IRIS PROVIDER AGREEMENT
between
WISCONSIN DEPARTMENT OF
HEALTH SERVICES
DIVISION OF MEDICAID
SERVICES
and
<<NAME OF ICA OR FEA>>
Issued January 1, 2021
Effective 1/1/2021 – 12/31/2022
Contract for IRIS Program between the
Wisconsin Department of Health Services, Division of Medicaid Services
and <<Name of ICA or FEA>>
Page 2
Table of Contents
I. Definitions ............................................................................................................................. 10
II. Functions and Duties of the Department ........................................................................... 24
Department of Health Services ...................................................................................... 24
Notification of Changes in Functional Eligibility Criteria ............................................. 24
Reports from the Contractors ......................................................................................... 24
Right to Monitor ............................................................................................................. 24
Technical Assistance .......................................................................................................... 24
Conflict of Interest ............................................................................................................. 24
III. Contractual Relationship .................................................................................................... 25
Contract .......................................................................................................................... 25
Precedence When Conflict Occurs ................................................................................. 25
Cooperation of Parties and Dispute Resolution ............................................................. 25
IRIS Contractor Certification ......................................................................................... 26
Reporting Deadlines ........................................................................................................... 26
Modification of the Contract .............................................................................................. 26
Corrective Action for Non-Compliance and Non-Performance .................................... 27
Sanctions for Violation, Breach, or Non-Performance .................................................. 28
Termination of the Contract ............................................................................................... 31
Indemnification .................................................................................................................. 35
Independent Capacity of the Contractor ......................................................................... 36
Omissions ........................................................................................................................... 36
Choice of Law ................................................................................................................ 36
Waiver ............................................................................................................................ 36
Severability ..................................................................................................................... 37
Force Majeure .................................................................................................................... 37
Headings ......................................................................................................................... 37
Assignability................................................................................................................... 37
Right to Publish.................................................................................................................. 37
Survival .............................................................................................................................. 37
Contract for IRIS Program between the
Wisconsin Department of Health Services, Division of Medicaid Services
and <<Name of ICA or FEA>>
Page 3
IV. Contractor Administration ................................................................................................. 38
General Administration Expectations ............................................................................ 38
FEA-Specific Administration Expectations ................................................................... 39
Liability Insurance .......................................................................................................... 39
Wisconsin Department of Financial Institutions Status ................................................. 40
Duplication of Services ...................................................................................................... 40
Separation in Lines of Business ......................................................................................... 40
Conflict of Interest ......................................................................................................... 41
Fraud............................................................................................................................... 41
Expansion and Geographic Service Regions ..................................................................... 41
Physical and Localized Presence ....................................................................................... 42
Company Structure and Leadership ............................................................................... 43
Administrative Services Agreements (ASA) ..................................................................... 43
Business Associate Agreement ...................................................................................... 44
Business Continuity........................................................................................................ 44
Commercial Leases ........................................................................................................ 45
Electronic Visit Verification (EVV) .................................................................................. 45
Participant Records ........................................................................................................ 47
Civil Rights Compliance and Affirmative Action Plan Requirements .......................... 51
Cultural Competency ......................................................................................................... 54
Policy and Procedure Manual ............................................................................................ 54
ICA-Specific Staff Expectations .................................................................................... 56
Participant Materials ...................................................................................................... 63
Marketing/Outreach Plans and Materials ....................................................................... 65
V. Eligibility ........................................................................................................................... 68
Individual Eligibility Requirements ............................................................................... 68
Separation from Eligibility Determination ..................................................................... 70
Cost Share Collection, Monitoring, and Reporting ........................................................ 70
Room and Board ............................................................................................................. 71
VI. Enrollment & Orientation .................................................................................................. 74
Contract for IRIS Program between the
Wisconsin Department of Health Services, Division of Medicaid Services
and <<Name of ICA or FEA>>
Page 4
ADRC Referral Process ................................................................................................. 74
Voluntary Enrollment ..................................................................................................... 74
Service Timeline Expectations ....................................................................................... 75
Enrollment and Orientation Services ............................................................................. 75
Individual Support and Service Plan Development ........................................................... 77
Orientation Service Level Expectations ............................................................................. 78
Disenrollment ................................................................................................................. 80
VII. Consulting Services ........................................................................................................... 83
Service Levels ................................................................................................................ 83
Competency Standards for IRIS Consultants ................................................................. 83
Ongoing Service Level Requirements ............................................................................ 84
Increased Service Levels ................................................................................................ 89
Participant Provider Service Agreement Language ........................................................... 91
Elder Adults/Adults at Risk Agencies and Adult Protective Services ............................... 93
IRIS Consultant Capacity Expectations ......................................................................... 94
Self-Directed Personal Care ........................................................................................... 94
VIII. Fiscal Employer Agent Services .................................................................................... 99
General Expectations ...................................................................................................... 99
Payroll and Claim System Requirements ....................................................................... 99
Bank Accounts ............................................................................................................... 99
Deposit Account ........................................................................................................... 100
Disbursement Account ..................................................................................................... 100
Account Reconciliation .................................................................................................... 100
Hold Harmless Agreement ........................................................................................... 100
Federal Employee Identification Number (FEIN) ....................................................... 100
Workers’ Compensation Payments .................................................................................. 101
IX. Service Providers ............................................................................................................. 103
Service Provider Setup ................................................................................................. 103
Service Provider Onboarding Packets .......................................................................... 103
Payments to Service Providers ..................................................................................... 104
Contract for IRIS Program between the
Wisconsin Department of Health Services, Division of Medicaid Services
and <<Name of ICA or FEA>>
Page 5
Timesheets for Participant-Hired Workers .................................................................. 106
Payments to Self-Directed Personal Care Worker ........................................................... 107
Employment-related Tax Reporting ................................................................................ 107
Reimbursement File ..................................................................................................... 107
Claims Adjudication ..................................................................................................... 108
Ineligible Service Providers ............................................................................................. 109
Home and Community-Based Settings Requirements Compliance ............................... 111
X. Information Technology/System Requirements .............................................................. 112
General Requirements .................................................................................................. 112
Governance and Privacy ............................................................................................... 115
Disaster Recovery Plan ................................................................................................ 117
WISITS: The Department Case management system (WISITS) ................................. 117
Functional Screen Information Access, ForwardHealth Partner Portal, and CARES ..... 119
XI. Hearings, Appeals, & Grievances .................................................................................... 121
Background .................................................................................................................. 121
Definitions .................................................................................................................... 121
Overall Policies and Procedures for Grievances and Appeals ..................................... 122
Notice of Action ........................................................................................................... 124
State Fair Hearing Process ............................................................................................... 125
XII. Financial Provisions ......................................................................................................... 127
Working Capital ........................................................................................................... 127
Restricted Reserve ........................................................................................................ 127
Financial Reporting ...................................................................................................... 130
Annual Financial Audit ................................................................................................ 130
Annual Financial Projections Submission ....................................................................... 133
Heightened Fiscal Monitoring ......................................................................................... 134
Fiscal Corrective Action ............................................................................................... 134
XIII. Quality Management (QM) .......................................................................................... 137
Department Oversight Activities. ................................................................................. 137
XIV. Reporting Requirements ............................................................................................... 140
Contract for IRIS Program between the
Wisconsin Department of Health Services, Division of Medicaid Services
and <<Name of ICA or FEA>>
Page 6
General ICA Reporting Expectations ........................................................................... 140
General FEA Reporting Expectations .......................................................................... 140
Encounter Reporting .................................................................................................... 140
Quarterly Employment Data Report ............................................................................ 141
Reports from the Department ........................................................................................... 142
Reports to the Department ............................................................................................... 142
FEA Data Integrity and Systems Assessments ............................................................ 142
XV. Payment to IRIS Contractors ........................................................................................... 145
Monthly Rate of Service (MROS) ............................................................................... 145
Suspension of Payment Based on Credible Allegation of Fraud ................................. 146
APPENDIX I. Contract Signatures ........................................................................................... 148
APPENDIX II. Key IRIS Program Publications and Forms ................................................... 149
Waiver and Manuals: .............................................................................................................. 149
Enrollment Reports and Maps: ................................................................................................ 149
Financial and Fiscal: ................................................................................................................ 149
Quality Management: .............................................................................................................. 149
Department Resources: ........................................................................................................... 149
Department of Health Services Forms Library ....................................................................... 149
Department of Health Services Publications Library: ............................................................. 149
APPENDIX III. Fiscal Employer Agent Paperwork Packet Expectations .............................. 150
Participant-Employer Packet ........................................................................................ 150
Participant-Hired Workers New Employee Packet ...................................................... 151
Vendor and Individual Provider Packet ....................................................................... 152
APPENDIX IV. Data Certification ........................................................................................... 154
Encounter Data Certification ........................................................................................ 154
Financial Certification .................................................................................................. 154
APPENDIX V. MATERIALS WITH SPECIFIC DUE DATES – ALL CONTRACTORS ... 156
Contract for IRIS Program between the
Wisconsin Department of Health Services, Division of Medicaid Services
and <<Name of ICA or FEA>>
Page 7
Preamble
Include, Respect, I Self-Direct (IRIS) is a program authorized under the Medicaid
Home and Community-Based Services (HCBS) waiver section 1915(c) of the
federal Social Security Act. The Wisconsin Department of Health Services (the
Department) oversees administration of the program including contracting with
IRIS consultant agencies (ICAs) and fiscal employer agents (FEAs) to provide
services as defined in this contract.
The goals related to the IRIS program are as follows:
INCLUDE – Wisconsin frail elders and adults with physical, intellectual or
developmental disabilities with long-term care needs who are Medicaid eligible
are included in communities across Wisconsin.
RESPECT – Participants are respected in that they are given the power to make
choices about their lives; they choose where they live, the relationships they build,
the work they perform, and the manner in which they participate in the
community.
I SELF-DIRECT – IRIS is a self-directed option in which the participant manages
a service plan within an individual budget to help meet his or her long-term care
needs.
