  (c) administered by that
				  county.
(c)
Family
				  care target group
. The person has a physical disability, is a frail
				  elder, or has a developmental disability.
(d)
Functional eligibility
.
				  The person meets the functional eligibility conditions under s.
				  DHS
				  10.33.
(e)
Financial eligibility
. The person meets the financial
				  eligibility conditions under s.
				  DHS
				  10.34.
(f)
Cost sharing
. The person pays any cost sharing obligations as
				  required under s.
				  DHS 10.34
				  (4).
(g)
Acceptance of medical assistance
				  if eligible
. If the person is eligible for medical assistance, he or
				  she applies for and accepts the medical assistance.
(h)
Other non-financial
				  conditions
. The person meets the nonfinancial conditions of
				  eligibility for medical assistance under s.
				  DHS 103.03 (2) to
				  (9).
(i)
Divestment
. The person
				  is not currently ineligible for the family care benefit, under the provisions
				  of ss. 49.453 and
				  49.454 (2) (c) and (3)
				  (b), Stats., and s.
				  DHS
				  103.065 because he or she divested assets. The
				  divestment provisions of ss.
				  49.453,
				  49.454 (2) (c) and (3)
				  (b), Stats., and s.
				  DHS
				  103.065 apply to all family care applicants and
				  enrollees, regardless of whether they are eligible for medical
				  assistance.
Wisconsin Administrative Code › Department of Health Services › DHS 1-19 - Management and Technology and Strategic Finance › Chapter DHS 10 - Family Care › Subchapter III - Access to the Family Care Benefit › Section DHS 10.33 - Conditions of functional eligibility

Current through June 24, 2024
(1) DEFINITIONS. In
				  this section:
(a) "ADL" means activities of
				  daily living.
(b) "IADL" means
				  instrumental activities of daily living.
(c) "Appropriately" means suitable in terms
				  of time and place.
(d) "Long-term
				  or irreversible condition" means a physical or cognitive impairment that is
				  expected to last for more than 90 days or result in death within one
				  year.
(e) "Requires ongoing care,
				  assistance or supervision" means a person cannot safely or appropriately
				  perform one or more ADLs or IADLs, as is evidenced by findings from functional
				  screening.
(f) "Safely" means
				  without significant risk of harm to oneself or others.
Wisconsin Administrative Code › Department of Health Services › DHS 1-19 - Management and Technology and Strategic Finance › Chapter DHS 10 - Family Care › Subchapter III - Access to the Family Care Benefit › Section DHS 10.34 - Financial eligibility and cost sharing

Current through June 24, 2024
(1) DEFINITIONS. In
				  this section:
(a) "Actual maintenance costs"
				  means the sum of the following:
1. Shelter
				  costs determined according to s.
				  49.455(4)
				  (d) 1 and 2., Stats.
2. An amount equal to the maximum food stamp
				  allotment for a household of one under
				  7 USC
				  2017.
3. An allowance for clothing as determined by
				  the department.
Wisconsin Administrative Code › Department of Health Services › DHS 1-19 - Management and Technology and Strategic Finance › Chapter DHS 10 - Family Care › Subchapter III - Access to the Family Care Benefit › Section DHS 10.35 - Protections against spousal impoverishment

Current through June 24, 2024
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.
Wisconsin Administrative Code › Department of Health Services › DHS 1-19 - Management and Technology and Strategic Finance › Chapter DHS 10 - Family Care › Subchapter III - Access to the Family Care Benefit › Section DHS 10.36 - Eligibility and entitlement

Current through June 24, 2024
(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:
(a) The person meets the conditions of
				  functional eligibility at the nursing home level under s.
				  DHS 10.33 (2)
				  (c).
(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:
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.
2. The person is eligible
				  for medical assistance.
(c) The person meets the criteria under s.
				  DHS 10.33
				  (3).
Wisconsin Administrative Code › Department of Health Services › DHS 1-19 - Management and Technology and Strategic Finance › Chapter DHS 10 - Family Care › Subchapter III - Access to the Family Care Benefit › Section DHS 10.37 - Private pay individuals

Current through June 24, 2024
(1) DEFINITIONS. In this section:
(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.
(b) "Private pay individual" means any of the
				  following:
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.
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).
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).
Wisconsin Administrative Code › Department of Health Services › DHS 1-19 - Management and Technology and Strategic Finance › Chapter DHS 10 - Family Care › Subchapter IV - Family Care Benefit; Delivery Through Care Management Organizations (CMOs) › Section DHS 10.41 - Family care services

