435400-W22-FAMCARE-01 My Choice.pdf

Revision: 12/2/2020 (previous versions obsolete)

Wisconsin Department of Health Services

Contract Centralization Legal Review

Agreement Number:

Bureau of Procurement and Contracting (BPC) Review:

This agreement uses a BPC template with Office of Legal Counsel (OLC) approved language.

This agreement uses intergovernmental cooperative purchasing.

OLC Review Required:

This agreement does not use a BPC template with Office of Legal Counsel (OLC) approved language or uses a BPC template with requested language changes.

Description:

Office of Legal Counsel (OLC) Review and Approval:

This agreement has been reviewed and approved by the Wisconsin Department of Health

Services Office of Legal Counsel.

Name: Date Signed

Title:

DocuSign Envelope ID: EB093585-CC7E-4367-AC7D-1E52DA685ACA

Reviewed and approved by Kevin Bailey and Cody Wagner in OLC.

Office of Legal Counsel

X

X

12/16/2021

435400-W22-FAMCARE-01

Cody Wagner

Revision: 7/27/2020 (previous versions obsolete)

CONTRACT FOR SERVICES

between

State of Wisconsin Department of Health Services (DHS) and

My Choice Wisconsin Health Plan Inc.

for

Family Care Program

This Contract is between the State of Wisconsin Department of Health Services (DHS), at 1 West Wilson

Street, Madison, Wisconsin 53703, and My Choice Wisconsin Health Plan Inc. at 10201 West Innovation

Drive, Suite 100, Wauwatosa, WI 53226-4822. With the exception of the terms being modified by this

Contract modification, all other terms and conditions of the existing contract, including funding, remain in full force and effect. This Modification, including any and all attachments herein and the existing contract, collectively, are the complete contract of the parties and supersede any prior contracts or representations.

DHS and the Contractor acknowledge that they have read the Modification and understand and agree to be bound by the terms and conditions of the existing contract as modified by this action. This Modification becomes null and void if the time between the earlier dated signature and the later dated signature exceeds sixty (60) days, unless waived by DHS.

Contract ID Number: 435400-W22-FAMCARE-01

Contract Amount: See per member per month capitation rates in this amendment.

Contract Term: January 1, 2022 to December 31, 2023

Optional Renewal Terms: N/A

DHS Division: Division of Medicaid Services

DHS Contract Administrator: Dana Raue

DHS Contract Manager: Kelly Van Sicklen

Contractor Contract Administrator: Maria Ledger, Chief Executive Officer

Contractor Telephone: 414-287-7610

Contractor Email: Maria.Ledger@mychoicefamilycare.org

Modification Description: The following changes are made to the contract through this amendment:

Effective January 1, 2022

Article I. Definitions

10. Tribal Aging and Disability Resource Specialist (Tribal ADRS): a position authorized under contract with the Wisconsin Department of Health Services to assure that tribal members receive culturally appropriate information on aging and disability services and benefits and receive support to access publicly funded long-term care programs.

DocuSign Envelope ID: EB093585-CC7E-4367-AC7D-1E52DA685ACA mailto:Maria.Ledger@mychoicefamilycare.org

17. Business Continuity Plan: Plan to restore program administration and member services after a disruptive event, like a declared emergency or disaster. This plan includes business impact analysis, plan development, testing, awareness, training, and processes to ensure minimal member and provider disruption.

23. Removed - Competitive Integrated Employment (CIE).

36. Disaster Recovery Plan: Plan that outlines the restoration of the MCO’s management information system after a disruptive event, like a declared emergency or disaster.

40. Electronic Visit Verification (EVV): Electronic Visit Verification is a system that uses technology to verify that authorized services are provided. Through EVV, a worker providing personal care services or applicable supportive home care services sends visit data to an EVV vendor at the beginning and end of each visit using methods such as a mobile application, a home phone (landline or fixed Voice over Internet Protocol [VoIP]), or fixed device.

78. Long Term Care Benefit Package/LTC Benefit Package: the services identified in Addendum

VI, Benefit Package Service Definitions, sections A and B.

81. Long Term Care Functional Screen or LTCFS: a uniform screening tool prescribed by DHS that is used to determine functional eligibility under Wis. Stat. §§ 46.286(1) (a) and (1m) and Wis.

Admin. Code §§ DHS 10.32 and 10.33.

85. Master Client Index or MCI: this index is a way to identify the same person between different computer systems. Client Assistance for Reemployment and Economic Support (CARES), the

LTCFS and the ForwardHealth interChange system all use MCI. The member ID used in the

ForwardHealth interChange system is also that member’s MCI.

122. Removed - Regional Long-Term Care Committee: has the meaning specified in Wis. Stat. §

46.2825.

Article II. MCO Governance and Consumer and Member Involvement

Removed - B. Regional Long Term Care Advisory Committees

Article III. Eligibility

A. Eligibility Requirements

3. Functional Eligibility

Functional eligibility for Family Care and Partnership is determined using the LTCFS (See

Section F., Long Term Care Functional Screen of this Article).

a. In order to be functionally eligible for Partnership, an otherwise eligible individual must have a nursing home level of care as determined by the LTCFS. The benefit package available to a Partnership member is identified in Addendum VI.A. and C.

b. In order to be functionally eligible for Family Care, an otherwise eligible individual must have either a nursing home level of care or a non-nursing home level of care as determined by the LTCFS.

i. The benefit package available to a Family Care member who has a nursing home level of care is identified in Addendum VI.A. and B.

ii. The benefit package available to a Family Care member who has a non-nursing home level of care is identified in Addendum VI.B.

