Wis. Admin. Code DHS § DHS 10.13

Current through November 25, 2024

Section DHS 10.13 - Definitions

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.

(b) Any of the following acts taken by a care management organization:

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.

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.

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

6. The development of an individualized service plan that is unacceptable to the member because any of the following apply:

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.

b. The plan does not provide sufficient care, treatment, or support to meet the enrollee's needs and identified family care outcomes.

c. The plan requires the enrollee to accept care, treatment or support items that are unnecessarily restrictive or unwanted by the enrollee.

7. Involuntary disenrollment from a CMO.

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.

9. The denial of an enrollee's request to dispute a financial liability, including copayments, premiums, deductibles, coinsurance, other cost sharing, and other member financial liabilities.

10. The denial of an enrollee, who is a resident of a rural area with only one care management organization, to obtain services outside of the care management organization's network of contracted providers.

(c) Any of the following failures on the part of a care management organization:

1. The failure to provide services and support items included in the individualized service plan in a timely manner, as defined in the department's contract with care management organizations.

2. The failure to act in a timely manner as specified in subch. V of this chapter to resolve grievances or appeals.

(1m) "Activities of daily living" or "ADLs" means bathing, dressing, eating, mobility, transferring from one surface to another such as bed to chair and using the toilet.

(2) "Adult family home" or "AFH" has the meaning specified in s. 50.01 (1), Stats.

(3) "Adult protective services" means protective services for individuals with intellectual disabilities and other developmental disabilities, for individuals with degenerative brain disorder, for individuals with chronic mental illness, and for individuals with other like incapacities incurred at any age as defined in s. 55.02, Stats.

(3m) Appeal" means a request for review of an adverse benefit determination.

(4) "Applicant" means a person who directly or through a representative makes application for the family care benefit.

(5) "Assets" means any interest in real or personal property that can be used for support and maintenance. "Assets" includes motor vehicles, cash on hand, amounts in checking and savings accounts, certificates of deposit, money market accounts, marketable securities, other financial instruments and cash value of life insurance.

(6) "Assistance" means cueing, supervision or partial or complete hands-on assistance from another person.

(7) "At risk of losing independence or functional capacity" means having the conditions or needs described in s. DHS 10.33 (2) (d).

(8) "Care management organization" or "CMO" means an entity that is certified as meeting the requirements for a care management organization under s. 46.284 (3), Stats., and this chapter and that has a contract under s. 46.284 (2), Stats., and s. DHS 10.42. "Care management organization" does not include an entity that contracts with the department to operate a PACE or Wisconsin partnership program.

(8m) "Choice counseling" means information and services designed to assist eligible applicants in making enrollment decisions.

(9) "Client" means a person applying for eligibility for the family care benefit, an eligible person or an enrollee.

(10) "Community-based residential facility" or "CBRF" has the meaning specified in s. 50.01 (1g), Stats.

(11) "Community spouse" means an individual who is legally married as recognized under state law to a family care spouse.

(13) "Countable assets" means assets that are used in calculating financial eligibility and cost sharing requirements for the family care benefit.

(14) "County agency" means a county department of aging, multicounty consortium, social services or human services, an aging and disability resource center, a family care district or a tribal agency, that has been designated by the department to determine financial eligibility and cost sharing requirements for the family care benefit.

(14m) "Day" means calendar day, unless otherwise indicated.

(14s) "Degenerative brain disorder" has the meaning given in s. 55.01 (1v), Stats.

(15) "Department" means the Wisconsin department of health services.

(16) "Developmental disability" has the meaning provided in s. 51.01 (5) (a), Stats.

(16m) "Disability benefit specialist" means a person providing services to individuals ages 18 to 59 under s. DHS 10.23 (2) (d).

(16p) "Electronic visit verification" or "EVV" means, with respect to personal care services or home health care services as defined and required in Section 12006 of the 21st Century Cures Act, 42 USC 1396b (l), a system under which in-home visits conducted as part of such services are electronically verified.