IRIS was created in response to consumer demand and to offer individuals who
are eligible for long-term care in Wisconsin, a fully self-directed option. Prior to
IRIS, managed long-term care included Family Care, and, where available,
Family Care Partnership and the Program for All-Inclusive Care for the Elderly
(PACE). IRIS was designed and began in July 2008 as Wisconsin’s fully self-
directed support Medicaid health and community-based services waiver program.
Frail elders and adults with physical, intellectual, or developmental disabilities
may choose to participate in IRIS. A key feature of the program is the emphasis
on participation. Individuals who choose IRIS are called participants because
they, or their family participants or representatives, are able to actively participate
in the program by making decisions about and effectively self-managing their
long-term supports and services.
Participants are given a budget amount determined by the long-term care
functional screen results. With the IRIS budget, participants develop an
individualized plan that outlines which supports and services will help them
achieve their long-term care goals.
IRIS facilitates active participation by fostering another important key feature of
the program, self-direction. Within the context of IRIS, self-direction means
participants decide:
Which goods, supports, and services are needed to achieve and maintain
individual long-term care outcomes;
Contract for IRIS Program between the
Wisconsin Department of Health Services, Division of Medicaid Services
and <<Name of ICA or FEA>>
Page 8
The amount and location of goods, supports, and services provided, as well as
who provides these services;
How the IRIS budget is used to meet their needs responsibly and cost effectively;
and
The amount of assistance needed in planning for required goods, supports and
services.
In IRIS, self-direction leads to self-determination through which participants take
control of their long-term care outcomes and have the freedom to live a
meaningful life at home, at work, and in their communities.
This contract and the following documents define the IRIS program’s philosophy
and implementation:
IRIS Policy Manual (P-00708);
IRIS Work Instructions (P-00708A); and
IRIS Service Definition Manual (P-00708B).
All services and supports within the benefit package are delivered through the
IRIS program including:
Integration and support for Medicaid eligibility determination and enrollment
procedures;
Participant-centered outcome-based planning;
IRIS Consultant support navigating the IRIS program;
Individual Support and Services plan and service authorization creation;
Support of participant rights;
Responsiveness to grievance and appeals; and
Quality management of IRIS services.
It is the Department’s expectation under this contract that supports and services
will 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 over personal resources,
and receive services in the community while supporting each participant’s
individual outcomes, recognizing each participant’s preferences, and respecting
participant decisions. The Department further expects that each participant will
have the opportunity to make informed choices about where he or she will live,
how he or she will make or maintain connections to the community, and whether
he or she will seek competitive employment.
Any ICA or FEA that delivers the IRIS benefit under this contract must first be
certified by the Department. The Department then pays the ICA and FEA a fixed
monthly payment for each participant.
Contract for IRIS Program between the
Wisconsin Department of Health Services, Division of Medicaid Services
and <<Name of ICA or FEA>>
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This Contract describes the contractual relationship between the contracted
agency and the Department, the Department’s administrative requirements,
performance standards and expectations, and how the Department will monitor
each.
This contract is entered into with the State of Wisconsin represented by the
Division of Medicaid Services in the Department of Health Services, whose
principal business address is: One West Wilson Street, P.O. Box 309, Madison,
Wisconsin, 53707-0309, and <<Generic>> an IRIS Consultant Agency or a Fiscal
Employer Agency, hereafter ICA or FEA, whose principal business address is
<<Address>>.
Contract for IRIS Program between the
Wisconsin Department of Health Services, Division of Medicaid Services
and <<Name of ICA or FEA>>
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I. Definitions
Refer to the IRIS Service Definition Manual (P-00708B) for service definitions
and codes.
1. Abuse: as defined by Wis. Stats § 46.90(1)(a), means any of the following:
a) Physical abuse: intention or reckless infliction of physical pain or injury, illness,
or any impairment of physical condition.
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 criminal assault law, 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 no
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 his/her 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 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 Care: treatment, including all supplies and services, for an abrupt onset as in
reference to a disease. Acute connotes an illness that is of short duration, rapidly
progressive, and in need of urgent care.
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 his/her ability to care for his/her needs and
who has experienced, is currently experiencing, or is at risk of experiencing abuse,
neglect, self-neglect, or financial exploitation.
5. 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)
Contract for IRIS Program between the
Wisconsin Department of Health Services, Division of Medicaid Services
and <<Name of ICA or FEA>>
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counseling and referral for services, (d), coordination of services for individuals, (e)
tracking and follow-up, (f) social services, (g) care 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, service 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 himself or herself,
or another person.
6. 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.
7. 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
participant has the notice in hand at least 10 (ten) 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 18
th
; in a thirty (30) day month, it’s on or around the 17
th
.
8. Aging and Disability Resource Center (ADRC) or Aging Resource Center or
Disability Resource Center or Resource Center: an entity that meets the standards for
the operation and is under contract with the 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
ADRC.
9. Aging and Disability Resource Specialist (ADRS): a position authorized under Wis.
Stat. § 46.283(1) and 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 and receive support to access publicly funded long-term
care programs.
10. 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.
11. Assistance: cueing, supervision or partial or complete hands-on assistance from another
person.
Contract for IRIS Program between the
Wisconsin Department of Health Services, Division of Medicaid Services
and <<Name of ICA or FEA>>
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12. Behavior Modifying Medication: a psychotropic medication (i.e., prescription
medication within the classification of antipsychotic, mood stabilizing, anti-anxiety,
antidepressant, or stimulant and/or medication outside of these classifications utilizing
off-label use as a means to regulate behaviors).
13. Business Day: Monday through Friday, except days which the office of the IRIS
consultant agency or fiscal employer agent are closed.
14. Centers for Medicare and Medicaid Services (CMS): the federal agency responsible
for oversight and federal administration of Medicare and Medicaid programs.
15. Claim: A request for payment for services and benefits received by an IRIS participant
that is authorized and program allowable.
16. Community Supports: supports and services that are not authorized or paid for by the
participant’s budget and that are readily available to the general population.
17. Complex Medication Regime: the participant 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.
18. 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 (PII);
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.
19. Conflict of Interest: a situation where a person or entity other than the participant is
involved in planning or delivery of services to the participant, and that has an interest in,
or the potential to benefit from, a particular decision, outcome, or expenditure.
Contract for IRIS Program between the
Wisconsin Department of Health Services, Division of Medicaid Services
and <<Name of ICA or FEA>>
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20. Contract/the Contract: the contractual agreement between the Wisconsin Department of
Health Services and the IRIS consultant agency or fiscal employer agent
21. Contractor: for purposes of this contract, Contractor is used to refer to contractual
obligations that are applicable to both IRIS consultant agencies and fiscal employer
agents.
22. Corrective Action Plan (CAP): a step-by-step plan of action that is developed to
achieve targeted outcomes for resolution of identified errors.
23. Cost Share: the contribution towards the cost of services required under 42 C.F.R. §
435.726 as a condition of eligibility for Medicaid for some participants who do not
otherwise meet Medicaid categorical or medically needy income limits.
24. 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.
25. 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.
26. Critical Incident: any actual or alleged event or situation that creates a significant risk of
substantial or serious harm to the physical or mental health, safety, or well-being of a
participant. This can occur when the participant receives non-routine treatment in a
hospital or urgent care facility, or when any other event occurs that places the
individual’s health and safety in jeopardy.
27. Days: calendar days unless otherwise noted.
28. Department: the Wisconsin Department of Health Services (DHS) or its designee.
29. 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 inflicted individual. “Development
disability” does not include senility that is primarily caused by the process of aging or the
infirmities of aging.
30. DHS: the Wisconsin Department of Health Services.
Contract for IRIS Program between the
Wisconsin Department of Health Services, Division of Medicaid Services
and <<Name of ICA or FEA>>
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31. 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.”
32. 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.
33. 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 in serious jeopardy;
b) Serious impairment to bodily functions; or
c) Serious dysfunction of any bodily organ or part.
34. Emergency Services: covered fee-for-service 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.
35. Encounter Reporting: the collection and reporting of encounter data to the Department
of Health Services is submitted via the Long-Term Care Information Exchange System
(IES). Encounter data are detailed records of services or items that have been provided to
IRIS participants.
36. Enrollment Consultant: the individual who performs enrollment counseling activities 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 an ICA
or FEA and advising on what factors to consider when choosing among these options.
37. Fair Hearing: a de novo proceeding under Wis. Admin. Code. ch. HA3, before an
impartial administrative law judge at the Division of Hearings and Appeals, 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 ICA in
the petitioner’s case should be corrected.
38. Fee-for Service (FFS): a payment model where health care services are paid for
separately, by each service performed.
39. 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 IRIS consultant agency or fiscal
Contract for IRIS Program between the
Wisconsin Department of Health Services, Division of Medicaid Services
and <<Name of ICA or FEA>>
Page 15
employer agent, 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 knowingly and/or intentionally misrepresented facts to obtain
payment.
40. Financial Exploitation: includes any of the following acts:
a) Fraud, enticement or coercion;
b) Theft;
c) Misconduct by a fiscal employer 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.
41. Fiscal employer agent (FEA): contracted agent to process payroll, manage Federal and
State tax withholdings, and report obligations related to participant-hired workers in the
IRIS program. FEAs also ensure provider qualifications, pay vendor claims, and collect
participant Medicaid cost share payments.
42. Fiscal Oversight: the Department of Health Services section responsible for the analysis,
review, and oversight of audited financial reports, financial projections, quarterly
financial reporting, restricted reserve payments, and working capital requirements.
43. 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.
44. Functional capacity: the skill to perform activities in an acceptable manner.
45. 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.
46. 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.
47. 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.
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Wisconsin Department of Health Services, Division of Medicaid Services
and <<Name of ICA or FEA>>
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48. 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 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.
49. Home: a place of abode and lands used or operated in connection with the place of
abode.
