435400-W25-FAMPARTNER-02.docx.pdf

PARTNERSHIP CONTRACT

between

WISCONSIN DEPARTMENT OF HEALTH SERVICES (DHS)

DIVISION OF MEDICAID SERVICES (DMS)

and

INDEPENDENT CARE HEALTH PLAN

DHS Contract ID Number: 435400-W25-FAMPARTNER-02

Contract Term: From January 1, 2025 to December 31, 2025

Docusign Envelope ID: CA377D81-5D19-4F52-B5A4-74F582D4FBB9

This page intentionally left blank.

Contract for Partnership Program between the Wisconsin Department of Health Services, Division of Medicaid Services and Independent Care Health Plan

Page i

Table of Contents

Preamble

I. Definitions

II. MCO Governance and Consumer and Member Involvement MCO Governing Board MCO Member Advisory Committee Tribal Liaison

III. Eligibility Eligibility Requirements

MCO Specific Eligibility Criteria Eligibility Determination Process

Medicaid Deductibles or Cost Share Room and Board Long Term Care Functional Screen

IV. Enrollment and Disenrollment Enrollment

Disenrollment Monitoring, Coordination, Transition of Care, Discrimination and Dates

V. Care Management Member Participation Interdisciplinary Team Composition

Assessment and Member-Centered Planning Process Timeframes

Providing, Arranging, Coordinating and Monitoring Services Re-Enrollment Assessment and MCP Update Reassessment and MCP Update

Interdisciplinary Team and Member Contacts Member Record Member Safety and Risk

Service Authorization

Services During Periods of Temporary Absence MCO Responsibilities When a Member Changes County of Residence Requirement to Notify Counties and Tribal Human/Human and Family Services of At-Risk Members:

Department Review

VI. Self-Directed Supports Option to Self-Direct

MCO Requirements

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IDT Staff Responsibilities

VII. Services General Provisions Provision of Services in the Family Care Benefit Package Provision of Services in the Partnership Benefit Package

Prohibited Services Primary Care and Coordination of Health Care Services Second Opinion Determining if Services, Procedures, Items and Treatments are Proven and

Effective

Changes to Medicaid Covered Services Mandated by Federal or State Law 24-Hour Coverage

Billing Members

Department Policy for Member Use of Personal Resources Prevention and Wellness Court-Ordered Services

Elder Adults/Adults at Risk Agencies and Adult Protective Services Facility Closures

MOU on Institute for Mental Disease (IMD) Discharge Planning Private Pay Care Management Provider Moral or Religious Objection

Electronic Visit Verification (EVV)

VIII. Provider Network

Member Choice Member Communications

Provider Agreements Provider Agreement Language Prohibited Provider Agreement Language

Network Providers Provider Certification and Standards

Equity and Inclusion Access to Providers Change in Providers

Health Information System

Payment Appeals to the MCO and Department for Payment/Denial of Providers Claims Standards for MCO Staff

Network, Coverage and Payment Provisions Applicable to Indian Health Care

Providers and Indian Members Non-risk Provisions for Members Receiving Care Management from an Indian

Health Care Provider (IHCP) Physician Incentive Plans for Partnership Business Separation

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IX. Marketing and Member Materials Marketing/Outreach Plans and Materials Member Materials – General Requirements Member Handbook Provider Network Directory and Information

Accessible Formats, Languages, and Cultural Respect Reproduction and Distribution of Materials MCO Identification (ID) Cards Dual Eligible Special Needs Plan Coordination and Integration

X. Member Rights and Responsibilities

Protection of Member Rights Member Rights

Member Responsibilities

Member Rights and Responsibilities Education Member Rights Specialist and MCO Advocacy Services Legal Decision Makers

Informal Resolution Advance Directives

Provision of Interpreters

XI. Grievances and Appeals Purpose and Philosophy

Definitions Overall Policies and Procedures for Grievances and Appeals

Notice of Adverse Benefit Determination Notification of Appeal Rights in Other Situations

MCO Grievance and Appeal Process The Department Review Process The State Fair Hearing Process

Documentation and Reporting

XII. Quality Management (QM) Leadership and Organization of the QM Program QM Annual Workplan and Evaluation Activities of the QM Program

Cooperation with the Department QM Program

XIII. MCO Administration Member Records Civil Rights Compliance/Affirmative Action Plan Requirements

Subcontracting and Entering Provider Agreements Management of Subcontractors and Providers Memorandum of Understanding (MOU) Claims Administration

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Required Disclosures Ineligible Organizations and Individuals

Compliance with Applicable Law and Cooperation with Investigations Access to Premises and Information Program Integrity Plan, Program and Coordination

Business Continuity Resource Center Conflict of Interest Policies and Procedures Commercial Leases MCO's Insurance Responsibility Supplier Diversity And Reporting Requirements

