Wis. Admin. Code Department of Health Services 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:
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.
Notes
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