50. Hospital: has the meaning specified in Wis. Stat. § 50.33(2).
51. Income Maintenance 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.
52. 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:
Contract for IRIS Program between the
Wisconsin Department of Health Services, Division of Medicaid Services
and <<Name of ICA or FEA>>
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a) Is a participant of a Federally recognized Indian tribe; or
b) Resides in an urban center and meets one or more of these four criteria:
c) Is a participant 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 participant;
d) Is an Eskimo or Aleut or other Alaska Native;
e) Is considered by the Secretary of the Interior to be an Indian for any purpose; or
f) Is determined to be an Indian under regulations issued by the Secretary;
g) 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.
53. Individual at Risk: an elder adult at risk (age 6o and over) or an adult at risk (age 18-
59).
54. Individual Support and Service Plan: A written plan developed by an IRIS participant
and their legal decision maker (if applicable) that lists the goods, supports, and services
chosen by the participant to meet their long-term care needs and outcomes; the cost of
services; their frequency; and the provider of each service. Unpaid goods and support, as
well as Medicaid-funded services received, are also listed on the plan, as well as goods,
supports, and services received at no cost.
55. Individually Identifiable Health Information: participant 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 services and supports, or payment for health care that identifies the
individual or could reasonably be expected to lead to the identification of the individual.
56. Ineligible Person: a person is ineligible for enrollment in the IRIS program if the person
fails to meet the eligibility requirements specified by the Department, the resource center
or income maintenance agency prior to enrollment in the ICA, or if the person
determined to be eligible prior to enrollment no longer meets eligibility requirements as
determined by DHS, the resource center, or income maintenance agency.
57. 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.
58. 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.
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59. IRIS (Include, Respect, I Self-Direct): Wisconsin’s self-directed long-term care
program for frail elders and adults with physical and/or developmental disabilities to get
the services they need to remain in their homes whenever possible and maintain
independence. IRIS is available to Wisconsin residents determined financially and
functionally eligible for Medicaid who met a level of care eligible for admittance to a
nursing home (i.e., frail elders and individuals with a physical disability) or intermediate
care facility for individuals with intellectual disabilities (ICF/IID).
60. IRIS Budget: The money necessary to fund an IRIS participant’s ongoing services,
which excludes one-time and high-cost items. Each participant receives a budget estimate
prior to their enrollment in IRIS and said budget is based upon an IRIS participant’s
needs and can be changed if needed.
61. IRIS Consultant Agency (ICA) and IRIS Consultant (IC): IRIS consultant agencies
hire and support a staff of IRIS consultants. IRIS consultants provide flexible and
specialized support that is responsive to a participant’s needs and preferences for long-
term care services. The IRIS consultant’s roles and responsibilities focus on supporting
the participant in self-direction, which includes enrollment and orientation, service
planning, plan development, quality monitoring, coordination with FEAs, ongoing
support and assistance, and continued eligibility assistance.
62. IRIS Self-Directed Personal Care (IRIS SDPC): the care provided to an IRIS
participant by his or her participant-hired worker. This care specifically refers to the
assistance provided in the areas of bathing, toileting, dressing, and transferring, feeding,
and related tasks. IRIS SDPC provides flexibility in where the care is provided and also
allows the participants to hire a spouse as caregiver. IRIS SDPC is governed by and
defined according to the 1915(j) state plan amendment, and is overseen by the contracted
IRIS SDPC Oversight Agency.
63. IRIS Self-Directed Personal Care Oversight Agency: a contracted agency with the
Department to administer the IRIS SDPC program. Agency nurses perform clinical
assessments and obtain the needed authorizations that enable the participant to employ
his or her own workers for personal cares.
64. Legal Decision Maker: a participant or potential participant’s legal decision maker is a
person who has legal authority to make certain decisions on behalf of a participant or
potential participant. A legal decision maker may be 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 participant 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
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relevant to that provision. A person designated by the participant or potential participant
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.
65. Limited English Proficient (LEP): a potential participant and participants 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.
66. Long-Term Care Facility: a nursing home, adult family home, community-based
residential facility, or residential care apartment complex.
67. Long-Term Care Functional Screen or LTCFS: a uniform screening tool prescribed by
DHS that is used to determine functional eligibility.
68. Marketing/Outreach: any communication, sponsorship of community events, or the
production and dissemination of marketing/outreach materials from an ICA or FEA,
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 a particular IRIS consultant agency, fiscal
employer agent, or managed care organization or to disenroll from another IRIS
consultant agency, fiscal employer agent, or managed care organization. This further
includes materials and presentations to community participants/groups, participants,
stakeholders, non-profit organizations, professional conferences, etc. on topics related to
the IRIS program or their agency’s role as a Contractor.
69. Marketing/Outreach Materials: materials in all mediums, including but not limited to,
internet websites, brochures and leaflets, newspapers, magazine, radio, television,
billboards, yellow pages, advertisements, other printed media and presentation materials,
used by or on behalf of an ICA or FEA to communicate with individuals who are not
participants, and that can be reasonably interpreted as intended to influence the
individuals to enroll or reenroll in the ICA or FEA, as well as those materials that are
intended to inform on the IRIS program, its policies, or a Contractor’s role as an ICA or
FEA. Marketing/Outreach Materials also refers to social media postings.
70. Master Client Index or MCI: this index is a way to identify the same person between
different computer systems. The Department’s case management system (WISITS),
Client Assistance for Reemployment and Economic Support (CARES), the LTC
Functional Screen and the ForwardHealth interChange Partner Portal system all use MCI.
71. 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.”
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72. Medical Assistance Personal Care Program (MAPC): a benefit of the Wisconsin
Medicaid State Plan provided by a Medicaid certified agency that provides personal care
in-home assistance with the ADLs to eligible State residents.
73. Medicaid Provider Agreement: a written agreement between a provider and the
Department.
74. 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.
75. Monthly Rate of Service (MROS): A contractually specified dollar amount paid to and
IRIS consultant agency or fiscal employer agent each month for each Medicaid eligible
person enrolled in the IRIS program on the first of the month for whom the contractor is
providing services to perform the IRIS consultant agency or fiscal employer agent
contracted services.
76. Natural Supports: individuals who are available to provide unpaid, voluntary assistance
to the participant in lieu of paid supports and/or State Plan or home and community-based
services (HCBS). They are typically individuals from the participant’s social network
(family, friends, neighbors, etc.).
77. Neglect: the failure of a caregiver, as evidenced by an act, omission, or course of
conduct, to endeavor to secure or maintain adequate care, services, or supervision for an
individual, including food, clothing, shelter, or physical or mental health care, and
creating significant risk or danger to the individual’s physical or mental health. “Neglect”
does not include a decision that is made to not seek medical care for an individual, if that
decision is consistent with the individual’s previously executed declaration or do-not-
resuscitate order under Wis. Stat. ch. 154, a power of attorney for health care under Wis.
Stat. ch. 155, or as otherwise authorized by law.
78. Outcome: a desirable situation, condition, or circumstance in a participant’s life that can
be a result of the support and services provided through the IRIS program. Long-term
care outcomes are situations, conditions, or circumstances that a participant and the legal
decision maker identifies that maximizes the participant’s highest level of independence.
This outcome is based on the participant’s identified clinical and functional outcomes, as
well as their personal experiences. Clinical outcomes relate to an identified need,
condition, or circumstance that relates to a participant’s individual physical, mental, or
emotional health, safety, or well-being, whereas functional outcomes relate to an
identified need, condition, or circumstance that results in limitations on the participant’s
ability to perform certain functions, tasks, or activities and require additional support to
help the participant maintain or achieve their highest level of independence, including,
but not limited to, assistance with ADLs and IADLs. Participant outcomes should address
a participant’s ability to maintain and/or establish a living arrangement of their own;
maintain and/or obtain community-integrated employment; maintain and/or establish
community inclusion; ensure health and safety; building positive relationships; and have
control of, and access to, transportation.
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79. Participant: an individual enrolled in the IRIS program.
80. Participant-hired worker (PHW): a caregiver that provides supports and services to an
IRIS participant when the participant is also the employer of record. The FEA functions
as employer agent for the participant, as the worker is not associated with an agency.
81. Participant materials: materials in any medium intended to inform participants of
benefits, procedures, providers, budget calculations, including but not limited to
brochures or other materials used by or on behalf of a Contractor to communicate with
participants.
82. Personally Identifiable Information: an individual’s last name and the individual’s first
name or first initial, in combination with and linked to any of the following elements, if
the element is not publicly available information and is not encrypted, redacted, or altered
in any manner that renders the element unreadable:
a) The individual’s Social Security number;
b) The individual’s driver’s license number or state identification number;
c) The individual’s date of birth;
d) The number of the individual’s financial account, including a credit or debit card
account number, or any security code, access code, or password that would permit
access to the individual’s financial account;
e) The individual’s DNA profile; or
f) The individual’s unique biometric data, including fingerprint, voice print, retina
or iris image, or any other unique physical characteristic.
83. Physical Abuse: the willful or reckless infliction of bodily harm. Bodily harm means
physical pain or injury, illness, or any impairment of physical condition.
84. Physical Disability: a physical condition, including an anatomical loss or
musculoskeletal, neurological, respiratory or cardiovascular impairment, that results from
injury, disease or congenital disorder and that significantly interferes with or significantly
limits at least one major life activity of a person. In the context of physical disability,
“major life activity” means self-care, performance of manual tasks unrelated to gainful
employment, walking, receptive and expressive language, breathing, working,
participating in educational programs, mobility other than walking, and capacity for
independent living.
85. Potential Participant or Potential Enrollee: a person who is or may be eligible to enroll
in the IRIS program, but who is not yet a participant.
86. Provider: any individual or entity that has a MA provider agreement with DHS.
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87. Residential Care Apartment Complex or RCAC: a place where 5 or more adults reside
that consists of independent apartments, each of which has an individual lockable
entrance and exit, a kitchen, including a stove, and individual bathroom, sleeping and
living areas, and that provides, to a person who resides in the place, not more than 28
hours per week of services that are supportive, personal and nursing services.
