Section 46.286. Family care benefit.

 

(1)   Eligibility. 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) Functional eligibility. 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:

1m. 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.

2m. 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.

(b) Financial eligibility.

1c. In this paragraph, “medical assistance" does not include coverage of the benefits under s. 49.471 (11) .

2m. A person is financially eligible if any of the following apply:

a. 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.

b. 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.

(2)   Cost sharing.

(a) 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.

(b) Funds received under par. (a) shall be used by a care management organization to pay for services under the family care benefit.

(c) 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.

(3)   Entitlement.

(a) 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:

1m. The person is at least 18 years of age.

2m. The person has a physical disability, as defined in s. 15.197 (4) (a) 2. , a developmental disability, as defined in s. 51.01 (5) (a) , or is a frail elder.

3m. The person is functionally eligible under sub. (1) (a) .

4m. The person is financially eligible under sub. (1) (b) 2m. a. , and fulfills any applicable cost-sharing requirements.

(b) An entitled individual who is enrolled in a care management organization may not be involuntarily disenrolled except as follows:

1. For cause, subject to the requirements of s. 46.284 (4) (a) .

2. 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:

a. The long-term support community options program under s. 46.27 .

b. Home and community-based waiver programs under 42 USC 1396n (c), including a community integration program under s. 46.275 , 46.277 , or 46.278 and the Community Opportunities and Recovery Program under s. 46.2785 .

c. The Alzheimer's family caregiver support program under s. 46.87 .

d. Community aids under s. 46.40 , if documented by the county under a method prescribed by the department.

e. County funding, if documented by the county under a method prescribed by the department.

3. The department or its designee determines that the person no longer meets eligibility criteria under sub. (1) .

(c) Within each county and for each client group, par. (a) shall first apply on the effective date of a contract under which a care management organization accepts a per person per month payment to provide services under the family care benefit to eligible persons in that client group in the county. Within 36 months after this date, the department shall assure that sufficient capacity exists within one or more care management organizations to provide the family care benefit to all entitled persons in that client group in the county.

(3m)   Information about enrollees. The department shall obtain and share information about family care enrollees as provided in s. 49.475 .

(4)   Divestment; rules. The department shall promulgate rules relating to prohibitions on divestment of assets of persons who receive the family care benefit, that are substantially similar to applicable provisions under s. 49.453 .

(5)   Treatment of trust amounts; rules. The department shall promulgate rules relating to treatment of trust amounts of persons who receive the family care benefit, that are substantially similar to applicable provisions under s. 49.454 .

(6)   Protection of income and resources of couple for maintenance of community spouse; rules. The department shall promulgate rules relating to protection of income and resources of couples for the maintenance of the spouse in the community with regard to persons who receive the family care benefit, that are substantially similar to applicable provisions under s. 49.455 .

(7)   Recovery of family care benefit payments. The department shall apply to the recovery from persons who receive the family care benefit, including by liens and affidavits and from estates, of correctly paid family care benefits, the applicable provisions under ss. 49.496 and 49.849 .

1999 a. 9 , 185 ; 2001 a. 16 , 109 ; 2003 a. 33 ; 2005 a. 25 , 264 , 388 ; 2007 a. 20 ; 2009 a. 28 ; 2013 a. 20 , 92 . Cross-reference: See also ch. DHS 10 , Wis. adm. code.