6. Enrollment in Partnership Dual Eligible SNP

A Partnership applicant who is eligible for Medicare must enroll in the Partnership MCO’s

Dual Eligible SNP. The Partnership Dual Eligible SNP may only enroll full-benefit dually beneficiaries who are also enrolled in its Partnership program.

C. Eligibility Determination Process

1. Eligibility Determination Prior to Initial Enrollment

c. The resource center coordinates eligibility determination prior to an individual’s initial enrollment in an MCO.

i. The resource center determines functional eligibility using the LTCFS and coordinates application for Medicaid as needed.

ii. The resource center provides individuals with counseling about the range of long term care programs and MCOs available.

iii. The resource center determines the individual’s choice of program and

MCO, and then processes the enrollment in ForwardHealth interChange.

2. Functional Eligibility Re-determination

Once enrolled, the MCO is responsible to assure that all members have a current and accurate level of care as determined by the LTCFS, in accordance with Section F. of this article. This includes at minimum an annual re-determination of level of care. It may also include a post-enrollment re-determination shortly after enrollment or a re-determination necessitated by a change in the member’s condition.

3. Assisting Members to Maintain Medicaid Eligibility

The MCO is responsible for assisting members in their responsibility to maintain Medicaid eligibility. This may include:

g. Coordinate with residential provider to assist member in completing Medicaid review.

4. Providing Information that May Affect Eligibility

Reportable information includes:

a. The member’s functional eligibility as determined by the LTCFS using procedures specified by the Department;

5. Medicare Coverage Elections - Partnership

The MCO is responsible to assist members to understand any Medicare coverage choices, including Medicare Advantage plan election periods and requirement to enroll in the

MCO’s Dual Eligible SNP, in order to avoid unintended disenrollment from the

Partnership program.

D. Medicaid Deductible or Cost Share

2. Cost Share or Patient Liability

c. The MCO is responsible for collecting the members’ monthly cost share or patient liability, subject to the following Department policies and procedures:

ii. If a member fails to pay the cost share or patient liability as billed by the due date, the MCO will:

a) Contact the member to determine the reason for non-payment.

b) Remind the member that non-payment may result in loss of eligibility and disenrollment.

c) Attempt to convince the member to make payment or negotiate a payment plan.

d) Offer the member assistance with financial management services or refer the member for establishment of a representative payee or legal decision maker if needed.

e) If all efforts to assist the member to meet the financial obligation are unsuccessful, refer the situation to the income maintenance agency for ongoing eligibility determination and the ADRC or Tribal ADRS (if applicable) for options counseling.

f) For a member with a cost share, inform the member that if he or she is having a financial hardship, he or she may file an Application for Reduction of Cost Share with the Department, requesting that it be reduced or waived

(see Addendum VIII.10.). The MCO shall also offer to assist the member in completing and submitting the Application.

g) Notify residential providers that member is in jeopardy of or will lose

Medicaid eligibility at a minimum of 15 days prior to disenrolling member.

d. The MCO shall reimburse members for cost share or patient liability amounts that were collected by the MCO that need to be returned to the member. The MCO may apply the reimbursement amount towards an outstanding member cost share balance, but the MCO must issue the remainder amount to the member when the reimbursement amount is higher than the outstanding balance.

3. Monitoring Cost Share or Patient Liability

a. When DHS grants a cost share reduction due to financial hardship, DHS will provide the MCO with a copy of the member’s cost share reduction award letter.

i. Annually thereafter, if the reduction is still in effect, the MCO shall verify whether the member continues to experience a financial hardship. The IDT shall conduct this verification during the member’s annual reassessment.

a) If the member indicates that they continue to experience a financial hardship and therefore need a cost share reduction, the IDT must notify the MCO’s enrollment/eligibility staff. Enrollment/eligibility staff shall verify whether the member’s income and monthly necessary living expenses necessitate the continuation of their cost share reduction. MCO staff may request any documentation needed to verify whether an ongoing hardship exists.

b) If the member indicates that they no longer need a cost share reduction or the MCO is unable to verify that an ongoing financial hardship exists, the MCO must ensure that this change is reported to the local IM agency.

E. Room and Board

1. Determining the Member's Room and Board Obligation

The MCO determines the member's room and board obligation in the facility in which the member resides, excluding members who reside in subsidized housing. MCOs must update member room and board obligations annually on February 1st or upon member request.

The member's room and board obligation is the lesser of:

The prior calendar year's HUD FMR rental amounts, based on residential type by county, plus the prior calendar year's maximum Supplemental Nutrition Assistance

Allocation for one person;

o HUD FMR amounts: HUD FMR rents are set at the 40% percentile of surveyed rental costs reflecting modest but reasonable housing, include utilities, vary by county and apartment size, and are updated yearly:

https://www.huduser.gov/portal/datasets/fmr.html o SNAP allocation: https://www.dhs.wisconsin.gov/foodshare/fpl.htm

The member's available income for room and board.