“Residential care apartment complex” does not include a nursing home or a community-
based residential facility, but may be physically part of a structure that is a nursing home
or community-based residential facility.
88. Restrictive Measure: any type of restraint, isolation, seclusion, protective equipment, or
medical restraint.
89. Secretary: means the secretary of the Wisconsin Department of Health Services.
90. Self-neglect: means a significant danger to an individual’s physical or mental health
because the individual is responsible for his/her own care but fails to obtain adequate
care, including food, shelter, clothing, or medical or dental care. See Wis. Stat. s.
46.90(1)(g).
91. Service Area: the service area also relates to the geographic service region in which
specific ICAs and FEAs operate.
92. Sexual Abuse: sexual conduct in the first through fourth degree as defined in Wis. Stat. §
940.225.
93. Supported Decision-Making: a set of strategies that help individuals understand their
options when making choices and communicating their own decisions through the use of
an agreement designed to help the person interact and communicate their decisions with
third parties. The agreement will include a list of decisions the person wants assistance in
making and identifies a supporter(s) they want to help them, as detailed and defined in
Wis. Stat. Ch. 52.
94. Target Group or Target Population: any of the following groups that an ICA or FEA
has contracted with DHS to serve:
a) Frail elderly.
b) Adults with a physical disability.
c) Adults with a developmental disability.
95. Timesheet: The document containing the participant-hired worker’s name and ID
number (if applicable), participant name and ID number (if applicable), hours worked
each day, total hours worked within the pay period, code for the service that was
provided, and the FEA-developed attestation language.
96. Urgent Care: medically necessary care that is required due to an illness or accidental
injury that is not life-threatening and will not result in further disability but has the
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potential to develop such a threat if treatment is delayed longer than twenty-four (24)
hours.
97. Vulnerable/High Risk Participant: a participant who is dependent on a single caregiver,
or two or more caregivers all of whom are related to the participant or all of whom are
related to one another, to provide or arrange for the provision of nutrition, fluids, or
medical treatment that is necessary to sustain life and to whom at least one of the
following applies:
a) Is nonverbal and unable to communicate feelings or preferences; or
b) Is unable to make decisions independently; or
c) Is clinically complex, requiring a variety of skilled services or high utilization of
medical equipment; or
d) Is medically frail.
98. Wisconsin’s Self-Directed Information Technology System (WISITs): the web-based
centralized case management system managed by DHS and utilized by all IRIS
contracted agencies. The Department case management system (WISITS) is the system of
record for all information about IRIS participants and retains records of eligibility,
contact information, service plans, service authorizations, care team, incidents,
complaints and grievances, work requests, case notes, personal cares, service providers,
etc. The system supports the operationalization of the IRIS program and IRIS SDPC
services.
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II. Functions and Duties of the Department
Department of Health Services
The Division of Medicaid Services (DMS) is the primary point of contact among
the Department, the Contractor, and the Department’s contracted agencies
responsible for the administration and operation of the IRIS program. DMS staff
may assist the Contractor in identifying system barriers to implementation of the
programs and may facilitate intra-and interagency communications and work
groups necessary to accomplish full implementation.
Notification of Changes in Functional Eligibility Criteria
The Department will notify the Contractors of any changes in administrative code
requirements related to functional eligibility, including, but not limited to, code
changes that result in changes to the LTCFS algorithms or logic in determining
functional eligibility for the programs.
Reports from the Contractors
The Department will acknowledge receipt of the reports required in this contract.
The Department shall have systems in place to ensure that reports and data
required to be submitted by the Contractor shall be reviewed and analyzed by the
Department in a timely manner. The Department will respond with any concerns.
Right to Monitor
The Department shall have the right to review any program related records,
documentation, and materials and to request any additional information. The
Department may also monitor any of the processes and expectations outlined in
this contract at any time to ensure compliance and quality performance.
Technical Assistance
The Department shall review reports and data submitted by the Contractor and
shall share results of this review with the Contractor. In conjunction with the
Contractor, the Department shall determine whether technical assistance is needed
to assist in improving performance in any identified areas. The Department, in
consultation with the Contractor, may develop a technical assistance plan and
schedule to assure compliance with all terms of this contract and quality service to
participants of the Contractor.
Conflict of Interest
The Department employees are subject to safeguards to prevent conflict of
interest as set forth in Wis. Stats. Ch. 19.
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III. Contractual Relationship
Contract
The Contractor acknowledges it is subject to certain federal and state laws,
regulations and policies, including those related to Title XIX of the Social
Security Act, those pertinent to Wisconsin’s Medicaid program, official written
policy as transmitted to the Contractor in the Wisconsin Medicaid program
handbooks and bulletins, the standards for the specific Medicaid waiver service
the Contractor will deliver and the other requirements as defined in these criteria
and the 1915(c) Home and Community Based Services (HCBS) Waiver.
The Contractor acknowledges that it is responsible for knowing the provisions of federal
and state laws, regulations, this contract, the IRIS 1915(c) HCBS Waiver, and policies
that apply, as well as for complying with applicable federal and state law as a condition
of its participation as a provider of IRIS consultant agency or fiscal employer agent
services under Wisconsin’s Medicaid program.
Precedence When Conflict Occurs
In the event of any conflict among the following authorities, the order of
precedence is as follows:
1. Federal law, state statutes, administrative code, and the accompanying IRIS
1915(c) Waiver;
2. DHS numbered memos;
3. This contract;
4. IRIS program governing documents, e.g., the IRIS Policy Manual, IRIS Work
Instructions, and the IRIS Service Definition Manual; and
5. IRIS contractor certification documents.
Cooperation of Parties and Dispute Resolution
1. Agreement to Cooperate
The parties agree to fully cooperate with each other in connection with the
performance of their respective obligations and covenants under this contract.
2. Contract Dispute Resolution
The parties shall use their best efforts to cooperatively resolve disputes and
problems that arise in connection with this contract. When a dispute arises that the
Contractor and the Department have been unable to resolve, the Department
reserves the right to final interpretation of contract language.
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3. Reconsideration
Contractors may request reconsideration of any decisions regarding certification,
contracting, or corrective action plans by submitting a request for reconsideration,
in writing, to the Department. It is the responsibility of the Contractor to provide
sufficient documentation and justification to refute the Department’s decision(s).
The Contractor must first exhaust the reconsideration process before resorting to
any other legal remedy it may have available.
The request for reconsideration must be received within 30 days of receiving
notice of the Department’s decision. The request must state the reason the
contractor believes the decision was made in error, and is encouraged to provide
documentation, and the accompanying narrative to explain the documentation.
The Department will review the information and a final decision will be rendered
within 30 days of receipt of the Contractor’s request.
Once a reconsideration decision has been reached, the decision shall be
considered final.
4. Performance of Contract Terms During Reconsideration
The existence of a dispute notwithstanding:
a. Both parties agree to continue without delay to carry out all their
respective responsibilities which are not affected by the dispute; and
b. The Contractor further agrees to abide by the interpretation of the
Department regarding the matter in dispute while the Contractor seeks
further review of that interpretation.
IRIS Contractor Certification
To be eligible to enter into a contractual relationship with the Department,
agencies need to be certified by the Department.
Reporting Deadlines
It is expected that the Contractor will meet deadlines outlined in this contract and
any other Department program materials. If the Contractor is unable to meet the
deadlines set forth, they will be expected to provide a request for extension, to
include the reason and the deadline they expect to provide the report. The
Department will review and approve or deny the request for extension. This
request should be submitted prior to the deadline.
Modification of the Contract
This Contract will be modified if changes in federal or state laws, regulations,
rules, or amendments to Wisconsin’s CMS approved waivers or the MA state plan
require modification to the contract. In the event of such change, the Department
will notify the Contractor in writing. If the change materially affects the
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Contractor’s rights or responsibilities under the contract and the Contractor does
not agree to the modification, the Contractor may provide the Department with
written notice of termination at least ninety (90) days prior to the proposed date of
termination.
This contract may be modified at any time by written mutual consent of the contractor
and the Department. Unless otherwise agreed to, the effective date of any modification(s)
of this contract is the later of the dates signed by authorized persons from the contractor
and the Department.
Corrective Action for Non-Compliance and Non-Performance
If the Contractor fails to meet the requirements or performance expectations
described in this contract, the Department may impose a plan of correction to
ensure that the Contractor comes into compliance with the contract.
1. Corrective Action Plan
Developed in collaboration with the Department and the Contractor, a corrective
action plan (CAP) is a step-by-step plan of action that is developed to achieve
targeted outcomes for resolution of identified errors in an effort to:
a. Identify the most cost-effective actions that can be implemented to correct
error causes;
b. Develop and implement a plan of action to improve processes or methods
so that outcomes are more effective and efficient;
c. Achieve measurable improvement in the highest priority areas; and
d. Eliminate repeated deficient practices.
2. Imposition of Intensive Oversight
The Department may also implement intensive oversight of the Contractor’s
operations in order to assist the Contractor to come into compliance with
performance expectations.
When intensive oversight is imposed, the Department may place Department staff
or designated representatives at the Contractor agency to assist the Contractor in
meeting its performance expectations by providing technical guidance and
correcting deficiencies.
3. Penalties and Authority to Impose Sanction
a. Corrective actions can be short or long-term, and it remains at the State’s
discretion for completion and resolution of corrective action.
b. If a Contractor is under Corrective Action, they may not expand into
additional geographic service regions. After completion of a CAP, as
indicated by a formal letter from the Department, Contractors must wait an
additional 90 days before requesting expansion, provided no other
corrective actions are pending.
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c. If improvement is not made, or a CAP is not resolved by the time
indicated on the plan without prior approval for an extension, additional
corrective action may be necessary, up to and including a formal sanction
and/or termination of the contract.
