Family Care & Family Care Partnership Programs from Wisconsin Medicaid

Last updated: August 27, 2021

 

Overview of the Family Care & Family Care Partnership Programs

Via Wisconsin’s Family Care and Family Care Partnership Programs (or just Partnership), elderly and disabled residents who require a nursing home level of care receive long-term care. While nursing home care is an available benefit, a variety of home and community based services (HCBS) are also available to prevent unnecessary nursing home admissions. For instance, a senior who lives alone might be able to continue to live independently with in-home personal care assistance, homemaker services, a personal emergency response system, and safety and accessibility home modifications. On the other hand, a senior who lives with his or her adult child might benefit from supports, such as adult day care and in-home respite care, to supplement care already being provided.

Family Care and Partnership program participants receive their long-term care benefits via a single Medicaid health plan. For the Partnership program, dental, vision, and medical benefits, such as hospitalization, wellness appointments, x-rays, and laboratory services, as well as prescription drugs, are integrated into the plan. This includes both Medicaid and Medicare benefits for persons who are “dual eligible”, meaning eligible for both Medicaid and Medicare. To be clear, Family Care does not integrate medical benefits into the program, but the program does help to coordinate medical care.

Both Family Care and Partnership health plans are provided by a managed care organization (MCO). A MCO is essentially a private healthcare company. The MCO has a network of care providers and program participants receive services via these providers. The availability of MCO’s vary based on one’s geographic region, although most counties offer multiple options of MCO.

 The main difference between Family Care Program and the Partnership Program is that the Partnership Program integrates vision, dental, and medical care into its managed care plan. This includes benefits from both Medicaid and Medicare for those who are “dual eligible”, or in other words, eligible for both Medicaid and Medicare.

Both programs offer a participant-directed option called self-directed supports (SDS) that allow program participants to manage their own service budget. This option gives program participants flexibility and choice in what long-term care services are needed and from whom they are received. This means that rather than receive services by the MCO’s network of licensed care providers, a program participant can hire their own caregiver. Relatives, including spouses and adult children, can be hired. A financial management services agency is available to handle the financial aspects of employment responsibilities such as tax withholding and caregiver payments.

While the Family Care Program is available statewide, the Partnership Program is not. As of August 2021, it is available in the following counties: Waupaca, Outagamie, Calumet, Sauk, Columbia, Dodge, Washington, Ozaukee, Dane, Jefferson, Waukesha, Milwaukee, Racine, and Kenosha. The state plans to expand the program in 2023 and include Fond du Lac, Manitowoc, Winnebago, Brown, and Shawano counties. To see a map of the counties in which the program serves, click here.

 The Partnership Program is not currently available statewide. At the time of this writing, it is limited to 14 counties.

Program beneficiaries can reside in their own home, the home of a close friend or relative, an adult family home (adult foster care), a community-based residential facility, or a residential care apartment complex (assisted living residence).

Family Care is considered an entitlement program, which means as long as an applicant meets eligibility criteria, benefits will be received. The Partnership Program, however, is not an entitlement program. This means the state limits the number of persons who can participate in the programs, and if all participants slots are filled, a waitlist forms. At the time of this writing, there was no waitlist.

The Family Care and Family Care Partnership Programs are authorized under a 1915(c) Medicaid Waiver. Via the 1915(c) Waiver, home and community based services (HCBS) are provided. Managed care via Family Care is authorized under a 1915(b) Waiver and managed care via Partnership is authorized under a 1932(a) Waiver.

 What is Medicaid Managed Care?
Medicaid pays doctors, hospitals, and other providers in one of two ways, either “Fee-For-Service” or “Managed Care”. Under Fee-For-Service, Medicaid pays providers directly for each service they provide. Beneficiaries can receive services from any Medicaid-certified provider. Under Managed Care, Medicaid contracts with a Managed Care Organization (MCO). Medicaid pays the MCO a set amount for each beneficiary, rather than for each service provided. The MCO has a network of doctors, hospitals, and other providers and the MCO pays them. Beneficiaries must use providers within the network.

 

Benefits of the Family Care & Family Care Partnership Programs

An individual care plan will determine which services and supports a program participant will receive. Although the list below may not be exhaustive of all available long-term care benefits, the following home and community based services are available. Via the Partnership Program, program participants also receive vision, dental, medical, and prescription drug benefits.