Round HUD FMR, SNAP allocation, and member's available income down to the nearest dollar. Use the prior calendar year's efficiency rent for owner-occupied Adult Family

Homes, the one bedroom rent for corporate-operated Adult Family Homes and Community

Based Residential Facilities, and the two-bedroom rent for Residential Care Apartment

Complexes. Use the HUD FMR amount for the county where the member lives. For a member residing in a shared room, divide the HUD FMR by two and add the maximum

SNAP allocation. To calculate the amount of income the member has available for room and board, MCOs must use the following calculation:

Deduct from the member's gross monthly income:

a. Discretionary income allowance of $100 for basic living expenses;

b. Health insurance premiums, defined in MEH 28.6.4.4;

c. Spousal income allocation, defined in MEH 18.6;

d. Income used for supporting others, defined in MEH 15.7.2.1;

e. Expenses associated with establishing and maintaining a guardianship, defined in

MEH 15.7.2.3;

f. Court ordered fees and payments, defined in MEH 15.7.2.3;

g. Garnishments;

h. Deductions from unearned income, including IRS and SSA paybacks; and

i. Medical and remedial expenses, defined in MEH 15.7.3;

j. State and federal income taxes.

2. Determining the Member’s Available Income

The MCO determines the amount of available income the member has to pay for room and board, using procedures specified by the Department.

The Room and board obligation calculation is not pro-rated for partial months. The MCO may collect from the member the room and board for actual days in residence.

3. Implementing Contingencies if the Member Lacks Funds for Room and Board

If the member lacks sufficient income available to pay room and board in the facility, the

MCO either:

a. Develops an alternative plan of care to support the member’s needs and outcomes;

or

b. May contribute to the member’s payment to the facility. The MCO may use its discretion to determine an amount to contribute to the member’s room and board obligation. Any MCO contribution to a member’s room and board obligation from capitation revenue shall not be considered a countable expense in developing MCO capitation rates.

4. Collecting and Giving the Member’s Room and Board Obligation to the Residential

Facility

The MCO shall collect the member’s room and board obligation and give it to the residential facility on behalf of the member.

5. Sharing Information with Income Maintenance

The MCO shall inform the income maintenance agency of the room portion of the member’s room and board obligation. The room portion is always the member’s obligation minus the maximum SNAP allocation (which is the board portion).That information may be used by income maintenance to determine any allowable excess housing costs that may reduce the member’s cost-share.

F. Long Term Care Functional Screen

1. Functional Screen Tool and Database

The tool used for determining level of care is the Long Term Care Functional Screen

(LTCFS). Information about the LTCFS is found at:

https://www.dhs.wisconsin.gov/functionalscreen/index.htm.

2. Notification of Changes in Functional Eligibility Criteria

The Department will notify the MCOs of any changes in administrative code requirements related to functional eligibility, including, but not limited to, code changes that result in changes to the LTCFS algorithms or logic in determining functional eligibility for the programs.

4. Initial Level of Care Determinations

In all circumstances the initial level of care determination for an individual is performed by a resource center prior to enrollment in an MCO. Level of care determinations may only be completed by an individual trained and certified to administer the LTCFS.

5. Level of Care Re-Determinations

a. Post-Enrollment Re-Determination https://www.dhs.wisconsin.gov/functionalscreen/index.htm

The MCO may re-determine level of care for a new member shortly after enrollment if the interdisciplinary team believes that different or additional information has come to light as a result of the initial comprehensive assessment.

The MCO shall consult with the ADRC or Tribal ADRS (if applicable) if the MCO re-determines level of care for a newly enrolled member or when a newly enrolled member is found to be functionally ineligible or eligibility changes to a non-nursing home level of care within six (6) months of the submission of the most recent pre-enrollment screen. The MCO shall review and compare the screens, attempt to resolve the differences, and contact the Department or its designee if differences cannot be resolved.

6. Level of Care Determinations and Re-determinations for Private Pay Individuals

7. Accuracy of Information

The MCO shall not knowingly misrepresent or knowingly falsify any information on the LTCFS. The MCO shall also verify the information it obtains from or about the individual with the individual’s medical, educational, and other records as appropriate to ensure its accuracy.

8. Long Term Care Functional Screener Certification

9. Administration of the Screening Program

a. Listing of Screeners

ii. When a screener leaves the MCO and/or no longer has a need for access to the LTCFS application, the agency shall submit the deactivation request within three (3) business days of the departure or reassignment of the screener.

c. Mentoring

ii. Complete practice screens on a paper version of the LTCFS;

d. Screen Liaison

ii. The duties of the Screen Liaison are to:

h) Consult with the ADRC or Tribal ADRS (if applicable) when the MCO re-determines level of care for a newly enrolled member or a newly enrolled member is found to be functionally ineligible or eligibility changes to a non-nursing home level of care within six months of the submission of the most recent pre-enrollment screen. Review and compare the screens and attempt to resolve differences. Contact the

Department or its designee if differences cannot be resolved.

iii. Either through the screeners’ supervisor or through the Screen

Liaison, or both, provide ongoing oversight to ensure that all screeners:

a) Follow the most current version of the LTCFS Instructions and all updates issued by the Department, including technical assistance documents and frequently asked questions. These are available and maintained on the Department’s website at:

https://www.dhs.wisconsin.gov/functionalscreen/ltcfs/instruc tions.htm.