Interoperability and Access to Health Information – Patient Access Application

Programming Interface (API, Provider Directory API, and Payer-to-Payer Data

Exchange) Business Separation MCO Staffing Location Requirement

XIV. Reports and Data

General Reporting and Data Requirements Encounter Data Reporting

Reports: Regular Interval Reports: As Needed Disclosure of Financial Information

Records Retention

MCO Data Integrity and Systems Assessments

Required Use of the Secure ForwardHealth Portal and Secure File Transfer

Protocol

Access to CARES Data Access to the Department’s Data Warehouse

XV. Functions and Duties of the Department

Division of Medicaid Services Reports from the MCOs

Enrollment and Disenrollment Reporting ForwardHealth ID Cards Capitation Payment Reporting

Utilization Review and Control

Right to Review Review of Study or Audit Results

Provider Certification

Technical Assistance Conflict of Interest

XVI. Contractual Relationship Contract Precedence When Conflict Occurs

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Cooperation of Parties and Dispute Resolution MCO Certification Sanctions for Violation, Breach, or Non-Performance Modification and Termination of the Contract Delegations of Authority

Indemnification Independent Capacity of the MCO Omissions Choice of Law Waiver

Severability

Force Majeure

Headings Assignability Right to Publish Survival

XVII. Fiscal Components/Provisions Financial Management

Financial Reporting Financial Certification Process Financial Examinations

Financial Audit

Other Regulatory Reviews and Identified Irregularities

Reporting on Savings Initiatives Medical Loss Ratio (MLR)

XVIII. Payment to the Managed Care Organization Purpose Medicaid Capitation Rates

Actuarial Basis Annual Determination of Capitation Rates

Pay for Performance Retention of Risk Payment Schedule

Payment Method

Coordination of Benefits (COB) Suspension of Payment Based on Credible Allegation of Fraud Recoupments

IMD Stays Within a Capitation Month For Members Age 21-64 Unauthorized Programs or Activities Risk Corridor – Family Care and Partnership Programs

XIX. MCO Specific Contract Terms Program

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Geographic Coverage Where Enrollment Is Accepted Contracting Contingencies:

Maximum Enrollment Level Age Group Target Group

Capitation Rate Signatures

I. Actuarial Basis Actuarial Soundness of Capitation Rates Retrospective Adjustments

II. Requirements for Memoranda of Understanding

III. MCO Quality Indicators Quality Indicators

Other Quality Indicators –Partnership Program

IV. Data Certification Encounter Data Certification for Files Submitted to IES

Financial Certification

V. Personal Experience Outcomes in Long-Term Care

VI. Benefit Package Service Definitions Home and Community-Based Waiver Services

Medicaid State Plan Services – Family Care Benefit Package Medicaid State Plan Services – Partnership Benefit Packages

VII. Data Use Agreement

ACCESS TO DATA:

USE OF DATA:

Notification, Review, and Approval Before Publication of Presentation:

Term of Data Disclosure Agreement:

Signed Agreement Required Before Data is Disclosed:

VIII. Materials Cited in This Contract & Other Related Communications

Preamble Page 1

PREAMBLE

The Wisconsin Department of Health Services (the Department) contracts with the Managed

Care Organization (MCO) to deliver the Family Care Program or the Family Care Partnership

Program (Partnership) as defined in this contract. These programs provide supports and services in the individual benefit package through a managed care service delivery model to enrollees in need of long-term care.

It is the intent of the Department that the Family Care and Partnership programs be truly integrated models for the delivery of all aspects of the members’ Medicaid services and that all of these programs employ the Family Care philosophy and basic methods. These programs differ primarily in the scope of services.

Family Care is a capitated Medicaid managed care program for the delivery of all

Medicaid long-term care services. Members enrolled in Family Care may be eligible at a

Wisconsin Medicaid nursing home-certifiable level of care or at a non-nursing home level of care. One of these functional levels of care is required as a condition of eligibility.

Partnership is a capitated integrated Medicaid managed care program that provides both managed Medicaid long-term care and health care benefits. Members enrolled in

Partnership must have a Wisconsin Medicaid nursing home-certifiable level of care.

This contract, the MCO’s Member Handbook, and Evidence of Coverage (EOC) define the philosophy and basic methods for the programs above. It is the Department’s expectation under this contract that benefits will be fully integrated and will afford options that foster opportunities for interaction and integration into the greater community, including opportunities to seek employment and work in competitive integrated settings, engage in community life, control personal resources, and receive services in the community while supporting each member’s individual outcomes and recognizing each member’s preferences. The Department further expects that each member will have the opportunity to make informed choices about where the member will live, how the member will make or maintain connections to the community and whether the member will seek competitive integrated employment.

Preamble Page 2

All services and supports within the benefit package are delivered through the Family Care or

Partnership program models of care including:

Integration and support for Medicaid eligibility determination and enrollment procedures and, in the case of Partnership, for Medicare enrollment procedures;

Maintenance of a network of providers with capacity to provide program benefits to members;

Member-centered outcome-based care planning;

Member-centered interdisciplinary care management;

Member-centered service authorization and delivery;

Support of member rights;

Responsiveness to grievances and appeals;

Quality management; and

Cost effective and efficient contracting and service utilization.