Current through June 24, 2024
(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.
(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.
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.
(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.
Wisconsin Administrative Code › Department of Health Services › DHS 1-19 - Management and Technology and Strategic Finance › Chapter DHS 10 - Family Care › Subchapter IV - Family Care Benefit; Delivery Through Care Management Organizations (CMOs) › Section DHS 10.42 - Certification and contracting

Current through June 24, 2024
(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.
(2)
(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.
(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:
1. Operations and
				  administration, including all of the following:
a. Administrative staffing and
				  resources.
b. Delegation and
				  oversight of entity responsibilities.
c. Enrollee and provider
				  communications.
d. Grievance and
				  appeals.
e. Member services and
				  outreach.
f. Provider network
				  management.
g. Program integrity
				  compliance.
2. Service
				  delivery, including all of the following:
a.
				  Case management/care coordination/service planning.
b. Quality improvement.
c. Utilization review.
3. Financial management, including all of the
				  following:
a. Financial reporting and
				  monitoring.
b. Financial
				  solvency.
4. Systems
				  management, including all of the following:
a.
				  Claims management.
b. Encounter
				  data and enrollment information management.
(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.
Wisconsin Administrative Code › Department of Health Services › DHS 1-19 - Management and Technology and Strategic Finance › Chapter DHS 10 - Family Care › Subchapter IV - Family Care Benefit; Delivery Through Care Management Organizations (CMOs) › Section DHS 10.43 - CMO certification standards

Current through June 24, 2024
If an organization applies for a contract to operate a
					 CMO, the department shall determine whether the organization meets the
					 requirements of s. 46.284 (2) and
					 (3), Stats., and all of the following
					 standards:
(1) CASE MANAGEMENT
				  CAPABILITY. Each organization applying to operate a CMO shall demonstrate to
				  the department that it has expertise in determining and arranging for services
				  and supports to meet the needs of its target population. Demonstration of this
				  expertise includes evidence that the organization, a subcontractor, or both,
				  has all of the following:
(a) A sufficient
				  number of qualified and competent staff to meet case management standards under
				  s.
				  DHS
				  10.44.
(b)
				  Thorough knowledge of local long-term care and other community
				  resources.
(c) Thorough knowledge
				  of methods for maximizing informal caregivers and community resources and
				  integrating them into individual service plans.
(d) Strong linkages with systems and services
				  that are not directly within the scope of the CMO's responsibility but that are
				  important to the organization's target population, including primary and acute
				  health care services, and the capacity to arrange for those services to be made
				  available to its enrollees.
(e)
				  Mechanisms to coordinate services internally and with services available from
				  community organizations and other social programs.
(f) Thorough knowledge of employment
				  opportunities and barriers for the organization's target population.
(g) Thorough knowledge of methods for
				  promoting and supporting the use of mechanisms under which individuals direct
				  and manage their own service funding.
Wisconsin Administrative Code › Department of Health Services › DHS 1-19 - Management and Technology and Strategic Finance › Chapter DHS 10 - Family Care › Subchapter IV - Family Care Benefit; Delivery Through Care Management Organizations (CMOs) › Section DHS 10.45 - Operational requirements for CMOs

Current through June 24, 2024
(1) 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 CMO. At
				  least one-fourth of the members of the governing board shall be older persons
				  or persons with physical or developmental disabilities or their family members,
				  guardians or other advocates who are representative of the CMO's
				  enrollees.
(2) OPEN ENROLLMENT.
(a) Except as provided in s.
				  DHS
				  10.36(2), a CMO shall conduct a
				  continuous open enrollment period, accepting enrollment of any member of its
				  target population who is enrolled by an aging and disability resource center
				  serving the area of the CMO, without regard to life situation, health or
				  disability status or cost sharing requirements.
(b) A CMO may not disenroll any enrollee
				  except under circumstances specified in its contract with the department and
				  the express approval of the department, unless the enrollee has requested to be
				  disenrolled. When a CMO requests department approval to disenroll an enrollee,
				  the CMO shall refer the enrollee to the resource center for counseling under s.
				  DHS
				  10.23(2) (j). A CMO may not encourage
				  any enrollee to disenroll. This paragraph shall be suspended until the first
				  day of the month following the end of the emergency period defined in
				  subsection (1) (B) of section 1135 (g) of the Social Security Act,
				  42 USC
				  1320b-5(g) (1) (B), and
				  declared by the United States Secretary of Health And Human Services in
				  relation to the COVID-19 pandemic.
Note:
Par. (b) is amended by CR 21-081 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, ends, to read:
(b) A CMO may not disenroll any enrollee
				  except under circumstances specified in its contract with the department and
				  the express approval of the department, unless the enrollee has requested to be
				  disenrolled. When a CMO requests department approval to disenroll an enrollee,
				  the CMO shall refer the enrollee to the resource center for counseling under s.
				  DHS
				  10.23(2) (j). A CMO may not encourage
				  any enrollee to disenroll.
Wisconsin Administrative Code › Department of Health Services › DHS 1-19 - Management and Technology and Strategic Finance › Chapter DHS 10 - Family Care › Subchapter IV - Family Care Benefit; Delivery Through Care Management Organizations (CMOs) › Section DHS 10.46 - Department responsibilities for monitoring CMO quality and operations