– Adaptive Aids
– Adult Day Care / Adult Day Health Care – daytime care and supervision in a community group setting
– Alcohol and Drug Treatment
– Assisted Living Services / Adult Family Home Services / Residential Care Services
– Assistive Technology / Communication Aids
– Care Management
– Clinical / Therapeutic Services – for caregivers
– Community Transition Services – assistance for persons moving from a nursing home back into the community. Includes security deposits and utility set up fees.
– Consumer Education / Training
– Counseling / Therapeutic Services
– Daily Living Skills Training
– Day Habilitation Services
– Durable Medical Equipment – i.e., wheelchairs
– Home Delivered Meals
– Home Health Care
– Home Modifications – i.e., grab bars, wheelchair ramps, and widening doorways
– Housing Counseling
– Mental Health Services
– Nursing Home Care
– Personal Emergency Response Systems (PERS)
– Personal Care Assistance
– Prevocational Services
– Respite Care – in-home and out-of-home short-term care to alleviate a primary caregiver
– Self-Directed Supports – assistance in self-directing care, including financial management services
– Skilled Nursing Services
– Specialized Medical Supplies – i.e., adult diapers, gloves
– Supported Employment
– Supportive Home Care – personal care assistance and homemaker services
– Therapies – physical, occupational, and speech
– Training Services – for unpaid caregivers
– Transportation – non-medical and medical
– Vocational Planning

Some program participants may have to pay a “share of cost” for services.

While program participants can reside in an adult family care home, a community-based residential facility, or an assisted living facility, the Family Care and Partnership Programs do not cover the cost of room and board.

 Wisconsin has another long-term care Medicaid program, IRIS (Include, Respect, I Self-Direct), which is a participant-directed program that allows seniors a large degree of control over which home and community based services they receive, who provides them, and when they are provided.

 

Eligibility Requirements for Family Care & Family Care Partnership Programs

The Family Care and Partnership Programs are for Wisconsin residents who are elderly (65+) or who are younger (18-64) and physically, developmentally, or intellectually disabled. Disabled persons who enroll prior to turning 65 can continue to receive waiver services upon turning 65. For the Partnership Program, applicants must live in a geographic region in which the program is offered. Additional criteria follows for persons 65+ years of age.

 The American Council on Aging provides a quick and easy Wisconsin Medicaid eligibility test for seniors

 

Financial Criteria: Income, Assets & Home Ownership

Income
The 2021 applicant income limit, which increases on an annual basis in January, is set at $2,382 / month. When both spouses are applicants, each spouse is considered individually, with each spouse allowed income up to $2,382 / month. When only one spouse is an applicant, the income of the non-applicant spouse is not counted towards the income eligibility of his/her spouse. Furthermore, monthly income from the applicant spouse can be transferred to the non-applicant spouse as a spousal income allowance, also called a monthly maintenance needs allowance.

There is a minimum income allowance, set at $2,903.34 / month (effective July 2021 – June 2022), which is intended to bring a non-applicant spouse’s monthly income up to this amount. There is also a maximum income allowance, which is $3,259.50 / month (effective January 2021 – December 2021), and is dependent on the non-applicant spouse’s shelter and utility costs. This monthly maintenance needs allowance is intended to ensure the non-applicant spouse does not become impoverished.

Assets
In 2021, the asset limit is $2,000 for a single applicant. For married couples, with both spouses as applicants, each spouse can have up to $2,000 in assets. When only one spouse is an applicant, the assets of both the applicant and non-applicant spouse are limited, though the non-applicant spouse is allocated a larger portion of the assets to prevent spousal impoverishment. (Unlike with income, Medicaid considers the assets of a married couple to be jointly owned). In this case, the applicant spouse can retain up to $2,000 in assets and the non-applicant spouse can keep up to $130,380. This larger allocation of assets to the non-applicant spouse is called a community spouse resource allowance.

Some assets are not counted towards Medicaid’s asset limit. These generally include an applicant’s primary home, household furnishings and appliances, personal effects, and a vehicle.

Assets should not be given away or sold under fair market value within 60-months of long-term care Medicaid application. This is because Medicaid has a look back rule and violating it results in a penalty period of Medicaid ineligibility.

 To determine if you might have assets over Medicaid’s countable limit, and if so, receive an estimate of the amount, use our spend down calculator

Home Ownership
The home is often the highest valued asset a Medicaid applicant owns, and many persons worry that WI Medicaid will take their home. Fortunately, for eligibility purposes, Medicaid considers the home exempt (non-countable) in the following circumstances.

– The applicant lives in the home or has “intent” to return to the home and his / her home equity interest is no greater than $750,000. Home equity interest is the current value of the home minus any outstanding mortgage.
– A spouse lives in the home.
– A minor (under 18 years old) lives in the home.
– A disabled child lives in the home.

To learn more about the potential of Medicaid taking the home, click here.