Any MCO that delivers the Family Care or Partnership benefit under this contract must first be certified by the Department. The Department pays the MCO a fixed monthly capitation payment for each member. The MCO provides to each member the Medicaid long-term care and health care services and supports identified in this contract that are appropriate to that individual member’s outcomes and needs.

As part of the Department’s quality management strategy, this contract describes desired outcomes, how the Department will determine that member-identified outcomes have been supported, and the standards of operation the Department expects to be met by MCO contractors.

This contract is entered into between the State of Wisconsin represented by its Division of

Medicaid Services, of the Department of Health Services, whose principal business address is

One West Wilson Street, P.O. Box 309, Madison, Wisconsin, 53701-0309, and <<Generic>>

Managed Care Organization, hereafter MCO, whose principal business address is <<Address>>.

An electronic version of this contract can be accessed at:

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

This contract is entered into between the State of Wisconsin represented by its Division of Medicaid Services, of the Department of Health Services, whose principal business address is One West Wilson Street, P.O. Box 309, Madison, Wisconsin, 53701-0309, and Independent Care Health Plan Managed Care Organization, hereafter MCO, whose principal business address is 1555 N. RiverCenter Dr., Suite 206, Milwaukee, WI 53121.

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

Article I, Definitions Page 3

I. Definitions

Refer to Addendum VI, Benefit Package Service Definitions for service definitions.

1. Abuse: as defined by Wis. Stats. s. 46.90(1), means any of the following:

a) Physical abuse: intentional or reckless infliction of bodily harm.

b) Emotional abuse: language or behavior that serves no legitimate purpose and is intended to be intimidating, humiliating, threatening, frightening, or otherwise harassing, and that does or reasonably could intimidate, humiliate, threaten, frighten, or otherwise harass the individual to whom the conduct or language is directed.

c) Sexual abuse: a violation of Wis. Stats. §§ 940.225 (1), (2), (3), or (3m).

d) Treatment without consent: the administration of medication to an individual who has not provided informed consent, or the performance of psychosurgery, electroconvulsive therapy, or experimental research on an individual who has not provided informed consent, with the knowledge that no lawful authority exists for the administration or performance.

e) Unreasonable confinement or restraint: the intentional and unreasonable confinement of an individual in a locked room, involuntary separation of an individual from the individual’s living area, use on an individual of physical restraining devices, or the provision of unnecessary or excessive medication to an individual, but does not include the use of these methods or devices in entities regulated by the department if the methods or devices are employed in conformance with state and federal standards governing confinement and restraint.

2. Activities of Daily Living or ADLs: bathing, dressing, eating, mobility, transferring from one surface to another such as bed to chair and using the toilet.

3. Acute and Primary Care Benefit Package: services covered in Addendum VI.C. that are not also included in Addendum VI.B.

4. Adult at Risk: as defined in Wis. Stat. § 55.01(1e), means any adult who has a physical or mental condition that substantially impairs the adult’s ability to care for their own needs and who has experienced, is currently experiencing, or is at risk of experiencing abuse, neglect, self−neglect, or financial exploitation.

5. Adult Incident Reporting System or AIRS: a centralized, web-based system that MCOs must use to report member incidents and other required information listed in Article V.

6. Adult Protective Services or APS: as defined by Wis. Stat. § 55.01(6r), includes any of the following: (a) outreach, (b) identification of individuals in need of services, (c)

Article I, Definitions Page 4 counseling and referral for services, (d) coordination of services for individuals, (e) tracking and follow-up, (f) social services, (g) case management, (h) legal counseling or referral, (i) guardianship referral, (j) diagnostic evaluation, and (k) any services that, when provided to an individual with developmental disabilities, degenerative brain disorder, serious and persistent mental illness, or other like incapacity, keep the individual safe from abuse, financial exploitation, neglect, or self-neglect or prevent the individual from experiencing deterioration or from inflicting harm on themself or another person.

7. Advance Directive: a written instruction, such as a living will or durable power of attorney for health care, recognized under Wisconsin law (whether statutory or recognized by the courts of Wisconsin) and relating to the provision of such care when the individual is incapacitated.

8. Adverse Action Date: by law, individuals must be given at least ten (10) calendar days advance notice before any adverse action (i.e., reduction or termination) can take effect relative to their Medicaid eligibility and benefits. The “Adverse Action Date” is the day during a given month by which an adverse action must be taken so as to assure that the member has the notice in hand at least ten (10) calendar days before the effective date of the adverse action. The effective date of most Medicaid benefit reductions or terminations is the first day of a given month. Therefore, the Adverse Action Date is generally mid-month in the month prior. In a thirty-one (31) day month, adverse action is on or around the 18th; in a thirty (30) day month, it's on or around the 17th.

9. Aging and Disability Resource Center (ADRC) or Resource Center: an entity that meets the standards for operation and is under contract with the Wisconsin Department of

Health Services to provide services under Wis. Stat. § 46.283(3), or, if under contract to provide a portion of the services specified under Wis. Stat. § 46.283(3), meets the standards for operation with respect to those services. For the purposes of this contract, entity will be referred to as Resource Center.