Current through June 24, 2024
(1)
				  MONITORING. The department shall monitor CMO operations to assure quality of
				  services and delivery, including consumer satisfaction. The department shall
				  develop indicators to measure and assess quality in all of the following areas:
(a) Family care benefit effectiveness in
				  increasing consumer long-term care choices, including choice of services,
				  service providers, living arrangement and daily routine.
(b) Family care benefit effectiveness in
				  improving access to long-term care services to support member care and choice
				  of living arrangement.
(c) Family
				  care benefit effectiveness at meeting the expectations of members in care and
				  services received, reliability of the long-term care system and providers, fair
				  and respectful treatment and privacy.
(d) Family care benefit effectiveness in
				  assuring member health and safety, including being free from abuse and neglect,
				  being protected against misappropriation of funds, being safe in chosen living
				  arrangement, and receiving needed health services, consistent with member
				  choices and preferences.
Wisconsin Administrative Code › Department of Health Services › DHS 1-19 - Management and Technology and Strategic Finance › Chapter DHS 10 - Family Care › Subchapter V - Protection of Applicant, Eligible Person and Enrollee Rights › Section DHS 10.51 - Client rights

Current through June 24, 2024
Clients shall have the rights in family care that are
					 outlined in the applicant information materials they receive when contacting a
					 resource center and in the member handbook they receive prior to enrollment in
					 a care management organization. The department shall review and approve the
					 statement of client rights and responsibilities in each resource center's
					 applicant information materials and in each CMO's member handbook. Client
					 rights shall, at a minimum, include an explanation of client rights in the
					 following areas:
(1) RIGHTS OF
				  CLIENTS. Clients have the right to all of the following:
(a) Freedom from unlawful discrimination in
				  applying for or receiving the family care benefit.
(b) Accuracy and confidentiality of client
				  information.
(c) Prompt
				  eligibility, entitlement and cost-sharing decisions and assistance.
(d) Access to personal, program and service
				  system information.
(e) Choice to
				  enroll in a CMO, if eligible, and to disenroll at any time.
(f) Information about and access to all
				  services of resource centers and CMOs within standards established under this
				  chapter to the extent that the client is eligible for such services.
(g) Support for all clients in understanding
				  their rights and responsibilities related to family care, including due process
				  procedures, and in providing their comments about resource centers, CMOs and
				  services, including through grievances, appeals and requests for department
				  review and fair hearings. Resource centers, CMOs and county agencies under
				  contract with the department shall assist clients to identify all rights to
				  which they are entitled and, if multiple grievance, review or fair hearing
				  mechanisms are available, which mechanism will best meet client
				  needs.
(h) Support for all clients
				  in the exercise of any rights and available grievance and appeal procedures
				  beyond those specified in this chapter.
Note: Examples of other rights and procedures available to
					 clients include those afforded to persons who receive treatment or services for
					 developmental disability, mental illness or substance abuse under ch. 51,
					 Stats. and ch. DHS 94, and those afforded to persons who reside in a nursing
					 home, community-based residential facility, adult family home or residential
					 care apartment complex, or who receive services from a home health agency under
					 statutes and rules of those programs.
Wisconsin Administrative Code › Department of Health Services › DHS 1-19 - Management and Technology and Strategic Finance › Chapter DHS 10 - Family Care › Subchapter V - Protection of Applicant, Eligible Person and Enrollee Rights › Section DHS 10.52 - Required notifications

