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State of Wisconsin |
HISTORY |
The policy on this page is from a previous version of the handbook.
Medicaid-eligible adults who meet the LOC requirements can receive their LTC services through enrollment in an MCO or through the fee-for-service program IRIS .
Managed LTC programs include:
Medicaid Eligibility
IM workers are responsible for determining Medicaid eligibility as well as cost share amounts, if applicable. If a member disenrolls from the managed LTC program for any reason and does not enroll in IRIS or a managed LTC program, his or her Medicaid eligibility must be tested under non-HCBW rules. Eligibility for HCBW would end following adverse action logic once the IM worker has been notified by the ADRC that the member has disenrolled from the managed LTC program or IRIS.
Managed Long-Term Care of IRIS Enrollment
Enrollment in managed LTC or IRIS is completed by the ADRC. The ADRC will submit the following information to IM workers:
ADRC Referral to Income Maintenance for Managed Long-Term Care Services, F-02053, which lists the anticipated program start date for HCBW
Medicaid application, if the ADRC is assisting the applicant with the Medicaid application process or establishing a Medicaid filing date
Functional Screen Eligibility Results page
Medical and Remedial Expenses: checklist For Medicaid Long-Term Care Waiver Programs, F-00295, or other communication of the total expenses
Housing expenses and any other verification items the ADRC has received from the applicant to support the Medicaid application
Estate Recovery Program (ERP) Disclosure, F-13039, if completed by the ADRC
Declaration Regarding Transfer of Resources Long-Term Care Medicaid Waiver Program and/or Community Options Program, F-20919D, if any potential divestment was reported to the ADRC
Disenrollment from the managed LTC program or IRIS, if applicable
To be eligible for EBD Medicaid or LTC Medicaid, a person must be elderly, blind, or disabled.
Adults over age 18 and younger than 65 years old must have a disability determination unless the person is eligible for BadgerCare Plus, WWWMA , Foster Care, or Adoption Assistance. If a person later loses eligibility for that program and must be tested for EBD Medicaid or LTC Medicaid, he or she must then be elderly, blind, or disabled to remain enrolled in Family Care, Family Care Partnership, PACE, or IRIS.
A disability finding made prior to the person’s 18th birthday, which remains in effect on the person’s 18th birthday, will be considered to meet the disability requirements for managed LTC or IRIS until the first of the following:
An adult disability determination can be completed
The child disability determination is no longer in effect
Managed LTC or IRIS eligibility will not be denied solely because the disability determination in effect at application was made prior to applicant’s 18th birthday.
Family Care is a managed long-term care program for adults with disabilities and frail elders.
To enroll in Family Care the individual must meet the following criteria:
The Family Care Partnership program is a managed long-term care program integrating health and long-term support services for adults with disabilities and frail elders.
To participate in the Family Care Partnership program the individual must meet the following criteria:
PACE is a program that provides comprehensive community-based services, including both acute and chronic care for frail elderly individuals. Most services are provided in a day health center, and members must receive medical services from a PACE physician. PACE is only available in select counties.
To enroll in PACE, the individual must meet the following criteria:
PACE participants who are not eligible for Medicaid will pay a premium to the PACE organization. If the PACE Participant is eligible for Medicaid, the participant is subject to the requirements in this chapter, including cost sharing.
IRIS (Include, Respect, I Self-Direct) is a fee-for-service long-term care support program available to individuals who meet the functional and financial eligibility requirements. IRIS participants receive a budget amount that is calculated based on the results of their long-term care functional screen that can be used to purchase long-term care supports and services related to the participant’s needs.
To participate in the IRIS program, individuals must meet the following criteria:
Individuals who want to change long-term care programs must complete this request through their Aging and Disability Resource Center (ADRC).
Spousal impoverishment policy applies to group B and B Plus waiver participants with a community spouse (see Section 26.3.7 Spousal Impoverishment).
The information concerning the Medicaid program provided in this handbook release is published in accordance with: Titles XI and XIX of the Social Security Act; Parts 430 through 481 of Title 42 of the Code of Federal Regulations; Chapters 46 and 49 of the Wisconsin Statutes; and Chapters HA 3, DHS 2, 10 and 101 through 109 of the Wisconsin Administrative Code.
Notice: The content within this manual is the sole responsibility of the State of Wisconsin's Department of Health Services (DHS). This site will link to sites outside of DHS where appropriate. DHS is in no way responsible for the content of sites outside of DHS.
Publication Number: P-10030