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. If elected by the Tribal Nation, this position may also provide enrollment counseling to Tribal members to access publicly funded long-term care programs.

11. Assets: 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.

12. Assistance: cueing, supervision or partial or complete hands-on assistance from another person.

Article I, Definitions Page 5

13. Auxiliary Aids and Services: includes qualified interpreters, screen readers, note takers, telephone headset amplifiers, telecommunications devices, qualified readers, audio recordings, large print or Braille materials, or other effective methods of making materials available to individuals with hearing or visual impairments.

14. Balanced Work Force: an equitable representation of handicapped persons, minorities and women in each level (job category) of a work force which approximates the percentage of individuals with disabilities, minorities, and women available for jobs at each level from the relevant labor market from which the contractors/vendor recruits job applicants.

15. Behavior Modifying Medication: a psychotropic medication (i.e., prescription medication within the classification of antipsychotic, mood stabilizer, anti-anxiety, antidepressant, or stimulant and/or medication outside of these classifications utilizing off-label use as a means to regulate behaviors).

16. Benefit: the package of services provided by the MCO under this contract to which a member has access if, within the benefit, a specific service is identified as a service necessary to support long-term care outcomes. The benefit packages that may be contracted for under this contract are:

a) The Family Care Benefit Package

i. The home and community-based waiver services defined in Addendum

VI.A;

ii. The Medicaid State Plan Services identified in Addendum VI.B; and

iii. Any cost-effective health care services the MCO substitutes for a

Medicaid State Plan service.

b) The Partnership Benefit Package

i. The home and community-based waiver services defined in Addendum

VI.A;

ii. All Medicaid State Plan Services identified in Addendum VI.C; and

iii. Any cost-effective health care services the MCO substitutes for a

Medicaid State Plan service.

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.

18. Business Day: Monday through Friday, except days which the office of the Managed

Care Organization is closed.

19. Care Management (also known as Case Management or Service Coordination):

individualized assessment and care planning, authorizing, arranging and coordinating

Article I, Definitions Page 6 services in the member-centered plan (MCP) and periodic reassessments and updates of the MCP. Care management also includes assistance in filing grievances and appeals, maintaining eligibility, accessing community resources and obtaining advocacy services.

20. Centers for Medicare and Medicaid Services (CMS): the federal agency responsible for oversight and federal administration of Medicare and Medicaid programs.

21. Centralized Provider Enrollment System: Department enrollment system for adult long-term care (LTC) waiver service providers. This centralized technology system allows providers to submit all information necessary to become a certified Medicaid provider through the ForwardHealth Portal.

22. Certifying Agency: an agency authorized by the Wisconsin Medicaid Standards for

Certified 1-2 Bed Adult Family Homes or by the Department to certify and recertify Adult

Family Homes. Agencies authorized to certify AFHs using these standards include

MCOs, county agencies, the Department, or approved Department subcontractors.

23. Client Rights: see Member Rights in this section.

24. Cold Call Marketing: any unsolicited personal contact by the MCO, including its employees, agents, subcontractors, and providers, with a potential enrollee for the purpose of marketing as defined in Article I.

25. Community Supports: supports and services that are not authorized or paid for by the

MCO and that are readily available to the general population.

26. Competitive Integrated Employment (CIE): Competitive Integrated Employment

(CIE) is as defined at https://dwd.wisconsin.gov/dvr/partners/cie/definition.htm.

27. Complex Medication Regime: the member takes eight (8) or more scheduled prescription medications for three (3) or more chronic conditions. Chronic conditions include, but are not limited to, dementia or other cognitive impairment (including intellectual and/or developmental disability), heart failure, diabetes, end-stage renal disease, dyslipidemia, respiratory disease, arthritis or other bone disease, and mental health disorders such as schizophrenia, bipolar disorder, depression or other chronic and disabling mental health conditions. Medication classes of particular concern are:

anticoagulants, antimicrobials, bronchodilators, cardiac medications, central nervous system (CNS) medications, and hormones.

28. Comprehensive Assessment: an initial and ongoing part of the member-centered planning process employed by the interdisciplinary team (IDT) to identify the member’s outcomes and the services and supports needed to help support those outcomes. It includes an ongoing process of using the knowledge and expertise of the member and caregivers to collect information about:

a) The member’s needs, strengths and outcomes;

Article I, Definitions Page 7

b) The member’s resources, natural supports and community connections through significant others, family members and friends;

c) Any ongoing conditions of the member or other risk factors that require a course of treatment or regular care monitoring; and

d) The member’s preferences for the way in which the services and supports identified in the member-centered planning process will be delivered or coordinated by IDT staff.

29. Confidential Information: all tangible and intangible information and materials accessed or disclosed in connection with this contract, transferred or maintained in any form or medium (and without regard to whether the information is owned by the

Department or by a third party), that consist of:

a) Personally Identifiable Information;

b) Individually Identifiable Health Information;

c) Non-public information related to the Department's employees, customers, technology (including databases, data processing, and communications networking systems), schematics, specifications, and all information or materials derived therefrom or based thereon; and

d) Information designated as confidential in writing by the Department.