Sanctions for Violation, Breach, or Non-Performance
1. Authority to Impose Sanctions
a. If DHS determines the Contractor has violated or breached the contract,
through failure to meet performance expectations or comply with
substantive terms of the contract, it may impose sanctions, as set forth
herein. DHS may base its determinations on findings from any source.
b. DHS may pursue all sanctions and remedial actions with the Contractor
consistent with those taken with Medicaid fee-for-service providers,
including any civil penalties not to exceed the amounts specified in the
Balanced Budget Amendment of 1997, § 4707(a). If a basis for imposition
of a sanction exists as described herein, the Contractor may be subject to
sanctions as described herein.
2. Basis for Imposing Sanctions
DHS may impose sanctions if it determines the Contractor has failed to meet any
of the following requirements and expectations:
a. The Contractor shall provide all required services under law and the
contract to any participant covered under the contract.
b. The Contractor shall not impose premiums or charges on participants that
are in excess of the premiums or charges permitted under the Medicaid
program.
c. The Contractor shall not act to discriminate among participants on the
basis of their health status or need for health care services. This includes,
but is not limited to, termination of enrollment or refusal to reenroll a
participant, except as permitted under the Medicaid program, or any
practice that would reasonably be expected to discourage enrollment by
participants whose medical condition or history indicates probable need
for substantial future contractual services.
d. The Contractor shall not misrepresent or falsify information that it
furnishes to CMS or to DHS.
e. The Contractor shall not misrepresent or falsify information that it
furnishes to a participant, potential participant, or a provider.
f. The Contractor shall not distribute directly or indirectly through any agent
or independent contractor, materials that have not been approved by DHS
or that contain false or materially misleading information.
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g. The Contractor shall meet financial performance expectations for solvency
and financial stability as set forth in this contract.
h. The Contractor shall meet the quality standards and performance criteria
of this contract such that participants are not at substantial risk of harm.
i. The Contractor shall meet all obligations described herein in order to
prevent the unauthorized use, disclosure, or loss of confidential
information.
j. The Contractor shall meet all other obligations described in federal law,
state law and the contract not otherwise described above.
k. FEAs shall meet the encounter reporting submission and data certification
requirements (See Appendix V).
3. Types of Sanctions
DHS may impose the civil monetary penalties for the violations described above,
as well as one or more of the following:
a. Appointment of temporary management for Contractor.
b. Notifying the affected participants of their right to disenroll.
The Contractor shall provide assistance to any participant electing to
terminate his or her enrollment, by making appropriate referrals and
providing the individual’s participant record to new providers and/or a
participant’s new ICA, FEA, or MCO.
DHS shall ensure that a participant who is disenrolled receives appropriate
choice counseling and is permitted to enroll in a new ICA, FEA, or MCO
of the participant’s choosing.
c. Suspension of all new enrollments after the effective date of the sanction.
The suspension period may be for any length of time specified by the
Department, or may be indefinite.
d. Suspension of monthly rate of service (MROS) payments for participants
enrolled after the effective date of the sanction and until CMS or DHS is
satisfied that the reason for imposition of the sanction no longer exists and
is not likely to recur.
e. Imposition of a plan of correction and/or intensive oversight of Contractor
operations by DHS without appointment of a temporary manager.
f. Withholding or recovering of MROS payments.
g. Termination of the contract.
h. Any other sanctions that DHS determines, in its sole discretion, to be
appropriate.
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4. Notice of Sanctions
a. Notice to Contractor
i. DHS must give the affected Contractor written notice that explains
the following:
a) The basis and nature of the sanction.
b) Any other due process protections that DHS elects to
provide.
b. Notice to CMS
DHS must notify CMS no later than 30 calendar days after the imposition
or lifting of any sanction described above. The notice shall include the
name of the Contractor, the kind of sanction, and the reason for DHS’s
decision to impose or lift the sanction.
5. Amounts of Civil Monetary Penalties
Civil monetary penalties may be imposed as follows:
a. A maximum of $25,000 for each of the following violations, as defined
above:
i. Failure to provide services.
ii. Misrepresentation or false statements to participants, potential
participants, or providers.
iii. Marketing violations.
b. A maximum of $100,000 for each violation of:
i. Discrimination.
ii. Misrepresentation or false statements to CMS or DHS.
c. A maximum of $15,000 for each participant DHS determines was not
enrolled because of a discriminatory practice (subject to the $100,000
overall limit above).
d. A maximum of $25,000 or double the amount of the excess charges,
(whichever is greater) for premiums or charges in excess of the amounts
permitted under the Medicaid program. DHS must deduct from the penalty
the amount of overcharge and return it to the affected participant(s).
e. A maximum of $50,000 per incident for a violation of HIPAA
confidentiality and security described herein, consisting of:
i. $100 for each individual whose confidential information was used,
disclosed, or lost; and
ii. $100 per day for each day that the Contractor fails to substantially
comply with the directives described herein;
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iii. In addition, in the event of a federal citation for a breach of
confidentiality caused by an action or inaction of the Contractor,
the Contractor is responsible for the full amount of any federal
penalty imposed without regard to the limit set forth above.
f. A maximum of $100,000 for any other violation described above.
6. Recovery of Damages
In any case under this contract where DHS has the authority to withhold Monthly
Rate of Service (MROS) payments, DHS also has the authority to use all other
legal processes for the recovery of damages.
DHS may withhold or recover portions of the MROS payments in liquidated
damages or otherwise recover damages from the Contractor notwithstanding the
provisions of this contract. The withholding or recoveries will be made absent the
Contractor’s prompt and reasonable efforts to remove the grounds described.
7. Authority to Terminate Contract
The Department has the authority to terminate a Contractor’s contract and enroll
that entity’s participants in other Contractor agencies of the participant’s
choosing, or provide their Medicaid benefits through other options included in the
State plan, if the Department determines that the Contractor has failed to carry out
the substantive terms of the contract.
Termination of the Contract
1. Termination
a. Mutual Agreement for Termination
The contract may be terminated at any time by mutual written consent of
both the Contractor and the Department.
b. Unilateral Termination
The contract may be unilaterally terminated only as follows:
i. Termination for Convenience
Either party may terminate this Contract at any time, without
cause, by providing a written notice to the other party at least 90
days in advance of the intended date of termination.
ii. Changes in Federal or State Law
The contract may be terminated at any time, by either party, due to
modifications mandated by changes in federal or state law or
regulations that materially affect either party’s rights or
responsibilities under this contract.
In such case, the party initiating such termination procedures must
notify the other party in writing, at least ninety (90) days prior to
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the proposed date of termination, of its intent to terminate this
contract. Termination by the Department under these
circumstances shall impose an obligation upon the Department to
pay the Contractor’s reasonable and necessary costs to end
operations and does not include ongoing expenses such as lease
payments due after the date of termination.
iii. Changes in Reporting Requirements
If the Department proposes additional reporting requirements
during the term of the contract, the Contractor will have thirty (30)
days to review and comment on the fiscal impact of the additional
reporting requirements. The Department will consider any
potential fiscal impact on the Contractor before requiring
additional reporting. If the change has significant fiscal impact, the
Contractor may provide the Department with written notice of
termination at least ninety (90) days prior to the proposed date of
termination and will not be required to provide the additional
reporting.
iv. Termination for Cause
If either party fails to perform under the terms of this Contract, the
other party may terminate the Contract by providing written notice
of any defects or failures to the non-performing party.
a) The Contractor will receive written notice of the
Department’s intent to decertify and terminate the contract
60 days prior to the effective date, to include the reason for
termination.
b) The Contractor will have 30 calendar days from the date of
receipt of notice to cure the failures or defects established
within the notice sent by the Department.
c) If the failures or defects are not cured within 30 days of the
non-performing party receiving the notice, the other party
may terminate the Contract.
v. Termination when Federal or State Funds are Unavailable
a) Permanent Loss of Funding
This contract may be terminated by either party, in the
event federal or state funding of contractual services
rendered by the Contractor becomes permanently
unavailable and such lack of funding would preclude
reimbursement for the performance of the Contractor’s
obligations. In the event it becomes evident state or federal
funding of claims payments or contractual services
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rendered by the Contractor will become unavailable, the
Department shall immediately notify the Contractor, in
writing, identifying the basis for the anticipated
unavailability of funding and the date on which the funding
will end. In the event of termination, the contract will
terminate without termination costs to either party.
b) Temporary Loss of Funding
In the event funding will become temporarily suspended or
unavailable, the Department will suspend the Contractor’s
performance of any or all of the Contractor’s obligations
under this contract if the suspension or unavailability of
funding will preclude reimbursement for performance of
these obligations. The Department shall attempt to give
notice of suspension of performance of any or all of the
Contractor’s obligations sixty (60) days prior to said
suspension, if possible; otherwise, such notice of
suspension should be made as soon as possible. Once the
funding is reinstated, the Contractor will resume the
suspended services within thirty (30) days from the date the
funds are reinstated. The contract will not terminate under a
temporary loss of funding.
2. Contract Non-Renewal
The Contractor or the Department may decide to not renew this contract. In the
case of a non-renewal of this contract, the party deciding to not renew this
contract must notify the other party in writing at least ninety (90) calendar days
prior to the expiration date of this contract.
3. Transition Plan – Transfer of Participants
a. After the Department notifies a Contractor that it intends to terminate the
contract for failing to carry out substantive terms of this Contract, the
Department may do the following:
i. Give the Contractor’s participants written notice of the Department’s
intent to terminate the contract and notify participants of the
requirement to transfer to another ICA or FEA.
ii. Notify the Contractor’s participants of their right to disenroll.
b. The Contractor shall provide assistance to any participant electing to
terminate his or her enrollment, by making appropriate referrals and
providing the individual’s participant record to new providers and/or a
participant’s new Contractor or MCO.
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c. The Department shall ensure that a participant who is disenrolled receives
appropriate choice counseling and is permitted to enroll with a new
Contractor or MCO of the participant’s choosing.
d. Contractors are encouraged to refer to the Transition of Care between
Medicaid Programs or Between Agencies within a Medicaid Program (P-
02364) for additional information.