10. Screen Quality Management

b. Continuing Skills Testing

The MCO shall require all of its certified screeners to participate in continuing-skills testing required by the Department. The Department requires each screener to pass a test of continuing knowledge and skills at least once every two years, in order to maintain their certification. The MCO will:

i. Provide for the participation of all certified screeners in any continuing skills training that is required by the Department.

ii. Administer continuing skills testing required by the Department in accordance with instructions provided by the Department at the time of testing.

iii. Cooperate with the Department in planning and carrying out remedial action if the results of the continuing skills testing indicate performance of any individual screener or group of screeners is below performance standards set for the test result, including retesting if the Department believes retesting to be necessary.

Article. IV. Enrollment and Disenrollment

A. Enrollment

1. Open Enrollment

Conduct enrollment consistent with the state Adult Long-Term Care Programs: Enrollment and Disenrollment Resource Guide approved by the Department. All applicants shall be enrolled provided the individual meets eligibility requirements as defined in Article III.A., Eligibility Requirements. Practices that are discriminatory or that could reasonably be expected to have the effect of denying or discouraging enrollment are prohibited.

Removed - 4. Enrollment of Persons Wanting to Relocate from a Nursing Home When There is a

Waiting List During the Transition to Entitlement

B. Disenrollment

The MCO shall comply with the following requirements and use Department issued forms related to disenrollment.

DocuSign Envelope ID: EB093585-CC7E-4367-AC7D-1E52DA685ACA https://www.dhs.wisconsin.gov/functionalscreen/ltcfs/instructions.htm https://www.dhs.wisconsin.gov/functionalscreen/ltcfs/instructions.htm

1. Processing Disenrollments

The state Long-Term Care Programs: Enrollment and Disenrollment Resource Guide shall be the agreement between entities for the accurate processing of disenrollments. The state

Adult Long-Term Care Programs: Enrollment and Disenrollment Resource Guide shall ensure:

Types of Disenrollment

b. Involuntary Disenrollment

i. Involuntary Disenrollment – General

d) Is age 21-64 and admitted to an Institution for Mental Disease

(IMD), except admission to an IMD for Residential Substance Use

Disorder (RSUD) treatment. Partnership members admitted to an

IMD as an in lieu of service or an alternate service should not be disenrolled.

iii. Disenrollment Due to Loss of Program Eligibility – Partnership Only

b) Choose to disenroll from, or if newly eligible chooses not to enroll, in the MCO’s Dual Eligible SNP. The MCO must notify the member of the potential for disenrollment and refer the member to the ADRC for options counseling prior to requesting disenrollment from the Department for failure to enroll in the Partnership Dual

Eligible SNP.

c) MCO-Requested Disenrollment

v. MCO-Requested Disenrollment Procedure.

e) If a disenrollment request is approved:

3) The MCO will forward form F-02403 to the applicable

ADRC or Tribal ADRS (if applicable) for disenrollment counseling and the appropriate regional Income Maintenance agency. The MCO is responsible for covered services it has authorized through the date of disenrollment.

C. Monitoring, Coordination, Transition of Care, Discrimination and Dates

2. Interactions with Other Agencies Related to Eligibility and Enrollment

b. The MCO shall participate in the Department’s annual review and revision of the state Adult Long-Term Care Programs: Enrollment and Disenrollment Resource

Guide, which describes how the agencies will work together to assure accurate, efficient, and timely eligibility determination, eligibility re-determination, enrollment and disenrollment. The state Adult Long-Term Care Programs:

Enrollment and Disenrollment Resource Guide, shall describe the MCO’s responsibility to timely report known changes in members’ level of care, finances, or other circumstances that may affect eligibility, and the manner in which to report those changes.

5. Dates of Enrollment and Disenrollment

h. Loss of eligibility resulting in disenrollment shall have the effective dates as identified in i. through v. below.

iii. If a member who is at least 21 years old and less than 65 years old has been admitted to an IMD, the MCO shall report this change in circumstance to the income maintenance agency as this change may result in a loss of

Medicaid coverage of services. The MCO disenrollment date shall be the date of admission to the IMD. Members admitted to an IMD for purposes of

RSUD treatment should not be disenrolled. For Partnership members this requirement does not apply when an IMD stay is covered as an in lieu of or alternate service.

Article. V. Care Management

Member Participation

1. The MCO is required to ensure that each member has a meaningful opportunity to participate in the initial development of, and updating of, his/her member-centered plan

(MCP). The MCO is required to encourage members to take an active role in decision-making regarding the long-term care and health care services they need to live as independently as possible.

The MCO is expected to ensure that the member, the member’s legal decision maker and any other persons identified by the member will be included in the care management processes of assessment, member outcomes identification, member-centered plan development, and reassessment. This process must reflect cultural and other identity considerations of the individual and must be conducted by providing information in plain language and in a manner that is accessible to individuals with disabilities through the provision of auxiliary aids and services as needed, at no cost to the individual and for persons who are limited English proficient through the provision of language services at no cost to the member. If the member’s enrollment form indicates the member is an American

Indian/Alaskan Native, the MCO must ask the member if he/she would like to invite a representative from his/her tribe to participate in the care management process. The MCO shall provide information, education and other reasonable support as requested and needed by members, other persons identified by the member or legal decision makers in order to make informed long-term care and health care service decisions.