30. Conflict of Interest: a situation where a person or entity other than the member is involved in planning or delivery of services to the member, and has an interest in, or the potential to benefit from, a particular decision, outcome or expenditure.

31. Contract/this Contract/the Contract: this contractual agreement between the

Wisconsin Department of Health Services and the Managed Care Organization.

32. Cost Share: the contribution toward the cost of services required under 42 C.F.R.

§ 435.726 as a condition of eligibility for Medicaid for some members who do not otherwise meet Medicaid categorical or medically needy income limits.

33. County Agency: a county department of aging, social services or human services, an

Aging and Disability Resource Center, a long-term care district or a tribal agency that has been designated by the Department of Health Services to determine financial eligibility and cost sharing requirements.

34. Crime: conduct which is prohibited by state or federal law and punishable by fine or imprisonment or both. Conduct punishable only by forfeiture is not a crime.

35. Days: calendar days unless otherwise noted.

36. Department: the Wisconsin Department of Health Services (DHS) or its designee.

Article I, Definitions Page 8

37. Developmental Disability: a disability attributable to brain injury, cerebral palsy, epilepsy, autism, Prader-Willi syndrome. This also includes an intellectual disability diagnosed before age 18 and characterized by below-average general intellectual function and a lack of skills necessary for daily living, or another neurological condition closely related to such intellectual disability or requiring treatment similar to that required for such intellectual disability, that has continued or can be expected to continue indefinitely and constitutes a substantial handicap to the afflicted individual. “Developmental disability” does not include senility that is primarily caused by the process of aging or the infirmities of aging.

38. DHS: the Wisconsin Department of Health Services.

39. 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. Donation: something of value voluntarily transferred by or on behalf of a member to the

MCO without compensation.

a) Something of value means cash or some other existing identifiable items that has a fair market value of more than $100.00.

b) Voluntarily transferred means any of the following:

i. The member or another person on behalf of the member transferring the item of value has the intention to voluntarily give it without compensation;

ii. The member or other person on behalf of the member transferring the gift is legally competent (in order to have intention);

iii. The MCO receiving the gift is an eligible recipient (e.g., some entities have prohibitions against employees accepting gifts);

iv. The item of value is an existing identifiable thing (e.g., a promise to give something in the future is not a gift); or

v. The item of value is actually transferred.

41. Dual Eligible: refers to an individual who meets the requirements to receive benefits from both the Federal Medicare Program and the Wisconsin Medicaid Program. “Dual eligibility” does not guarantee “dual coverage.”

42. Elder Adult at Risk: as defined in Wis. Stat. § 46.90(br), means any person age 60 or older who has experienced, is currently experiencing, or is at risk of experiencing abuse, neglect, self−neglect, or financial exploitation.

43. Electronic Visit Verification (EVV): Electronic Visit Verification is an electronic system that uses technology to verify that authorized services were provided. EVV visit data must be submitted for care provided under service codes listed on the Department’s

EVV website (https://dhs.wisconsin.gov/evv/programadmin.htm). Workers are required to send visit information at the beginning and end of each visit to an EVV system including:

Article I, Definitions Page 9

a) Who receives the service

b) Who provides the service

c) What service is provided

d) Where service is provided

e) Date of service

f) Time in and out

44. Emergency Medical Condition: a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in the following:

a) Placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy;

b) Serious impairment to bodily functions; or

c) Serious dysfunction of any bodily organ or part.

45. Emergency Services: covered inpatient and outpatient services that are:

a) Furnished by a provider that is qualified to furnish these services under Title 19 of the Social Security Act; and

b) Needed to evaluate or stabilize an emergency medical condition.

46. Encounter Data: detailed records of health care services or items that have been provided to MCO members by providers. The Department uses encounter data for rate setting, Federal Reporting, ad-hoc reporting, special programs, and any other purpose authorized by federal regulation or Wisconsin Statute or Administrative Code.

47. Encounter Data Reporting: electronic submission of encounter data from an MCO to the Department. See Article XIV.B, Encounter Reporting, for requirements pertaining to the reporting of encounter data.

48. Enrollee: see Member in this section.

49. Enrollment Counseling: Activities performed by ADRCs or Tribal ADRS to potential enrollees such as, answering questions and providing information in an unbiased manner on available delivery system options, including the option of enrolling in a publicly funded long-term care program, selecting an MCO and advising on what factors to consider when choosing among these options.

50. Experimental Surgery and Procedures: “experimental” means a service, procedure, item, or treatment that is “not proven and effective” for the conditions for which it is intended to be used.

Article I, Definitions Page 10

51. Fair Hearing: a de novo proceeding under Wis. Admin. Code § HA 3, before an impartial administrative law judge in which the petitioner or the petitioner’s representative presents the reasons why an action or inaction by the Department of Health

Services, a county agency, a resource center or an MCO in the petitioner’s case should be corrected.