(16r) "EVV record" means the information or data related to an electronically verified visit which contains all of the following:

(a) The type of service performed.

(b) The individual receiving the service.

(c) The date of the service.

(d) The location of service delivery.

(e) The individual providing the service.

(f) The time the service begins and ends.

(17) "Eligible person" means a person who has been determined under ss. DHS 10.31 and 10.32 to meet all eligibility criteria under s. 46.286 (1), Stats., and this chapter.

(18) "Enrollee" means a person who is enrolled in a care management organization to receive the family care benefit.

(19) "Exceptional payments" means the state supplement to federal supplemental security income authorized under s. 49.77 (3s), Stats.

(20) "Fair hearing" means a de novo proceeding under ch. HA 3 before an impartial administrative law judge in which the petitioner or the petitioner's representative presents the reasons why an administrative action under s. HA 3.03 or inaction by the department, a county agency, a resource center or a CMO in the petitioner's case should be corrected.

(21) "Family care benefit" has the meaning given in s. 46.2805 (4), Stats., namely, financial assistance for long-term care and support items for an enrollee.

(22) "Family care district" means a special purpose district created under s. 46.2895 (1), Stats.

(23) "Family care spouse" means an individual who is a family care applicant or enrollee and is legally married as recognized under state law to an individual who does not reside in a medical institution or a nursing facility.

(24) "Financial eligibility and cost-sharing screening" means a uniform screening tool prescribed by the department that is used to determine financial eligibility and cost-sharing under s. 46.286 (1) (b) and (2), Stats., and ss. DHS 10.32 and 10.34.

(25) "Food stamps" means the food stamp program authorized under 7 USC 2011.

(25m) "Frail elder" means an individual aged 65 or older who has a physical disability, or an irreversible dementia, that restricts the individual's ability to perform normal daily tasks or that threatens the capacity of the individual to live independently.

(26) "Functional capacity" means the skill to perform activities in an acceptable manner.

(27) "Functional screening" means a uniform screening tool prescribed by the department that is used to determine functional eligibility under s. 46.286 (1) (a), Stats., and ss. DHS 10.32 and 10.33.

(28) "Grievance" means an expression of dissatisfaction about any matter that is not an adverse benefit determination.

(29) "Home" means a place of abode and lands used or operated in connection with the place of abode.

Note: Note: In urban situations the home usually consists of a house and lot. There will be situations where the home will consist of a house and more than one lot. As long as the lots adjoin one another, they are considered part of the home. In farm situations, the home consists of the house and building together with the total acreage property upon which they are located and which is considered a part of the farm. There will be farms where the land is on both sides of a road, in which case the land on both sides is considered part of the homestead.

(30) "Hospital" has the meaning specified in s. 50.33 (2), Stats.

(32) "Instrumental activities of daily living" or "IADLs" means management of medications and treatments, meal preparation and nutrition, money management, using the telephone, arranging and using transportation and the ability to function at a job site.

(34) "Long-term care facility" means a nursing home, adult family home, community-based residential facility or residential care apartment complex.

(35) "Medical assistance" or "MA" means the assistance program operated by the department under ss. 49.43 to 49.499, Stats., and chs. DHS 101 to 108.

(36) "Medical institution" means a facility that meets all of the following conditions:

(a) Is organized to provide medical care, including nursing and convalescent care.

(b) Has the necessary professional personnel, equipment and facilities to manage the medical, nursing and other health care needs of patients on a continuing basis in accordance with accepted professional standards.

(c) Is authorized under state law to provide medical care.

(d) Is staffed by professional personnel who are responsible for professional medical and nursing services. The professional medical and nursing services include adequate and continual medical care and supervision by a physician, registered nurse or licensed practical nurse supervision and services and nurses' aide services sufficient to meet nursing care needs and a physician's guidance on the professional aspects of operating the institution.