Current through June 24, 2024
(1) NOTIFICATION OF GENERAL CLIENT RIGHTS AND
				  RESPONSIBILITIES. Each resource center, county agency and CMO shall provide
				  clients with written notification of their rights and responsibilities in
				  accordance with timelines and other requirements established in its contract
				  with the department in every instance in which:
(a) The client applies for the family care
				  benefit and is initially counseled by a resource center about the family care
				  benefit or enrollment in a specific care management organization.
(b) The client enrolls in a care management
				  organization.
Wisconsin Administrative Code › Department of Health Services › DHS 1-19 - Management and Technology and Strategic Finance › Chapter DHS 10 - Family Care › Subchapter V - Protection of Applicant, Eligible Person and Enrollee Rights › Section DHS 10.53 - Grievances and appeals

Current through June 24, 2024
(1) GRIEVANCE PROCESS IN RESOURCE CENTERS.
(a) The governing board of each resource
				  center shall approve and effectively operate a process for reviewing and
				  resolving client grievances. The board may delegate, in writing, its
				  responsibility for reviewing and resolving grievances to a committee of the
				  resource center's senior management, provided the process ensures that the
				  board is made aware of grievances and requests for department review and fair
				  hearings.
(b) The department shall
				  review and approve a resource center's grievance process as part of its
				  contracting with the resource center.
(c) A resource center shall inform clients of
				  all of the following:
1. The circumstances
				  under which expedited resolution of a grievance is available and how to request
				  it.
2. The client has the right to
				  appear in person before the resource center personnel assigned to resolve a
				  grievance filed, if the enrollee files the grievance.
3. The availability of independent advocacy
				  services and other local organizations that might assist a client with a
				  grievance.
4. The client may
				  obtain, free of charge, copies of client records relevant to the grievance and
				  how to obtain the copies.
(d) A resource center shall assist
				  individuals with the filing of grievances with the resource center.
(e) A client may file a grievance with the
				  resource center at any time.
(f)
				  The resource center shall complete its review of a grievance and issue its
				  written decision to the client within 10 business days of its receipt of the
				  grievance, unless the client and the resource center agree to an extension for
				  a specified period of time.
Wisconsin Administrative Code › Department of Health Services › DHS 1-19 - Management and Technology and Strategic Finance › Chapter DHS 10 - Family Care › Subchapter V - Protection of Applicant, Eligible Person and Enrollee Rights › Section DHS 10.54 - Department reviews

Current through June 24, 2024
(1) DEPARTMENT REVIEW PROCESS FOR GRIEVANCES
				  FILED WITH A RESOURCE CENTER. The department shall review, investigate, and
				  analyze the facts surrounding client grievances in an attempt to resolve
				  concerns and problems informally, whenever either of the following occurs:
(a) A client makes a grievance directly to
				  the department.
(b) A client
				  requests department review of a decision arrived at through a county agency or
				  resource center grievance process.
Wisconsin Administrative Code › Department of Health Services › DHS 1-19 - Management and Technology and Strategic Finance › Chapter DHS 10 - Family Care › Subchapter V - Protection of Applicant, Eligible Person and Enrollee Rights › Section DHS 10.55 - Fair hearing

Current through June 24, 2024
(1) RIGHT TO FAIR HEARING IN RESOURCE CENTER
				  AND COUNTY AGENCY ADVERSE BENEFIT DETERMINATIONS. Except as limited in sub. (3)
				  and s. DHS 10.62 (4), a client may contest any of the following adverse benefit
				  determinations by filing, within 45 days of receipt of notice of the adverse
				  benefit determination, a written request for a hearing to the division of
				  hearings and appeals:
(a) Denial of
				  eligibility under s. DHS 10.31 (6) or 10.32 (4).
(b) Determination of cost sharing
				  requirements under s. DHS 10.34.
(c) Determination of entitlement under s. DHS
				  10.36.
Wisconsin Administrative Code › Department of Health Services › DHS 1-19 - Management and Technology and Strategic Finance › Chapter DHS 10 - Family Care › Subchapter V - Protection of Applicant, Eligible Person and Enrollee Rights › Section DHS 10.56 - Continuation of services