52. Family Care: a capitated Medicaid managed care program for the delivery of all

Medicaid long-term care services. Members enrolled in Family Care may be eligible at a

Wisconsin Medicaid nursing home-certifiable level of care or at a non-nursing home level of care. One of these functional levels of care is required as a condition of eligibility.

53. Family Care Benefit: see Benefit in this section.

54. Federally Qualified Health Center or FQHC: defined in Section 4161 of the Omnibus

Budget Reconciliation Act of 1990. The purpose of FQHC Program is to enhance the provision of primary care services in underserved urban and rural communities. FQHCs are providers such as community health centers, outpatient health programs funded by the

Public or Indian Health Service, and programs serving migrants and the homeless.

55. Financial Abuse: a practice that is inconsistent with sound fiscal, business, or medical practices and results in unnecessary program costs or any act that constitutes financial abuse under applicable Federal and State law. Financial abuse includes actions that may, directly or indirectly, result in: unnecessary costs to the Managed Care Organization, improper payment, payment for services that fail to meet professionally recognized standards of care, or services that are medically unnecessary. Financial abuse involves payment for items or services when there is no legal entitlement to that payment and the provider has not knowingly and/or intentionally misrepresented facts to obtain payment.

56. Financial Eligibility and Cost-Sharing Screen: a uniform screening tool prescribed by

DHS that is used to determine financial eligibility and cost-sharing under Wis. Stat. §§

46.286(1) (b) and (2) and Wis. Admin. Code §§ DHS 10.32 and 10.34.

57. Financial Exploitation: includes any of the following acts:

a) Fraud, enticement or coercion;

b) Theft;

c) Misconduct by a fiscal agent;

d) Identity theft;

e) Unauthorized use of the identity of a company or agency;

f) Forgery; or

g) Unauthorized use of financial transaction cards including credit, debit, ATM and similar cards.

Article I, Definitions Page 11

58. Frail Elder: an individual who is 65 years of age or older and has a physical disability or irreversible dementia that restricts the individual’s ability to perform normal daily tasks or that threatens the capacity of the individual to live independently.

59. Fraud: any intentional deception made for personal gain or to damage another individual, group, or entity. It includes any act that constitutes fraud under applicable federal or state law. Fraud is knowingly and willfully executing, or attempting to execute, a scheme or artifice to defraud any health care benefit program or to obtain (by means of false or fraudulent pretenses, representations, or promises) any of the money or property owned by, or under the custody or control of, any health care benefit program (18 U.S.C.

1347).

60. Functional Capacity: the skill to perform activities in an acceptable manner.

61. Functionally Equivalent: means a service provided via telehealth where the transmission of information is of sufficient quality as to be the same level of service as an in-person visit. Transmission of voices, images, data, or video must be clear and understandable.

62. Gift: something of value voluntarily transferred by one person or entity to another person or entity without compensation.

a) Something of value means cash or some other existing identifiable thing that has a fair market value of more than $100.00.

b) Voluntarily transferred means:

i. The person or entity transferring the thing of value has the intention to voluntarily give it without compensation; and

ii. The person transferring the gift is competent (in order to have intention);

and

iii. The person or entity receiving the gift is an eligible recipient (e.g., some entities have prohibitions against employees accepting gifts); and

iv. The thing of value is an existing identifiable thing (e.g., a promise to give something in the future is not a gift); and

v. The thing of value is actually transferred.

63. Group A: persons age 18 and over who are financially eligible for full-benefit Medicaid on a basis separate from qualifying to receive home-and-community-based waiver services.

64. Group B: persons age 18 and over who are not in Group A, meet the non-financial requirements to receive home and community-based waiver services and have a gross monthly income no greater than a special income limit equal to 300% of the SSI federal benefit rate for an individual.

Article I, Definitions Page 12

65. Group B+: persons age 18 or over not in Group A, meeting all requirements for Group B except for income, whose monthly income after subtracting the cost of institutional care is at or below the medically needy income limit.

66. Harassment: any unwanted offensive or threatening behavior, which is linked to one or more of the below characteristics when:

a) Submission to such conduct is made either explicitly or implicitly a term or condition of an individual’s employment or eligibility for services;

b) Submission to or rejection of such conduct by an individual is used as the basis for employment or service decisions affecting such individual; or

c) Such conduct has the purpose or effect of substantially interfering with an individual’s work performance, or of creating an intimidating, hostile or offensive work or service delivery environment, which adversely affects an individual’s opportunities.

Harassing behavior may include, but is not limited to, demeaning or stereotypical comments or slurs, ridicule, jokes, pranks, name calling, physical or verbal aggression, gestures, display or possession of sexually graphic materials, cartoons, physical contacts, explicit or implicit threats separate from supervisory expressions of intention to use the disciplinary process as a consequence of continued inappropriate behavior, malicious gossip or any other activity that contributes to an intimidating or hostile work environment.

Sexually harassing behavior is unwelcome behavior of a sexual nature toward males or females which may include, but, is not limited to, physical contact, sexual advances or solicitation of favors, comments or slurs, jokes, pranks, name calling, gestures, the display or possession of sexually graphic materials which are not necessary for business purposes, malicious gossip and verbal or physical behaviors which explicitly or implicitly have a sexual connotation.

