Section 10.37. Private pay individuals.

 

(1)   Definitions. In this section:

(a) "Case management" means assessment, care planning, assistance in arranging and coordinating services in the care plan, assistance in filing grievances and appeals and obtaining advocacy services, and periodic reassessment and updates to the person's care plan.

(b) "Private pay individual" means any of the following:

1. A person who is a member of a CMO's target population and who does not qualify financially for the family care benefit under s. DHS 10.34 .

2. A person who is eligible for the family care benefit under s. DHS 10.32 , but who is not entitled to receive the benefit immediately as specified in s. DHS 10.36 (3) .

3. A person who meets the entitlement conditions specified in s. DHS 10.36 (1) , but who is waiting for enrollment in a CMO under the phase-in provisions of s. DHS 10.36 (2) .

(2)   Case management available for purchase. A care management organization shall offer case management services, at rates approved by the department, to private pay individuals who wish to purchase the services. A private pay individual may purchase from the CMO any types and amounts of case management. The types and amounts of case management and the cost of the services shall be specified in a written agreement signed by the authorized representative of the CMO and the individual purchasing the service or the person's authorized representative.

(3)   Limitations on purchase of other services.

(a) A private pay individual may not enroll in a care management organization, but, subject to pars. (b) and (c) , may purchase services other than case management services, on a fee-for-service basis, from a care management organization.

(b) An individual who meets the definition under sub. (1) (b) 1. may purchase any service that the CMO provides directly and offers to the general public, at prices normally charged to the public.

(c) An individual who meets the definition under sub. (1) (b) 2. or 3. may purchase any service purchased or provided by the CMO for its members.

History: Cr. Register, October, 2000, No. 538 , eff. 11-1-00; CR 04-040 : am. (1) (a) Register November 2004 No. 587 , eff. 12-1-04.