C. Assessment and Member-Centered Planning Process

Comprehensive Assessment

Purpose

ii. The comprehensive assessment is essential in order for IDT staff to comprehensively identify the member’s personal experience outcomes (as defined in Addendum VI), long term care outcomes, strengths, needs for support, preferences, natural supports, and ongoing clinical or functional conditions that require long-term care, a course of treatment or regular care monitoring.

Procedures

ii. As a part of the comprehensive assessment, the IDT staff shall review the

LTCFS, all available medical records of the member and any other available background information.

Documentation

xiii. An assessment of the member’s understanding of his/her rights, such as control of money, freedom of speech, freedom of religion, right to vote, right to privacy, freedom of association, right to possessions, right to employment, right to education, access to healthcare, and right to choose leisure and rest, the member’s preferences for executing advance directives and whether the member has a guardian, durable power of attorney or activated power of attorney for health care.

xiv. An assessment of vulnerability and risk factors for abuse and neglect in the member’s personal life or finances including an assessment of the member’s potential vulnerability/high risk per Article V.J.1., and an assessment of the member’s understanding of abuse, neglect and exploitation.

3. Member-Centered Planning

a. Purpose

i. Member-centered planning is a process through which the IDT identifies appropriate and adequate services and supports to be authorized, provided and/or coordinated by the MCO sufficient to assure the member’s health, safety, and well-being including being free from abuse, neglect and exploitation.

D. Timeframes

Initial Assessment and MCP Timeframes

c. Initial Assessment

ii. Explain the MCO’s program and the philosophy of managed long term care, including the member’s responsibility as a team member of the IDT;

F. Re-Enrollment Assessment and MCP Update

2. Expedited Procedures

b. IDT staff must review the most recent LTCFS.

H. Interdisciplinary Team and Member Contacts

2. Required Contacts for Members Residing in a 1-2 Bed Adult Family Home

a. For members residing in 1-2 Bed Adult Family Homes, a member of the IDT will be required to conduct an in person visit to the home, as expeditiously as the member's situation requires but no later than 30 days from the IDT receiving notice of any of the following situations:

i. A significant change in the member's long term care or health care condition;

ii. There has been significant staff turnover at the Adult Family Home;

iii. APS, police and/or crisis involvement;

iv. IMD discharge; or

v. The IDT receives notice of a concern about the care or treatment the member receives at the 1-2 bed AFH.

b. A member of the IDT will be required to conduct an in person visit to the member's home between 15-30 days after a change is made to the member's Behavior Support

Plan or Restrictive Measures plan.

J. Member Safety and Risk

1. Policies and Procedures Regarding Member Safety and Risk

g. Training and guidance for IDT staff that at every in-person contact, the IDT staff are required to check and document in the chart that each member with a

Behavioral Support Plan (BSP) and/or Restrictive Measure have an effective, up to date BSP and/or Restrictive Measure in place and that residential provider staff are trained and following the BSP and/or Restrictive Measure appropriately.

2. Abuse, Neglect, Exploitation and Mistreatment Prohibited

The MCO shall implement a policy that expressly prohibits all forms of abuse, neglect, exploitation and mistreatment of members by MCO employees and contracted providers.

This policy shall include instruction in recognizing abuse, neglect and exploitation, mandated reporting responsibilities, and the proper reporting procedures when abuse or neglect is suspected.

Service Authorization

9. Timeframe for Decisions

The IDT staff shall make decisions on direct requests for services and provide notice as expeditiously as the member’s health condition requires.

a. Standard Service Authorization Decisions

i. Standard service authorization decisions shall be made no later than fourteen (14) calendar days following receipt of the request for the service unless the MCO extends the timeframe for up to fourteen (14) additional calendar days. If the timeframe is extended, the MCO must send the following written notification of extension to the member no later than the fourteenth day after the original request.

Extension notice for Family Care and Partnership Medicaid-only:

https://www.dhs.wisconsin.gov/forms/f0/f00232b.docx

Expedited Grievance Rights letter for Partnership Dual Eligible SNP:

https://www.dhs.wisconsin.gov/familycare/mcos/noa.htm

b. Expedited Service Authorization Decisions

For cases in which a member or provider indicates, or the MCO determines, that following the standard timeframe could seriously jeopardize the member’s life or health or ability to attain, maintain, or regain maximum function, the MCO shall make an expedited service authorization no later than seventy two (72) hours after receipt of the request for service.

The MCO may extend the timeframes of expedited service authorization decisions by up to eleven fourteen (114) additional calendar days if the member or a provider requests the extension or if needed by the MCO to gather more information. For any extension not requested by the member, the MCO must give the member written notice of the reason for delay.