Harassment is illegal when it is a form of discrimination based upon age, disability, association with a person with a disability, national origin, race, ancestry or ethnic background, color, record of arrest or conviction which is not job-related, religious belief or affiliation, sex or sexual orientation, marital status, military participation, political belief or affiliation, and use of a legal substance outside of work hours.

67. HCBS Settings Rule Modification: Restrictions or limitations to a member’s HCBS rights defined in 42. C.F.R.§ 441.301(c)(4)(vi)(B) through (D) for an individual resident that is implemented by the residential services provider (adult family homes of 1-2 beds, adult family homes of 3-4 beds, community-based residential facilities, residential care apartment complexes), supported by a specific assessed need to ensure the health, safety, and well-being of the individual or the community, and documented in accordance with

42 CFR 441.301(c)(2)(xiii).

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68. Home: a place of abode and lands used or operated in connection with the place of abode.

69. Hospital: has the meaning specified in Wis. Stat. § 50.33(2).

70. Income Maintenance Agency or IM Agency: a subunit of a county, consortia, or tribal government responsible for administering IM Programs including Wisconsin Medicaid;

formerly known as the Economic Support Agency.

71. Indian: an individual defined at 25 U.S.C. 1603(13), 1603(28), or 1679(a), or who has been determined eligible as an Indian, under 42 C.F.R. 136.12. This means the individual:

a) Is a member of a Federally recognized Indian tribe; or

b) Resides in an urban center and meets one or more of these four criteria:

i. Is a member of a tribe, band, or other organized group of Indians, including those tribes, bands, or groups terminated since 1940 and those recognized now or in the future by the State in which they reside, or who is a descendant, in the first or second degree, of any such member;

ii. Is an Eskimo or Aleut or other Alaska Native;

iii. Is considered by the Secretary of the Interior to be an Indian for any purpose;

iv. Is determined to be an Indian under regulations issued by the Secretary; or

c) Is considered by the Secretary of the Interior to be an Indian for any purpose; or

d) Is considered by the Secretary of Health and Human Services to be an Indian for purposes of eligibility for Indian health care services, including as a California

Indian, Eskimo, Aleut, or other Alaska Native.

72. Indian Health Care Provider (IHCP): a health care program operated by the Indian

Health Service (IHS) or by an Indian Tribe, Tribal Organization, or Urban Indian

Organization (otherwise known as an I/T/U) as those terms are defined in section 4 of the

Indian Health Care Improvement Act (25 U.S.C. § 1603).

73. Individual at Risk: an elder adult at risk (age 60 and over) or an adult at risk (age 18-

59).

74. Individually Identifiable Health Information: member demographic information, claims data, insurance information, diagnosis information, and any other information that relates to an individual’s past, present or future physical or mental health or condition, provision of health care, or payment for health care that identifies the individual or could reasonably be expected to lead to the identification of the individual.

75. Institution for Mental Disease: a hospital, nursing facility, or other institution of more than 16 beds that is primarily engaged in providing diagnosis, treatment, or care of persons with mental diseases.

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76. Instrumental Activities of Daily Living or IADLs: 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.

77. Interdisciplinary Team or IDT: the member and individuals identified by the MCO to provide care management services to members.

78. Interdisciplinary Team Staff: individual employees assigned to an IDT that shall have specialized knowledge of the conditions of the target populations served by the MCO, the full range of long-term care resources and community alternatives.

79. Legal Decision Maker: a member’s or potential member’s legal decision maker is a person who has the legal authority to make certain decisions on behalf of a member or potential member. A legal decision maker may be a guardian of the person or estate (or both) registered under Chapter 53 of the Wisconsin Statutes, a guardian of the person or estate (or both) appointed under Chapter 54 of the Wisconsin Statutes, a conservator appointed under Chapter 54 of the Wisconsin Statutes, a person designated power of attorney for health care under Chapter 155 of the Wisconsin Statutes or a person designated durable power of attorney under Chapter 244 of the Wisconsin Statutes. A legal decision maker may have legal authority to make certain kinds of decisions, but not other kinds of decisions. A member may have more than one legal decision maker authorized to make different kinds of decisions. In any provision of this Contract in which the term “legal decision maker” is used, it applies only to a person who possesses the legal authority relevant to that provision. A person designated by the member or potential member as an “authorized representative” under 42 C.F.R. § 435.923 for assisting with Medicaid application and renewal of eligibility is not a legal decision maker.

80. Limited English Proficient (LEP): potential members and members who do not speak

English as their primary language and who have a limited ability to read, write, speak, or understand English may be LEP and may be eligible to receive language assistance for a particular type of service, benefit, or encounter.

81. Long-Term Care Benefit Package/LTC Benefit Package: the services identified in

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

82. Long-Term Care District: a special purpose district created under Wis. Stat. §

46.2895(1).