4. Transition Plan
In the case of this contract being terminated or there is a decision by either party
not to renew this contract, the Contractor shall submit a written plan that receives
the Department’s approval, to ensure uninterrupted delivery of services to
participants and their successful transition to applicable programs (e.g., Medicaid
fee-for-service). The plan will include provisions for the transfer of all
participant-related information held by the Contractor or its providers and not also
held by the Department.
a. Submission of the Transition Plan
The Contractor shall submit the plan at one of the following times,
depending on which applies: no less than ninety (90) calendar days prior
to the contract’s expiration when the Contractor decides to not renew the
contract; within ten (10) business days of notification of termination by
the Department; or along with the Contractor’s notice of termination.
b. Management of the Transition
The Contractor shall designate a person responsible for coordinating the
transition plan and will assign staff as the Department determines is
necessary to assist in the transition. Status meetings including staff from
all parties involved in the transition will be held as frequently as the
Department determines is necessary.
c. Continuation of Services
If the Contractor has been unable to successfully transition all participants
to applicable programs or agencies by the time specified in the approved
transition plan, the Contractor shall continue operating as an ICA or FEA
under this contract until all participants are successfully transitioned. The
Department will determine when all participants have been successfully
transitioned to applicable programs or agencies.
If the Department determines it necessary to do so, the Contractor will
agree to extend this contract, in order to continue providing services to
participants until they are successfully transitioned to applicable programs.
During this period the Contractor remains responsible, and shall provide,
the services identified within this contract, and all terms and conditions of
the contract will apply during this period.
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5. Obligations of Contracting Parties
When termination or non-renewal of the contract occurs, the following
obligations shall be met by the parties:
a. Notice to Participants - The Department shall be responsible for
developing the format for notifying all participants of the date of
termination and the process by which the participants continue to receive
services;
b. Contractor Responsibilities - The Contractor shall be responsible for
duplication, mailing, and postage expenses related to said notification;
c. Transfer of Information - The Contractor shall promptly supply all
information necessary for the reimbursement of any outstanding Medicaid
claims; and
d. Recoupments - Recoupments will be handled through a payment by the
Contractor within ninety (90) calendar days of the end of the contract.
6. Declaration of National or State Emergencies or Disasters
In the event of a federal or state declared emergency or disaster, the Department
has the ability to modify or waive contractual obligations and regulations that are
necessary to address the emergency or disaster. The Department will maintain
documentation of any modifications to or waivers of contract requirements.
Contractors must follow all relevant ForwardHealth updates and other
Department communications issued during a federal or state emergency or
disaster.
Indemnification
1. Contractor and the Department’s Liability
The Contractor will indemnify, defend if requested and hold harmless the State
and all of its officers, agents, and employees from all suits, actions, or claims of
any character brought for or on account of any injuries or damages received by
any persons or property resulting from the operations of the Contractor or any of
its contractors, in prosecuting work under this contract.
The Department acknowledges that the State may be required by Wis. Stat. §
895.46(1) to pay the cost of judgements against its officers, agents or employees,
and that an officer, agent or employee of the State may incur liability due to
negligence or misconduct. To the extent protection is afforded under Wis. Stat. §§
893.82 and 895.46(1), the Department agrees to be responsible to the Contractor
and all of its officers, agents and employees from all suits, actions or claims of
any character brought for on account of any injuries or damages received by any
persons or property resulting from the negligence of the Department, its
employees, or agents in performing under this contract.
2. Pass Along Federal Penalties
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a. The Contractor shall indemnify the Department for any federal fiscal
sanction taken against the Department or any other state agency which is
attributable to action or inaction by the Contractor, its officers, employees,
agents, providers, or subcontractors that is contrary to the provisions of
this contract.
b. Prior to invoking this provision, the Department agrees to pursue any
reasonable defense against federal fiscal sanction in the available federal
administrative forum. The Contractor shall cooperate in that defense to the
extent requested by the Department.
c. Upon notice of a threatened federal fiscal sanction, the Department may
withhold monthly rate of service (MROS) payments otherwise due to the
Contractor to the extent necessary to protect the Department against
potential federal fiscal sanction. The Department will consider the
Contractor’s requests regarding the timing and amount of any withholding
adjustments.
Independent Capacity of the Contractor
The Department and the Contractor agree that the Contractor and any agents or
employees of the Contractor, in the performance of the contract and these criteria,
shall act in an independent capacity, and not as officers or employees of the
Department.
Omissions
In the event that either party hereto discovers any material omission in the
provisions of the contract and these criteria that are essential to the successful
performance of the contract, said party may so inform the other party in writing.
The parties hereto will thereafter promptly negotiate the issues in good faith in
order to make reasonable adjustments necessary to perform the objectives of the
contract.
Choice of Law
The contract and these criteria shall be governed by and construed in accordance
with the laws of the State of Wisconsin. The Contractor shall be required to bring
all legal proceedings against the Department in the state courts in Dane County,
Wisconsin.
Waiver
No delay or failure by the Contractor or the Department to exercise any right or
power accruing upon noncompliance or default by the other party with respect to
any of the terms of this contract shall impair such right or power or be construed
to be a waiver thereof. A waiver by either of the parties hereto of a breach of any
of the covenants, conditions, or agreements to be performed by the other shall not
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be construed to be a waiver of any succeeding breach thereof or of any other
covenant, condition, or agreement contained herein or within the contract.
Severability
If any provision of the contract or these criteria is declared or found to be illegal,
unenforceable, invalid or void, then both parties shall be relieved of all
obligations arising under such provision; but if such provision does not relate to
payments or services to participants and if the remainder of the contract and these
criteria shall not be affected by such declaration or finding, then each provision
not so affected shall be enforced to the fullest extent permitted by law.
Force Majeure
Both parties shall be excused from performance hereunder for any period that
they are prevented from meeting the terms of the contract or these criteria as a
result of a catastrophic occurrence or natural disaster including but not limited to
an act of war, and excluding labor disputes.
Headings
The article and section headings used herein are for reference and convenience
only and shall not enter into the interpretation thereof.
Assignability
This contract is not assignable by the Contractor either in whole or in part without
the prior written consent of the Department.
Right to Publish
The Department agrees to allow the Contractor to write and have such writings
published, provided the Contractor receives prior written approval from the
Department before publishing writings on subjects associated with the work under
the contract and these criteria. The Contractor agrees to protect the privacy of
individual participants, as required under 42 C.F.R. § 434.6(a)(8).
Survival
The terms and conditions contained in the contract that by their sense and context
are intended to survive the performance by the parties shall so survive the
completion of the performance, expiration, or termination of the contract. This
specifically includes, but is not limited to recoupments and confidentiality
provisions. All rights and remedies of the parties provided under the contract and
these criteria, including but not limited to any and all sanctions for violation,
breach or non-performance, survive from one contract year to the next, and
survive the completion of the performance, expiration, or termination of the
contract.
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IV. Contractor Administration
General Administration Expectations
1. The Contractor must comply with all applicable federal, state, and waiver
regulations, as well as all policies and procedures governing services and all terms
and conditions of the contract.
2. The ontractor must comply with all policies, procedures, and requirements
specified in the IRIS Policy Manual (P-00708), IRIS Work Instructions (P-
00708A), and IRIS Service Definition Manual (P-00708B).
3. If a Contractor identifies a discrepancy or requires clarification of existing
policies, procedures, or requirements, the Contractor is expected to contact the
Department.
4. The Contractor must have internal control procedures in place to ensure
separation of duties for financial and bank account transactions.
5. The provider shall claim reimbursement only for the services provided to
individual waiver participants that are eligible for and enrolled in IRIS.
6. In accordance with 42 CFR § 431.107 of the federal Medicaid regulations, the
Contractor agrees to keep any records necessary to document the extent of
services provided to recipients for a period of 7 years, but the program requests
that these records be retained for 10 years as best practice. Upon request, the
Contractor may be required to furnish to the Department, the federal Department
of Health and Human Services, or the state Medicaid Fraud Control Unit, any
information regarding services provided and payments claimed by the provider
for furnishing services under the Wisconsin Medicaid Waiver program. For state
policy related to record retention see DHS 106.02, Wis. Administrative Code.
7. The Contractor agrees to comply with the disclosure requirements of 42 CFR Part
455, Subpart B, as now in effect or as may be amended. To meet those
requirements, and address real or potential conflict of interest that may influence
service provision, the provider shall furnish to the Department in writing:
a. The names and addresses of all vendors of drugs, medical supplies or
transportation, or other providers in which it has a controlling interest or
ownership;
b. The names and addresses of all persons who own or have a controlling
interest in the provider;
c. Whether any of the persons named in compliance with (a) and (b) above
are related to any owner or to a person with a controlling interest as
spouse, parent, child or sibling;
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d. The names and addresses of any subcontractors, as defined in 42 CFR
455.101, who have had business transactions, as reportable under 42 CFR
455.105, with the provider;
e. The identity of any person, named in compliance with (a) and (b) above,
who has been convicted of a criminal offense related to that person’s
involvement in any program under Medicare, Medicaid or Title XIX
services programs since the inception of those programs.
8. The provider consents to the use of statistical sampling and extrapolation as the
means to determine the amounts owed by the provider to the Medicaid program as
a result of an investigation or audit conducted by the Department, the Department
of Justice Medicaid Fraud Control Unit, the federal Department of Health and
Human Services, the Federal Bureau of Investigation, or an authorized agent of
any of these.
FEA-Specific Administration Expectations
Internal Revenue Service Registration
The FEA is responsible for registering and maintaining good standing with the
United States Treasury, Internal Revenue Service Revenue, Proc. 70-06 (Form
2678).