M. MCO Responsibilities When a Member Changes County of Residence

2. MCO Responsibilities

b. For Moves to Another Geographic Service Region Served by the MCO:

DocuSign Envelope ID: EB093585-CC7E-4367-AC7D-1E52DA685ACA

iii. Inform the member that options counseling is available from the ADRC or

Tribal ADRS (if applicable) in the county to which the member is moving should the member wish to consider a change in MCO (if another MCO operates in the geographic service region) or in long term care program.

c. For Moves to Another Geographic Service Region Not Served by the MCO:

ii. Explain to the member that to assure uninterrupted services, and in the case of a member in the special home and community-based waiver eligibility group (Group B or B+) uninterrupted Medicaid eligibility, it is necessary to contact the ADRC or Tribal ADRS (if applicable) in the new county of residence to enroll in another MCO or another long term care program, preferably with the same effective date as the disenrollment from the current MCO. The MCO should facilitate this contact and coordinate disenrollment/enrollment dates with the receiving ADRC or Tribal ADRS

(if applicable).

Article. VII. Services

B. Provision of Services in the Family Care Benefit Package

1. Services for Members at the Nursing Home Level of Care

The MCO shall promptly provide or arrange for the provision of all health and long term care services in the benefit package, consistent with the member-centered plan

(MCP) described in Article V.C., Assessment and Member-Centered Planning

Process.

2. Services for Members at the Non-Nursing Home Level of Care – Family Care

The following policies apply to Family Care members who are at the non-nursing home level of care:

b. If a member at the non-nursing home level of care is admitted to a nursing facility or ICF-IID, the LTCFS must be updated by a certified screener within ten (10) business days of admission to determine whether changes in the member’s long-term health and care needs are consistent with the nursing home level of care. If the re-screening result continues to indicate a non-nursing home level of care, before notifying the member and nursing facility that nursing home services are not coverable for the member, the

MCO shall:

c. If a member at the non-nursing home level of care enrolls when residing in a nursing facility or ICF-IID, LTCFS must be updated by a certified screener within three (3) business days of enrollment to determine the appropriate level of care. If the re-screening result continues to indicate a non-nursing home level of care, before notifying the member and nursing facility that nursing home services are not coverable for the member, the

MCO shall follow the steps and requirements under b. i.-iii above

If the member remains at the non-nursing home level of care and the most recent MDS assessment indicates that the member’s nursing home services are not Medicaid reimbursable, the MCO shall notify the member and nursing facility that this service is not in the member’s benefit package and the member must be referred to the ADRC or Tribal ADRS (if applicable).

If the MCO will terminate the nursing home service, it must provide appropriate notice in accordance with Article XI.D., Notice of Adverse

Benefit Determination.

L. Prevention and Wellness

2. Prevention and Wellness Program

j. Respectfulness to Population

Long-term care and health care related educational materials produced by the MCO shall be appropriate for its target population(s) and reflect sensitivity to the diverse cultures and identities served.

Article. VIII. Provider Network

D. Provider Agreement Language

5. Term and Termination

b. Residential rates

When a rate has been in effect for at least twelve (12) months, and a change is proposed for an individual member or facility:

d) A State directed rate increase shall not be considered a rate change for purposes of this twelve (12) month period.

20. Member Records

The provider agrees to the requirements for the confidentiality protection, maintenance and transfer of member records described in Article XIII.A.

The provider agrees to make records available to members and individuals the member has authorized in writing to receive records within ten (10) business days of the record request if the records are maintained on site and sixty (60) calendar days if maintained off site in accordance with the standards in 45 C.F.R. Wis. Stats. § 164.524 (b)(2).

The provider agrees to forward records to the MCO pursuant to grievances and appeals within fifteen (15) business days of the MCO’s request or, immediately, if the appeal is expedited. If the provider does not meet the fifteen (15) business day requirement, the provider must explain why and indicate when the records will be provided.

G. Provider Certification and Standards

1. Wisconsin Provider Standards

a. For waiver services in Addendum VII.A.:

iv. Licensed or certified residential provider* or an operating non-residential setting in which adult day care, prevocational, adult day habilitation, or group supported employment services are provided, if the setting has been determined by the certification agency or the Department to be in compliance with the home and community based setting requirements under

42 C.F.R. § 441.301(c)(4) or is a non-residential setting pending determination of compliance by the Department. An exception to this requirement is a setting that was operating prior to March 17, 2014 that is subject to heightened scrutiny and is awaiting a determination of compliance from CMS; or

c. Meet the MCO’s provider standards that have been approved by the Department.

H. Equity + Inclusion

1. Equity + Inclusion and Values

The MCO shall encourage and foster Equity + Inclusion among MCO staff and providers.

The MCO shall incorporate in its policies, administration, provider contract, and service practice the values of honoring members’ beliefs, being respectful to member and staff culture, heritage, and other identity facets including members with limited English proficiency, diverse cultural and ethnicity, disabilities, sexual orientation, gender identity, and fostering in staff/providers attitudes and interpersonal communication styles which respect members’ cultural backgrounds and other identity facets.

The MCO shall have specific policy statements on these topics and communicate them to subcontractors and providers.

2. Cultural + Identity Preference and Choice

The MCO shall permit members to choose providers from among the MCO’s network of providers based on cultural and identity preference, including the choice of Indian members to choose to receive services from any Indian health care provider in the network as long as that provider has capacity to provide the services.