Current through June 24, 2024
(1) REQUEST FOR
				  CONTINUATION OF SERVICES PENDING OUTCOME OF CMO APPEAL. Prior to reducing,
				  suspending or terminating services under the family care benefit, a CMO shall
				  provide to the enrollee prior notification of its intent to reduce, suspend or
				  terminate the services in accordance with s. DHS 10.52 (3). If an enrollee who
				  has received a notice that services will be reduced, suspend or terminated
				  files an appeal with the CMO under s. DHS 10.53 (2) before the effective date
				  of the reduction, suspension or termination, the enrollee may request that the
				  CMO continue to provide the services pending the outcome of the
				  appeal.
(1m) REQUEST FOR
				  CONTINUATION OF SERVICES PENDING OUTCOME OF DHA FAIR HEARING. An enrollee is
				  entitled to continuation of services pending the outcome of a fair hearing if
				  all of the following apply:
(a) The CMO's
				  decision on appeal under s. DHS 10.53 (2) is to proceed with reducing,
				  suspending, or terminating the enrollee's service.
(b) The enrollee's services were continued
				  pending the outcome of the CMO appeal decision.
(c) The enrollee requests a fair hearing on
				  the CMO's appeal decision before the effective date of the CMO's appeal
				  decision.
(d) The enrollee requests
				  continuation of services before the effective date of the CMO's appeal
				  decision.
Wisconsin Administrative Code › Department of Health Services › DHS 1-19 - Management and Technology and Strategic Finance › Chapter DHS 10 - Family Care › Subchapter V - Protection of Applicant, Eligible Person and Enrollee Rights › Section DHS 10.57 - Cooperation with advocates

Current through June 24, 2024
(1) DEFINITIONS. In
				  this section:
(a) "Advocate" means an
				  individual or organization whom a client has chosen to assist him or her in
				  articulating the client's preferences, needs and decisions.
(b) "Cooperate" means:
1. To provide any information related to the
				  client's eligibility, entitlement, cost sharing, care planning, care
				  management, services or service providers to the extent that the information is
				  pertinent to matters in which the client has requested the advocate's
				  assistance.
2. To assure that a
				  client who requests assistance from an advocate is not subject to any form of
				  retribution for doing so.
Wisconsin Administrative Code › Department of Health Services › DHS 1-19 - Management and Technology and Strategic Finance › Chapter DHS 10 - Family Care › Subchapter VI - Recovery of Paid Benefits › Section DHS 10.61 - Recovery of incorrectly paid benefits

Current through June 24, 2024
County agencies, on behalf of the department, shall recover
					 benefits incorrectly paid under the family care benefit, whether paid on behalf
					 of individuals eligible for medical assistance or not, according to provisions
					 of s.
					 49.497,
					 Stats., s.
					 DHS
					 108.03(3) and policies established by
					 the department or by the department of workforce development. The amount to be
					 recovered is the amount actually paid by a CMO on behalf of a family care
					 enrollee.
Wisconsin Administrative Code › Department of Health Services › DHS 1-19 - Management and Technology and Strategic Finance › Chapter DHS 10 - Family Care › Subchapter VI - Recovery of Paid Benefits › Section DHS 10.62 - Recovery of correctly paid benefits

Current through June 24, 2024
(1) RECOVERY FROM
				  THE ESTATE OF AN ENROLLEE. The department shall file a claim against the estate
				  of an enrollee to recover all medical assistance services provided to an
				  individual 55 years or older while the individual was enrolled in family care.
				  Recoveries from the estates of all family care enrollees shall be made in
				  accordance with the provisions in ss.
				  49.496 (1), (3), (6m), and
				  (7), and
				  49.849, Stats., and s.
				  DHS 108.02 (11) and
				  (12). The amount to be recovered under this
				  section shall be equal to the amount of the total capitated payment made by the
				  department to the CMO for the enrollee.
(a)
				  The amount to be recovered under this section shall be the actual cost of
				  services received by an enrollee through the family care benefit as reported to
				  the department by the CMO in which the person was enrolled.
Note:
Paragraph (a) was inadvertently left in
					 by rule CR 23-046 and will be removed in future rulemaking.
Wisconsin Administrative Code › Department of Health Services › DHS 1-19 - Management and Technology and Strategic Finance › Chapter DHS 10 - Family Care › Subchapter VII - Assuring Timely Long-term Care Consultation › Section DHS 10.74 - Requirements for resource centers