Liability Insurance
Contractors are required to maintain specific forms of insurance for their agency. If
operating under a subsidiary or related party organizational structure, Contractors must
maintain required coverage at the subsidiary or related party level. Annually, during the
recertification site visit, contractors will be required to provide to their Contract
Specialist current certificate(s) of insurance demonstrating the following forms of
coverage:
1. Documentation of Workers Compensation insurance or applicable exemption, if
the contractor is self-insured;
2. Commercial liability, bodily injury and property damage insurance against any
claim(s), which might occur in carrying out this contract with a minimum
coverage of one million dollars ($1,000,000) per occurrence liability for bodily
injury and property damage including products liability and completed operations;
3. Motor vehicle insurance for all owned, non-owned and hired vehicles that are
used in carrying out this contract, with a minimum coverage of one million dollars
($1,000,000) per occurrence combined single limit of automobile liability and
property damage;
4. Professional Liability (malpractice) with a minimum coverage of one million
dollars ($1,000,000) per occurrence;
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5. Director and Officers liability or equivalent coverage specific to the entity
structure;
6. Umbrella coverage; and Employee Dishonesty or Fidelity Bond as a stand-alone
policy or included under the entity's Commercial property coverage.
Wisconsin Department of Financial Institutions Status
The Department reserves the right to ad hoc require the Contractor to provide a
Certificate of Status (e.g. certificate of “good standing”) from the Wisconsin Department
of Financial Institutions (https://www.wdfi.org/) indicating current status and status date.
Duplication of Services
The Contractor is prohibited from providing any paid Wisconsin Medicaid
supports or services to the participants for whom they provide ICA or FEA
services without the expressed prior approval of the Department. This prohibition
includes agencies that the Contractor, their parent organization, or owner(s) has
any direct or indirect financial or fiduciary relationship.
If determined as unallowable, the participant will be required to make a choice of
receiving services from the Contractor or receiving paid Medicaid supports or
services from the Contractor’s affiliate entity providing services.
This excludes administrative contracts that do not provide direct service or
eligibility and enrollment for services, as well as agencies that provide
accessibility assessments.
Separation in Lines of Business
The Contractor must maintain business separation from any agency involved with
enrollment counseling and/or ADRCs, functional and/or financial eligibility
determination, including Income Maintenance consortia, administration of any
other Wisconsin long-term care programs, and any paid supports or services it
provides for any Wisconsin Medicaid programs or recipients.
The Contractor must be capable of demonstrating to the satisfaction of the
Department that the Contractor’s agency is able to maintain complete separation
and must not influence a person’s choice of Wisconsin long-term care programs
and/or influence of a person’s choice of service and support providers within the
area of business. The Contractor must be capable of demonstrating to the
satisfaction of the Department that the Contractor’s IRIS management/leadership
is separate from the administration of any other Wisconsin long-term care
program.
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Conflict of Interest
The Contractor must demonstrate the mitigation of any real or perceived conflicts
of interest. This includes, but is not limited to, board or executive oversight,
management and field supervision of staff operating under this contract,
management and non-management, overlapping roles and responsibilities,
conflict of interest policies, paper and electronic security systems, and segregation
of administration functions.
Fraud
The Contractor shall report any suspected fraud, waste, or abuse involving the
program to the Department as soon as possible, but within ten (10) business days.
a. Email notification: [email protected].
b. Reporting hotline: 1-877-865-3432 or the on-line reporting system at
www.reportfraud.wisconsin.gov.
The FEA shall suspend payments to a participant-hired worker or agency provider
pursuant to 42 C.F.R. § 455.23 when it is informed by the Department that it has
suspended fee-for-service Medicaid payments to the provider because of a
credible allegation of fraud.
If the FEA believes there is good cause for suspending its payments, the FEA
shall contact the Department immediately upon identification.
The Contractor shall cooperate with any investigation of fraud and abuse,
including directly conducting investigations as needed. The Contractor shall assist
the Department and any other entity legally authorized to investigate fraud and
abuse in determining any amounts to be repaid, and with other follow up as
requested.
Expansion and Geographic Service Regions
The Contractor must demonstrate the capacity to provide immediate services to
the geographic service regions identified through initial certification and
expansion requests. The Contractor is responsible for serving all IRIS program
target groups.
The Contractor must be in operation for a minimum of 90 days, without any
CAPs, before applying for expansion to additional geographic service regions. If a
CAP has been resolved, the Contractor must wait 90 days from the date of the
resolution letter to apply for expansion.
The Contractor must identify, in writing to the Department, in which service
region it is looking to expand, including the proposed date of expansion. The
proposed expansion date must be a minimum of 60 days from the date of the
request and shall begin of on the first date of the following month.
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When an ICA is expanding, the Department will need to work with the
Functional Screen team to ensure systems are adequately prepared and
ADRCs to ensure workforce training has occurred prior to options
counseling.
When an FEA is expanding, the ICA and FEA will need to collaborate to
ensure proper IRIS consultant workforce training has occurred.
All contractors must provide thorough and comprehensive responses to
Department inquires as it relates to their agency’s proposed expansion.
The contractor must demonstrate the fiscal capacity to expand to the proposed
geographic service regions identified in the expansion request.
The contractor must demonstrate fiscal stability over the most recent two
quarterly financial reporting submissions.
The contractor must demonstrate satisfaction of the working capital and
restricted reserve requirements in the most recent two quarterly financial
reporting submissions and the ability to satisfy the working capital and
restricted reserve requirements in the proposed expansion area.
Physical and Localized Presence
The Contractor must maintain an office within Wisconsin. Signage must be
present and visibly posted to indicate to participants or other visitors of the
agency’s name and/or association with the IRIS program.
Signage may be posted on the exterior of the building, on an internal
directory sign, and/or posted on the entrance door/window to the agency’s
office(s).
The signage must state the name of the IRIS agency.
ICA Expectations
ICAs must have a localized presence in each region in which they will
operate or provide services. This assures relative proximity to participants,
as well as knowledge of the services and providers available in the region.
Consultant agencies may be asked to supply the county of domicile and
the county of assignment for consultant personnel as assurance of said
localized presence.
ICAs must identify a location(s) in each GSR and county within the region
to conduct meetings with participants when it is not possible to do so in
the participant’s home.
This location must comply with the Americans with Disabilities Act.
FEA Expectations
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FEAs are not expected to maintain a localized presence in each service
region in which they operate, but must have at least one office located in
Wisconsin.
FEAs must provide documentation to the Department indicating the
number of FEA staff physically based in Wisconsin and the services they
will be providing.
Company Structure and Leadership
If organizational structure of the contractor changes, the contractor will notify the
Department within 30 days. Documentation of the changes may include, but are
not limited to:
Articles of Incorporation,
Articles of Organization,
Partnership Agreement,
Bylaws (if operating with a Board of Directors),
Organizational chart (Executive leadership),
Transition of assets and liabilities
Comparable documentation, including but not limited to: identification of
positions, responsibilities, and descriptions of how internal contractors are
used for separation of duties between entities and/or unrelated operations
are established, maintained, and verified; percentage of allocation to IRIS
and other lines of business (and method used to establish and validate the
identified percentage); and staff oversight responsibilities.
If Board membership changes or is expected to change by the end of the contract
term, the Contractor must provide updated disclosure forms for each new board
member, as well as completed Conflict of Interest Disclosure – Provider (F-
01310) forms to the IRIS Contract Specialist.
Contractors are expected to notify the Department if there are any changes in
leadership of the agency or their parent organization’s Executive Director, Chief
Executive Officer, Chief Financial Officer, Chief Operations Officer, President,
Controller, Certified Public Accountant, IT Security Officer, or Program Director.
Administrative Services Agreements (ASA)
Before entering into any Administrative Services Agreements (ASA) during the
contract term, the Contractor must provide the following documentation for ASAs
with related entities to the IRIS Contract Specialist, including:
Actual agreement,
Services purchased,
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Anticipated percentage of allocation to the IRIS program versus other lines of
business, as described and defined in the ASA,
Description and examples of analytics used to evaluate and ensure accuracy of
cost allocations and program charges related to the IRIS program.
Business Associate Agreement
Due to the Contractor using and/or disclosing protected health information subject to
HIPAA, the Contractor shall review and execute a Business Associate Agreement (BAA)
(F-00759) with the Department as a mandatory and critical exhibit to the contract. A
BAA must be executed before the Contractor performs any work of any kind for DHS as
a result of the contract.
Business Continuity
The Contractor shall have a Business Continuity Plan, available to the Department
upon request. The Business Continuity Plan shall address, at a minimum, the
following:
A description of the organization and the urgency with which activities and
processes will need to be resumed in the event of a disruption.
Inclusion of a business impact analysis and risk assessment. This will address
each continuity management strategy both at the corporate and key functional
area separately and will identify, quantify and qualify areas that will be used to
continue the organization’s business impacts of a disruption to determine at what
point in time the disruption exceeds the maximum allowable recovery time,
activities and processes after an interruption.
Clearly identified roles and responsibilities within the organization during the
implementation of the business continuity plan.
A description of the steps that will be taken to document and ensure participant
safety and wellbeing in the event of a disruption or disaster through supporting
the mitigation of risks and to access community resources as needed.
Criteria for executing the business continuity plan, including escalation
procedures.
A detailed communication plan with participants, employees, the Department, and
other stakeholders.
Business functions and dependent functions that must be maintained and services
that must be restored, including key business information that would be required
within 24 to 48 hours of a declared disaster or event.
A description of the organization and the urgency with which activities and
processes will need to be resumed in the event of a disruption. Recording and
updating business events information, files, data updates once business processes
have been restored.
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Recovery time for each major business function, based on priority.
A description of an annual testing and evaluation plan.
Upon the Department’s request, after a federal or state declared emergency or
disaster expires, the Contractor shall submit an ‘After Emergency Report’ to the
Department within a designated timeframe. The report will provide feedback
regarding the operation of the Contractor’s business continuity plan, including a
discussion of successes and challenges, during the federal or state-declared
emergency or disaster.
Commercial Leases
If the Contractor enters into leases of real property to support the administrative
responsibilities of the Contractor, at the time the Contractor enters into a new
lease or renews an existing lease the Contractor shall include a termination clause
in that lease allowing the Contractor to terminate the lease on reasonable notice to
the landlord, not to exceed 90 days, if the Contractor ceases to operate as an IRIS
Contractor due to a discontinuation of this Contract with the Department. Such
termination must not be considered a default of the lease, must occur without
penalty, and must limit any future rent liability.