3. Appeals and Grievances

The MCO shall accept appeals and grievances from members related to a lack of access to culturally and identity responsive care. Culturally and identity responsive care is care delivered with sensitivity, understanding, and respect for the member’s culture and other identity facets.

J. Change in Providers

Required Notifications

Notice to Department

The MCO is required to notify the Department at

DHSDMSLTC@dhs.wisconsin.gov within seven (7) calendar days when:

L. Payment

7. Medicaid Rates

b. Payment Rates for Nursing Home Services

In determining the payment rate for nursing home services, the MCO must employ the Medicaid fee-for-service nursing home rate methodology in effect for the dates of service, including any retroactive adjustments. MCOs must apply nursing home retroactive rate adjustments within 90 days of DHS posting an updated rate for the nursing home, utilizing provider submitted member acuity information. DHS will periodically provide MCOs with member-specific acuity rosters, which MCOs have the option to use to further reconcile provider-submitted acuity levels. There is no timeframe for this optional reconciliation.

11. 2021 State Directed Rate Increase

a. For purposes of this section, “home and community-based services provider” means providers of adult day care services, daily living skills training, habilitation services, residential care (adult family homes of 1-2 beds, adult family homes of 3-

4 beds, community-based residential facilities, residential care apartment complexes), individual and group supported employment, prevocational employment, vocational futures planning, respite care services provided outside of a nursing home, and supportive home care. Providers of self-directed services are not eligible for this increase for self-directed services. Nursing homes, personal care agencies, and MCOs are not home and community-based services providers under this section.

b. MCOs are required to provide a unit rate increase to all eligible providers equal to

4.24% of each eligible provider’s rates for Family Care and Family Care

Partnership covered services in effect on June 1, 2021. The 4.24% unit rate increase on covered services equates to a unit rate increase of 3.51% when calculated on covered and non-covered services for residential providers. MCOs will need to identify this unit rate increase in their contracts with providers as a separate line item from other components of the MCO’s contracted rate with the provider. This mailto:dhsbmc@dhs.wisconsin.gov line item will be labeled “2021 State Directed Rate Increase” and contracts with the provider should include a line item for this same per unit amount. MCOs may not modify the amount of the 2021 State Directed Rate Increase line item.

12. 2022 American Rescue Plan Act Rate Increase

The 2022 American Rescue Plan Act (ARPA) Rate Increase is subject to Wisconsin

Legislature Joint Finance Committee approval.

For purposes of this section, “ARPA eligible service provider” are providers of:

adult day care services, alcohol and other drug abuse (AODA) services, AODA Day Treatment, Assistive technology and communication aids consultative clinical and therapeutic services for caregivers, consumer directed supports (self-directed supports) broker, consumer education and training, counseling and therapeutic, financial management services, habilitation services (daily living skills training and day habilitation resources), home delivered meals, home health services, housing counseling, mental health day treatment, mental health services, nursing provided in the home, occupational therapy provided in the home, personal care, physical therapy provided in the home, prevocational services, residential care, respiratory care, respite, self-directed personal care, skilled nursing services (RN/LPN) , speech and language pathology services provided in the home, supported employment - individual employment support, supported employment - small group employment support, supportive home care (SHC), training services for unpaid caregivers, transportation as defined in Wis. Admin. Code DHS § 107.23, excluding ambulance, transportation (specialized transportation) - community transportation, transportation (specialized transportation) - other transportation, and vocational futures planning and support (VFPS).

Providers of services not listed, including but not limited to retail providers, nursing homes, community support program, common carrier transportation, and

MCOs are not ARPA eligible service providers under this section.

MCOs are required to provide a unit rate increase to all eligible providers equal to

5% of each eligible provider’s rates for Family Care and Family Care Partnership covered services effective January 1, 2022. The 5% unit rate increase on covered services equates to a unit rate increase of 4.13% when calculated on covered and non-covered services for residential providers. MCOs will need to identify this unit rate increase in their contracts with providers as a separate line item from other components of the MCO’s contracted rate with the provider. This line item will be labeled “2022 American Rescue Plan Act Rate Increase” and contracts with the provider must include a line item for this same per unit amount. MCOs may not modify the amount of the American Rescue Plan Act Rate Increase line item.

MCOS are required to complete issuing payments for this increase by April 1, 2022. MCOs are required to have all provider contracts related to this increase updated by July 1, 2022.

The MCO shall provide to the Department the following items by deadlines established by the Department:

Financial reporting documenting:

The number of provider rate increases implemented as of the time period covered in the financial reporting, The number of provider rate increases still to be implemented as of the time period covered by the financial reporting, An Estimate of the funding paid out to providers as the 2022

American Rescue Plan Act Rate Increase, and

An estimate of the increased funding received from the Department through capitation payments for this 2022 American Rescue Plan

Act Rate Increase.

Amounts must document actual amount paid and not accrued.

A signed attestation that all of the funding paid to the MCO by the

Department for this purpose was paid to ARPA eligible service providers in accordance with VIII.12. of this contract.

The MCO shall send all required documents and reports to the Department to

DHSLTCFiscalOversight@dhs.wisconsin.gov with “Attention: 2022 American

Rescue Plan Act Rate Increase MCO Submission” in the subject line.