(36m) "Multicounty consortium" means a group of counties specified in s. 49.78 (1) (br), Stats.

(37) "Nursing home" has the meaning specified in s. 50.01 (3), Stats.

(38) "Older person" means a person who is at least 65 years of age.

(39) "PACE" means a program of all-inclusive care for the elderly authorized under 42 USC 1395 to 1395gg.

(40) "Physical disability" means a physical condition, including an anatomical loss or musculoskeletal, neurological, respiratory or cardiovascular impairment, that results from injury, disease or congenital disorder and that significantly interferes with or significantly limits at least one major life activity of a person. In the context of physical disability, "major life activity" means self-care, performance of manual tasks unrelated to gainful employment, walking, receptive and expressive language, breathing, working, participating in educational programs, mobility other than walking and capacity for independent living.

(41) "Residential care apartment complex" or "RCAC" has the meaning specified in s. 50.01 (6d), Stats.

(42) "Resource center" or "aging and disability resource center" means an entity that meets the standards for operation and is under contract with the department to provide services under s. 46.283 (3), Stats., and this chapter or, if under contract to provide a portion of the services specified under s. 46.283 (3), Stats., meets the standards for operation with respect to those services.

(43) "Respite care" means temporary placement in a long-term care facility for maintenance of care, treatment or services, as established by the person's primary care provider, in addition to room and board, for no more than 28 consecutive days at a time.

(44) "Secretary" means the secretary of the department.

(45) "Supplemental security income" means the supplemental security income program authorized under 42 USC 1381.

(46) "Target population" means any of the following groups that a resource center or a care management organization has contracted with the department to serve:

(a) Adults age 60 and older.

(b) Adults with a physical disability.

(c) Adults with a developmental disability.

(47) "Wisconsin partnership program" means a demonstration program known by this name under contract with the department to provide health and long-term care services under a federal waiver authorized under 42 USC 1315.

Wis. Admin. Code Department of Health Services DHS 10.13

Cr. Register, October, 2000, No. 538, eff. 11-1-00; CR 04-040: renum. (1) to be (1m), cr. (1), (3m), and (25m), am. (24) and (27), r. and recr. (28), r. (31) Register November 2004 No. 587, eff. 12-1-04; correction in (17) made under s. 13.93(2m) (b) 7, Stats., Register November 2004 No. 587; corrections in (15) and (35) made under s. 13.92(4) (b) 6 and 7., Stats., Register November 2008 No. 635; CR 08-109: cr. (16m) Register June 2009 No. 642, eff. 7-1-09; corrections and renum. of (33) to be (40m) made under s. 13.92(4) (b) 1, 6. and 7., Stats., Register November 2009 No. 647; correction in (41) made under s. 13.92(4) (b) 7, Stats., Register December 2013 No. 696.

Amended by, 2019 Wis. Act 1: am. (3), (16) Register May 2019 No. 761, eff. 6/1/2019

Amended by, CR 22-026: am. (1) (intro.), (b) 1., 2., r. (1) (b) 4., 5., am. (1) (b) 7., cr. (1) (b) 8. to 10., (c), am. (3m), cr. (8m), r. (12), am. (14), cr. (14m), am. (16), (20), (28), cr. (36m), r. (40m), am. (46) Register May 2023 No. 809, eff. 6-1-23; correction in (1) (c) 2., (20) made under s. 35.17, Stats., Register May 2023 No. 809, eff. 6/1/2023

Amended by, EmR2306: emerg. cr. (16g), (16r), eff. 5-1-23; CR 23-045: cr. (16g), (16r) Register January 2024 No. 817, eff. 2-1-24; renum. (16g) to (16p) under s. 13.92 (4) (b) 1, Stats., Register January 2024 No. 817, eff. 2/1/2024

Amended by, CR 23-046: am. (3), cr. (14s), am. (16) Register April 29 No. 820, eff. 5/1/2024