Current through June 24, 2024
The department shall establish, through its contracts with
					 resource centers, minimum timeliness requirements for completion of resource
					 center duties related to responding to referrals from long-term care
					 facilities. Minimum timeliness requirements shall specify that the resource
					 center initiate contact with the person who was referred or the person's
					 designated representative as soon as practical following receipt of a request
					 or referral for the screen or for long-term care services. The resource
					 center's initial contact is for the purpose of informing the person about the
					 family care benefit and the availability of functional and financial
					 eligibility and cost-sharing screens and long-term care options consultation,
					 and for setting an appointment to provide further consultation and to conduct
					 the screen. The consultation provided by the resource center shall meet the
					 requirements for long-term care options counseling under s.
					 DHS 10.23 (2) (c)
					  and shall be provided in conjunction with
					 performance of the functional and financial eligibility and cost-sharing
					 screens or at another mutually agreed upon time.
Wisconsin Administrative Code › Department of Health Services › DHS 1-19 - Management and Technology and Strategic Finance › Chapter DHS 12 - Caregiver Background Checks › Subchapter I - General Provisions › Section DHS 12.01 - Authority and purpose

Current through June 24, 2024
This chapter is promulgated under the authority of s.
					 48.685(1)
					 (ag) 1 a., (2) (d), (4), (5) (a), (6) (b) and
					 (c), Stats.; and s.
					 50.065(1)
					 (ag) 1 a., (2) (d), (4), (5), (6) (b) and
					 (c), Stats.; and s.
					 227.11(2),
					 Stats., to protect from harm clients served by department-regulated programs,
					 children placed in foster homes licensed by county departments of social or
					 human services or private child-placing agencies or children who are being
					 adopted, and children served in day care programs contracted by local school
					 boards under s.
					 120.13(14),
					 Stats., by requiring uniform background information screening of persons
					 regulated and persons who are employees of or under contract to regulated
					 entities or who are nonclient residents of regulated
					 entities.
Administrative rules governing county certified day care
						centers appear in ch. DCF 202.
Wisconsin Administrative Code › Department of Health Services › DHS 1-19 - Management and Technology and Strategic Finance › Chapter DHS 12 - Caregiver Background Checks › Subchapter I - General Provisions › Section DHS 12.02 - Applicability

Current through June 24, 2024
(1) SCOPE.
(a)
Persons and agencies
				  affected.
This chapter applies to the department; to applicants for
				  regulatory approval from the department; to persons, agencies and entities that
				  have received regulatory approval from the department; to county department and
				  child-placing agencies that license foster homes and approve applications for
				  adoption home studies; to foster home license applicants and licensees and
				  applicants for an adoption home study; to school boards that establish or
				  contract for daycare programs under s.
				  120.13(14),
				  Stats., and to applicants and persons under contract to a school board to
				  operate a day care program under s.
				  120.13(14),
				  Stats.
(b)
Entities
				  covered.
The entities subject to this chapter are those regulated
				  under: chs.
				  DHS 34, 35,
				  36,
				  40,
				  61,
				  63,
				  75,
				  82,
				  83,
				  85,
				  88,
				  89,
				  105,
				  110,
				  124, 127,
				  131,
				  132,
				  133, and
				  134, and any other direct client
				  care or treatment program that may be licensed or certified or registered by
				  the department.
Wisconsin Administrative Code › Department of Health Services › DHS 1-19 - Management and Technology and Strategic Finance › Chapter DHS 12 - Caregiver Background Checks › Subchapter II - Background Checks › Section DHS 12.04 - Contracting for background checks

Current through June 24, 2024
(1) An entity may
				  enter into and shall retain an agreement or contract with any entity identified
				  under s.
				  48.685(1)
				  (b) or
				  50.065(1)
				  (c), Stats., or with any college, or
				  university, including any vocational or technical college or school, or
				  temporary employment agency or other person, to have the entity, school,
				  temporary employment agency, or other person obtain and retain required
				  background information related to caregivers, including contractors, students,
				  or temporary employees, who, as part of their curriculum, must participate in
				  clinical or practicum experiences at an entity
(2) An entity that enters into an agreement
				  or contract under sub. (1) shall obtain, at a minimum, from the other entity,
				  university, college or technical school, temporary employment agency, or other
				  person contracted with, and shall retain so that it may be promptly retrieved
				  for inspection by the agency, a letter indicating the name or names and social
				  security numbers, if available, of the caregivers, including temporary
				  employees, contractors, or students, listing any convictions learned of during
				  the course of the required background checks, along with any substantiated
				  findings of misconduct, licensure denial or restriction or any other credential
				  limitation found by either the department or the department of safety and
				  professional services.
Note:
Caregiver background check forms and
					 resources are available by accessing:
https://www.dhs.wisconsin.gov/caregiver/cbcprocess.htm
.
The only persons who may access information maintained by
						a county department regarding a substantiated report of child abuse or neglect
						against a person are those identified in s.
						48.981(7),
						Stats.