N. Standards for MCO Staff

6.. Certification and Contracting with 1-2 Bed AHFs

a. MCO must adhere to the Wisconsin Medicaid Standards for Certified 1-2

Bed Adult Family Homes:

https://www.dhs.wisconsin.gov/publications/p0/p00638.pdf

b. Placing MCOs are required to notify a 1-2 bed certifying agency of all new placements in a 1-2 bed AFH.

c. Placing MCOs are required to notify the certifying agency of any incidents, identified in Article V.H.2.i., that occur in a 1-2 bed AFH within 24 hours.

d. Certifying MCOs are required to inform all placing agencies (agencies can be MCOs, IRIS or Counties) of any incidents that may jeopardize the health and safety of residents residing in a 1-2 bed AFH they certify within 24 hours.

e. Certifying MCOs are required to investigate and follow up when incidents, identified in Article V.H.2.i., take place in the homes they certify.

f. Certifying and placing MCOs are responsible for assuring that 1-2 bed

AFHs are notifying both the placing agencies and certifying agency of all incidents, identified in Article V.H.2.i.

g. Certifying MCOs are responsible for tracking all incidents, identified in

Article V.H.2.i., and the incident outcomes that take place in the homes they certify.

h. Certifying MCOs are required to submit their training plans and policies to

DHS on how the MCO ensures their staff have the knowledge and capability to certify and contract with 1-2 bed AHFs.

i. Certifying MCOs must inform contracting agencies immediately if the certification will be revoked or the certifying MCO plans to let the certification lapse without renewal.

Article. IX. Marketing and Member Materials

K. Marketing/Outreach Plans and Materials

4. MCO Agreement to Abide by Marketing/Outreach and Distribution Criteria

b. Any marketing/outreach activities must occur in its entire service area in a county.

All marketing/outreach materials must be distributed to potentially eligible members in an entire service area, as defined in MCO’s marketing/outreach plan, and must be equitably available to all consumers eligible for enrollment in the

MCO’s service area.

B. Member Materials – General Requirements

Member materials are defined in Article I, Definitions.

1. Member materials shall be accurate, readily accessible, appropriate for, and easily understood by the MCO target population and in accordance with accessibility of language requirements in this article Section E, Accessible Formats and Languages and Cultural

Responsiveness.

12. The MCO must provide all enrollment notices, informational materials, and instructional materials related to the enrollee and potential enrollees in a manner and format that may be easily understood and is readily accessible.

All materials produced and/or used by the MCO must be understandable and readable for the average consumer and reflect respect to the diverse and other identity facets served.

The MCO must make all reasonable efforts to locate and use culturally and identity responsive material. Materials shall take into account individuals who are visually limited or who’s primary language is other than English.

C. Member Handbook

1. The MCO must develop and maintain an up-to-date member handbook:

a. Text must be easy to read, understand, and use and in a font no smaller than 12 point.

d. The handbook must include a tagline in a conspicuously visible font and information on how to request auxiliary aids and services, including the provision of the materials in alternative formats.

5. The Member Handbook, at a minimum, will include information about:

h. The right to receive services from culturally and identity respectful providers, and information about specific capacities of providers, such as languages spoken by staff and diversity of staff;

v. The appeal and grievance process, including:

v. The toll-free numbers that the member can use to register a grievance or an appeal orally;

D. Provider Network Directory and Information

5. The provider directory shall include providers that are under contract with the MCO, including physicians, hospitals, pharmacies, behavioral health providers, and long-term care providers. The directory will include the following information for providers under contract with the MCO:

g. The provider’s cultural, identity, and linguistic capabilities, including languages

(including American Sign Language) offered by the provider or skilled medical interpreter at the provider’s office, and whether the provider has completed training in an Equity + Inclusions framework such as Cultural Competence, Cultural

Humility, or other; and

E. Accessible Formats and Languages and Cultural + Identity Respectfulness

3. Cultural + Identity Respect

Materials for marketing/outreach and for health-promotion or wellness information produced by the MCO must be appropriate for its target population and reflect respect to the diverse cultures and identities served.

If the MCO uses material produced by other entities, the MCO must review these materials for appropriateness to its target population and for respectfulness to the diverse cultures and identities served.

Article. X. Member Rights and Responsibilities

I. Provision of Interpreters

The MCO shall provide interpreter services for members, as necessary, to ensure availability of effective communication regarding treatment, medical history, health education and information provided to members. The MCO must offer an interpreter, such as a primary non-English language or a sign language interpreter or a translator, in all crucial situations requiring language assistance as soon as it is determined that the member is of limited English proficiency or needs other interpreter services. (For related information, refer to Article IX.E., Accessible Formats and

Languages and Cultural + Identity Respectfulness. The MCO shall meet the following requirements in the provision of interpreter services.

Article. XI. Grievances and Appeals

B. Definitions

Adverse benefit determination

a. An “adverse benefit determination” is any of the following:

i. The denial of functional eligibility under Wis. Stat. § 46.286(1)(a) as a result of the MCO’s administration of the LTCFS, including a change from nursing home level of care to non-nursing home level of care.

iv. The denial, in whole or in part, of payment for a service that falls within the benefit package specified in Addendum VII.