 

Medical Criteria: Functional Need

An applicant must require a nursing facility level of care (NFLOC). For the Family Care / Family Care Partnership Programs, the tool used to make this determination is the Wisconsin Adult Long-term care Functional Screen (LTC FS). One’s ability / inability to independently complete their activities of daily living (i.e., transferring from the bed to a chair, mobility, eating, toileting, eating) and instrumental activities of daily living (i.e., meal preparation, money management, housework) is considered when making this determination. While persons with Alzheimer’s disease or another irreversible dementia may be eligible, a diagnosis of dementia in and of itself does not mean one will meet the criteria for NFLOC.

 

Qualifying When Over the Limits

Having income and / or assets over Wisconsin’s Medicaid’s limit(s) does not mean an applicant cannot still qualify for Medicaid. There are a variety of planning strategies that can be used to help persons who would otherwise be ineligible to become eligible. Some of these strategies are fairly easy to implement, and others, exceedingly complex. Below are the most common.

WI has a Medically Needy Medicaid Program called the Medicaid Deductible Program for Medicaid applicants who have high medical expenses relative to their income. Also known as a spend-down program, applicants are permitted to spend “excess” income on medical expenses and health care premiums, such as Medicare Part B, in order to meet Medicaid’s income limit. The amount that must be “spent down” for each six-month period can be thought of as a deductible. Once one’s “deductible” has been met for the period, Family Care / Partnership will pay for care services and supports.

When persons have assets over the limits, trusts are an option. Irrevocable Funeral Trusts are pre-paid funeral and burial expense trusts that Medicaid does not count as assets. Another option are Medicaid Asset Protection Trusts, which not only protects assets from Medicaid’s asset limit, but also preserves them as inheritance by protecting them from Medicaid’s estate recovery program. There are many other options when the applicant has assets exceeding the limit.

Inadequate planning or improperly implementing a Medicaid planning strategy can result in a denial or delay of Medicaid benefits. Professional Medicaid planners are educated in the planning strategies available in the state of Wisconsin to meet Medicaid’s financial eligibility criteria without jeopardizing Medicaid eligibility. While there are a variety of planning strategies, some do violate Medicaid’s 60-month look back rule, and therefore, should be implemented well in advance of the need for long-term care. However, there are some workarounds, like the Modern Half-a-Loaf Strategy, and Medicaid planners are aware of them. For all of these reasons, it is highly suggested one consult a Medicaid planner for assistance in qualifying for Medicaid when over the income and / or asset limit(s). Find a Medicaid planner.

 

How to Apply for the Family Care & Family Care Partnership Programs

Before You Apply

Prior to applying for Family Care or Family Care Partnership, applicants need to ensure they meet the eligibility criteria. Applying when over the income and / or asset limit(s) will be cause for denial of benefits. The American Council on Aging offers a free Medicaid eligibility test to determine if one might meet Medicaid’s eligibility criteria. Take the Medicaid eligibility test.

As part of the application process, applicants will need to gather documentation for submission. Examples include copies of Social Security and Medicare cards, bank statements up to 60-months prior to application, proof of income, and copies of life insurance policies, property deeds, and pre-need burial contracts. Unfortunately, a common reason applications are held up is required documentation is missing or not submitted in a timely manner.

Since the Partnership Program is not an entitlement program, there could potentially be a waitlist for program benefits. However, at the time of this writing, there wasn’t a waitlist.

 

Application Process

To apply for the Family Care Program or Family Care Partnership Program, persons should contact their local Aging and Disability Resource Center (ADRC). Contact information can be found here. As part of the application process, an in-person functional needs assessment will be completed.

For additional information about Family Care, click here, and to learn more about Partnership, click here. Persons can also contact their local ADRC or call Member Services at 800-362-3002 for more information.

To see availability of MCO’s for Family Care by county, click here, and to see MCO’s for Family Care Partnership by county, click here 
The Wisconsin Department of Health Services (DHS) administers the Family Care and Family Care Partnership Medicaid Programs.

 

Approval Process & Timing

The WI Medicaid application process can take up to 3 months, or even longer, from the beginning of the application process through the receipt of the determination letter indicating approval or denial. Generally, it takes one several weeks to complete the application and gather all of the supportive documentation. If the application is not properly completed, or required documentation is missing, the application process will be delayed even further. In most cases, it takes between 45 and 90 days for the Medicaid agency to review and approve or deny one’s application. Based on law, Medicaid offices have up to 45 days to complete this process (up to 90 days for disability applications). Despite the law, applications are sometimes delayed even longer. Furthermore, if there is a waitlist for the Partnership Program, applicants may have to wait for a participant slot to become available.

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