State of Wisconsin Department of Health Services

Release 24-03 December 18, 2024

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28.1 Adult Home and Community-Based Waivers Long-Term Care Introduction

Medicaid-eligible adults who meet the LOClevel of care. Used in the Family Care, PACE, Family Care Partnership, IRIS, and Home and Community-Based Waiver programs. requirements can receive their LTClong-term care services through enrollment in an MCOManaged Care Organization or through the fee-for-serviceA method of payment for health services. The medical provider bills the Medicaid fiscal agent rather than an HMO for specific individual services. program IRISInclude, Respect, I Self-Direct. A Medicaid waiver program..

Managed LTC programs include:

• Family Care
• Family Care Partnership
• PACEProgram of All-Inclusive Care for the Elderly

Medicaid Eligibility

Community waivers enable elderly, blind, or disabled people to live in community settings rather than in state institutions or nursing homes. They allow Medicaid to pay for services and supports permitting a person to remain in a community setting that normally are not covered by Medicaid. These programs include Family Care, Family Care Partnership, PACE, and IRIS.

IMincome maintenance workers are responsible for determining Medicaid eligibility as well as cost share amounts, if applicable. ADRC staff and IRIS consultants are responsible for determining the person’s eligibility for enrollment in the specific community waiver program.

If a member disenrolls from the managed LTC program for any reason and does not enroll in IRIS or a managed LTC program, their 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 ADRCAging and Disability Resource Center that the member has disenrolled from the managed LTC program or IRIS.

If an 18-year-old is disenrolled from their managed LTC program during their 12-month continuous coverage period, and they are not eligible for another category of full-benefit health care, they will keep their HCBW Medicaid and can keep getting Medicaid card services for the rest of the 12-month continuous coverage period. However, a voluntary disenrollment will be treated as a voluntary disenrollment from HCBW Medicaid and continuous coverage under HCBW Medicaid will end (see SECTION 1.2 CONTINUOUS COVERAGE FOR QUALIFYING CHILDREN).

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

28.1.1 Adult Home and Community Based Waivers Long-Term Care Disability Policy

To be eligible for EBDElderly, Blind, or Disabled 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, WWWMAWisconsin Well Woman Medicaid, 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 was redetermined and the child was found to no longer be disabled.

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.

28.1.2 Family Care

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:

• Be 18 years of age or older.
• Meet financial and non-financial eligibility criteria for:
  • A full benefit category of EBD Medicaid, including Long Term Care Medicaid (see 28.1.1 Disability Policy),
  • BadgerCare Plus (BCP),
  • WWWMAWisconsin Well Woman Medicaid,
  • Adoption Assistance (AA), or
  • Foster Care Medicaid; and
• Meet the nursing home or non-nursing home functional level of care.

28.1.3 Family Care Partnership

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:

• Be 18 years of age or older,
• Meet financial and non-financial eligibility criteria for:
  • A full benefit category of EBD Medicaid, including Long Term Care Medicaid (see 28.1.1 Disability Policy),
  • BadgerCare Plus (BCP) Standard Plan,
  • WWWMAWisconsin Well Woman Medicaid,
  • Adoption Assistance (AA), or
  • Foster Care Medicaid; and
• Meet the nursing home functional level of care.

28.1.4 PACE

PACEProgram of All-Inclusive Care for the Elderly 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:

• Be 55 years of age or older,
• Meet the nursing home functional level of care,
• Reside in a county that offers PACE.

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.

28.1.5 IRIS

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:

• Be 18 years of age or older;
• Meet the nursing home level of care;
• Meet the financial and non-financial eligibility criteria for one of the following:
  • A full-benefit category of EBD Medicaid, including Long-Term Care Medicaid
  • BadgerCare Plus
  • WWWMAWisconsin Well Woman Medicaid
  • Adoption Assistance
  • Foster Care Medicaid; and
• Reside in an IRIS eligible living setting:
  • Individual's own home or apartment;
  • 1-2 or 3-4 bed Adult Family Home (AFH);
  • Residential Apartment Care Complex (RCAC).

28.1.6 Changing Programs

Individuals who want to change long-term care programs must complete this request through their Aging and Disability Resource Center (ADRC).

28.1.7 Spousal Impoverishment

Spousal impoverishment policy applies to group B and B Plus waiver participants with a community spouse (see Section 26.3.7 Spousal Impoverishment).

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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