83. Long-Term Care Facility: a nursing home, adult family home, community-based residential facility or residential service apartment complex.

84. Long Term Care Functional Screen or LTCFS: a uniform screening tool administered by the Department and certified functional screeners 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.

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85. Managed Care Organization or MCO: an entity that the Department has certified as having capacity for financial solvency and stability as defined in Article XVII, Fiscal

Components/Provisions, and which has agreed under this contract to make the services in the benefit package defined in Article VII, Services, available to members for payment as defined in Article XVIII, Payment to the Managed Care Organization.

86. Marketing/Outreach: any communication, sponsorship of community events, or the production and dissemination of marketing/outreach materials from an MCO, including its employees, agents, subcontractors, and providers, to an individual who is not enrolled in that entity that can reasonably be interpreted as intended to influence the individual to enroll in or not to enroll in that particular managed care organization’s Medicaid product, or to disenroll from another managed care organization’s Medicaid product.

Communications from a Qualified Health Plan to Medicaid beneficiaries are excluded from the definition of marketing, even if the issuer of the Qualified Health Plan is also an entity providing Medicaid managed care.

87. Marketing/Outreach Materials: materials in all mediums, including but not limited to, internet, brochures and leaflets, newspaper, magazine, radio, television, billboards, yellow pages, advertisements, other print media and presentation materials, used by or on behalf of the MCO to communicate with individuals who are not members, and that can be reasonably interpreted as intended to influence the individuals to enroll or reenroll in the MCO.

88. Medicaid: the Wisconsin Medical Assistance program operated by the Wisconsin

Department of Health Services under Title XIX of the Federal Social Security Act, Wis.

Stats. ch. 49 and related state and federal rules and regulations. The term “Medicaid” will be used consistently in this contract. However, “Medicaid” is also known as “MA,”

“Medical Assistance,” and “Wisconsin Medical Assistance Program” or “WMAP.”

89. Medicaid Deductible: a way of attaining full-benefit Medicaid financial eligibility in which an applicant is given a six-month deductible period in which incurred medical and remedial costs can be used to lower excess income to medically needy limits. The applicant's deductible amount is equal to six times the difference between net monthly income and the monthly medical needy limit. Once the applicant has met the deductible, the person becomes eligible for Medicaid for the remainder of the six-month period and may enroll in Family Care. A person can also pre-pay a deductible instead of incurring medical and remedial expenses.

90. Medicaid Recipient: any individual receiving benefits under Title XIX of the Social

Security Act and the Medicaid State Plan as defined in Wis. Stats. ch. 49.

91. Medical Equipment or Appliances: are items that are primarily or customarily used to serve a medical purpose, generally are not useful to an individual in the absence of a disability, illness or injury, can withstand repeated use, and can be reusable or removable.

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92. Medical Supplies: are health care related items that are consumable or disposable or cannot withstand repeated use by more than one individual, that are required to address an individual medical disability, illness, or injury.

93. Medically Necessary Services: for the State plan services in Addendum VI.B and C medically necessary has the meaning in Wis. Admin. Code DHS §101.03(96m):

Medicaid services (as defined under Wis. Stat. § 49.46 and Wis. Admin. Code § DHS

107) that are required to prevent, identify or treat a member’s illness, injury or disability;

and that meet the following standards:

a) Are consistent with the member’s symptoms or with prevention, diagnoses or treatment of the member’s illness, injury or disability;

b) Are provided consistent with standards of acceptable quality of care applicable to the type of service, the type of provider and the setting in which the service is provided;

c) Are appropriate with regard to generally accepted standards of medical practice;

d) Are not medically contraindicated with regard to the member’s diagnoses, symptoms, or other medically necessary services being provided to the member;

e) Are of proven medical value or usefulness and, consistent with Wis. Admin. Code

§ DHS 107.035 are not experimental in nature;

f) Are not duplicative with respect to other services being provided to the member;

g) Are not solely for the convenience of the member, the member’s family or a provider;

h) With respect to prior authorization of a service and other prospective coverage determinations made by DHS, are cost-effective compared to an alternative medically necessary service which is reasonably accessible to the member; and

i) Is the most appropriate supply or level of service that can safely and effectively be provided to the member.

For the home and community-based waiver services in Addendum VI.A medically necessary means that the service is reasonable, appropriate and cost-effectively addresses a member’s assessed long-term care need or outcome related to any of the following purposes:

a) The prevention, diagnosis, and treatment of a disease, condition, and/or disorder that results in health impairments and/or disability;

b) The ability to achieve age-appropriate growth and development;

c) The ability to attain, maintain, or regain functional capacity; and

d) The opportunity to have access to the benefits of community living, to achieve person-centered goals, and live and work in the setting of their choice.

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94. Medication Review and Intervention: a comparison of medications prescribed by health care providers and medications taken by the member.

95. Member: a person who is currently enrolled in a Managed Care Organization (MCO).

96. Member-Centered Plan or MCP: a record that documents a process by which the member and the interdisciplinary team staff further identify, define and prioritize the member’s outcomes initially identified in the comprehensive assessment.