The Contractor is not required to negotiate such a clause into any existing lease
until such time as the lease term expires and a new lease or renewal is required.
If after a good faith attempt to negotiate, the Contractor is unable to include such
a clause in a lease of rental property but determines that such a lease is essential to
the operation of the Contractor, the Contractor may apply to the Department for a
waiver of this requirement. Any such waiver shall be at the discretion of the
Department.
If the Contractor enters into leases of commercial property other than real
property on a long-term basis, e.g., office equipment, the Contractor shall attempt
to include a termination without penalty clause in those leases, to the extent
practicable.
Electronic Visit Verification (EVV)
Please see the IRIS EVV policy for further information.
The Contractors shall implement EVV for designated service codes. The FEA will
use data collected from the EVV system to validate claims pertaining to affected
service codes against approved authorizations during the claim adjudication
process. Prior to implementation, the Contractors shall outline expectations for
contracted providers regarding the use of the EVV data collection system. The
Contractors shall also provide assistance and support to DHS and contracted EVV
vendor for training, outreach, and utilization of the data collection system, as
requested.
ICA Responsibilities
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a. Ensure the participant understands the following:
i. The EVV requirements and EVV’s impact on the IRIS program.
ii. Where to find EVV information and resources.
b. Follow up with the participant during monthly contacts to ensure EVV
compliance, create EVV risk agreement if needed, and initiate participant
disenrollment for EVV non-compliance as outlined in the IRIS EVV
Policy.
c. Confirm, when applicable, that the IRIS Participant-Hired Worker
Relationship Identification Form (F-01201A) is completed and that the
required supporting documentation is provided to the fiscal employer
agency before listing a participant-hired worker as a live-in worker on an
authorization.
d. Evaluate whether the participant needs a fixed visit verification devices
(only when using the DHS-provided Sandata EVV system and there is no
other EVV collection method available).
e. Communicate with the fiscal employer agency when a participant needs a
fixed visit verification device.
FEA Responsibilities
a. Enter participant-hired worker information into the ForwardHealth Portal.
b. Verify live-in worker validation information.
c. Provide the participant with EVV set-up information for their participant-
hired workers.
d. Communicate EVV compliance information to IRIS consultant agencies
via biweekly reports.
e. Clear exceptions to achieve verified visits.
f. Create a document collection system for requested EVV corrections.
g. Provide the participant and participant-hired worker with information on
the process for EVV corrections.
h. Link provider agency claims to verified visits and deny provider agency
claims that are missing EVV information.
i. Provide remittance to provider agencies regarding denial of payment due
to insufficient EVV data.
j. Link participant-hired worker timesheets to verified visits in EVV.
k. Send DHS applicable EVV data with encounter details.
l. Use the chosen EVV system to verify visits.
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m. Fiscal employer agencies and provider agencies that use the DHS-
provided Sandata EVV system can find training resources online at
https://www.dhs.wisconsin.gov/evv/training.htm.
n. Fiscal employer agencies and provider agencies may choose to use an
alternate EVV system. Alternate EVV systems must be certified. The
alternate EVV certification process is detailed online at
https://www.dhs.wisconsin.gov/evv/alternateevv.htm. Fiscal employer
agencies and provider agencies that use an alternate EVV system are
required to provide training and education to their users.
Participant Records
The Contractor shall have a system for maintaining participant records and
policies and procedures that ensure compliance with the following requirements.
Confidentiality of Records and HIPAA Requirements
The Contractor shall implement specific procedures to assure the security and
confidentiality of health and medical records and of other personal information
about participants, in accordance with Wis. Stats. Chapter 49, Subchapter IV;
Wis. Admin. Code § DHS 108.01; 42 C.F.R. Part 431, Subpart F; 42 C.F.R. Part
438; 45 C.F.R. Parts 160,162, and164; the Health Insurance Portability and
Accountability Act (HIPAA); and any other confidentiality law to the extent
applicable.
Duty of Non-Disclosure and Security Precautions
The Contractor shall protect and secure all confidential information and
shall not use any confidential information for any purpose other than to
meet its obligations under this contract. The Contractor shall hold all
confidential information in confidence, and not disclose such confidential
information to any persons other than those directors, officers, employees,
agents, subcontractors, and providers who require such confidential
information to fulfill the Contractor’s obligations under this contract. The
Contractor shall institute and maintain procedures, including the use of
any necessary technology, which are necessary to maintain the
confidentiality of all confidential information. The Contractor shall be
responsible for the breach of this contract and subsequent contract in the
event any of the Contractor’s directors, officers, employees, or agents fail
to properly maintain any confidential information.
Limitations on Obligations
The Contractor’s obligation to maintain the confidentiality of confidential
information shall not apply to the extent that the Contractor can
demonstrate that such information:
Is required to be disclosed pursuant to a legal obligation in any
administrative, regulatory, or judicial proceeding. In this event, the
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Contractor shall promptly notify the Department of its obligation
to disclose the confidential information (unless it has a legal
obligation to the contrary) so that the Department may seek a
protective order or other appropriate remedy. In the event that such
protective order is not obtained, the Contractor shall furnish only
that portion of the confidential information that is legally required
and shall disclose it in a manner designed to preserve its
confidential nature to the extent possible. Notification to the
Department would not include routine subpoenas issued with
record requests unless said subpoena extends beyond the standard
documentation requested from said entity.
Is part of the public domain without any breach of this contract by
the Contractor;
Is or becomes generally known on a non-confidential basis,
through no wrongful act of the Contractor;
Was known by the Contractor prior to disclosure hereunder
without any obligation to keep it confidential;
Was disclosed to it by a third party which, to the best of the
Contractor’s knowledge, is not required to maintain its
confidentiality;
Was independently developed by the Contractor;
Is the subject of a written agreement whereby the Department
consents to the disclosure of such confidential information by the
Contractor on a non-confidential basis; or
Was a permitted use or disclosure, in accordance with Wis. Stat.
Chapter 49, Subchapter IV; Wis. Admin. Code § DHS 108.01; 42
C.F.R. 431, Subpart F; 42 C.F.R. 438; 45 C.F.R. 160; 45 C.F.R.
162; and 45 C.F.R. 164 or other applicable confidentiality laws.
Unauthorized Use, Disclosure, or Loss
If the Contractor becomes aware of any threatened or actual use or
disclosure of any confidential information that is not specifically
authorized by this contract, or if any confidential information is lost or
cannot be accounted for, the Contractor shall notify the Department and
the Privacy Officer in the Department’s Office of Legal Counsel within
one day of the Contractor becoming aware of such use, disclosure or loss.
The notice shall include, to the best of the Contractor’s understanding, the
persons affected, their identities, and the confidential information that was
disclosed.
The Contractor shall take immediate steps to mitigate any harmful effects
of the unauthorized use, disclosure, or loss. The Contractor shall
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reasonably cooperate with the Department’s efforts, if any, to seek
appropriate injunctive relief or otherwise prevent or curtail such
threatened or actual breach, or to recover its confidential information,
including complying with the following measures, which may be directed
by the Department, at its sole discretion:
Notifying the affected individuals by mail or the method
previously used by the Department to communicate with the
individual. If the Contractor cannot with reasonable diligence
determine the mailing address of the affected individual and the
Department has not previously contacted that individual, the
Contractor shall provide notice by a method reasonably calculated
to provide actual notice;
Notify consumer reporting agencies of the unauthorized release;
Offer credit monitoring and identity theft insurance to affected
individuals from a company, and under terms, acceptable to the
Department for one year from the date the individual enrolls in
credit monitoring;
Provide a customer service or hotline to receive telephone calls and
provide assistance and information to affected individuals during
hours that meet the needs of the affected individuals, as determined
by the Department; and
Indemnification
In the event of unauthorized use, disclosure, or loss of confidential
information, the Contractor shall indemnify and hold harmless the
Department and any of its officers, employees, or agents from any claims
arising from the acts or omissions of the Contractor, and its
subcontractors, providers, employees, and agents, in violation of this
section, including but not limited to costs of monitoring the credit of all
persons whose confidential information was disclosed, disallowances or
penalties from federal oversight agencies, and any court costs, expenses,
and reasonable attorney fees, incurred by the Department in the
enforcement of this section. In addition, notwithstanding anything to the
contrary herein, the Contractor shall compensate the Department for its
actual staff time and other costs associated with the Department’s response
to the unauthorized use, disclosure, or loss of confidential information.
Equitable Relief
The Contractor acknowledges and agrees that the unauthorized use,
disclosure, or loss of confidential information may cause immediate and
irreparable injury to the individuals whose information is disclosed and to
the Department, which injury will not be compensable by money damages
and for which there is not an adequate remedy at law. Accordingly, the
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Contractor agrees that the Department, which injury will not be
compensable by money damages and for which there is not an adequate
remedy at law. Accordingly, the Contractor agrees that the Department, on
its own behalf or on behalf of the affected individuals, shall be entitled to
obtain injunctive or other equitable relief to prevent or curtail any such
breach, threatened or actual, without posting security and without
prejudice to such other rights as may be available under this contract or
under applicable law.
Sanctions
In the event of an unauthorized use, disclosure, or loss of confidential
information, the Department may impose sanctions, in the form of civil
monetary penalties, pursuant to the terms described herein.
Record and Documentation Standards
The contractor shall maintain individual participant records in accordance with
any applicable professional and legal standards.
Documentation in participant records must reflect all program contact including
documentation of assistance with transitional care in the event of disenrollment
from the program. Participant records must be readily available for participant
encounters (encounter data via the LTCare IES) and for administrative purposes.
Record Retention
The contractor shall retain, preserve, and make available upon request all records
or documents relating to the performance of its obligations under this contract,
including paper and/or electronic claim forms, for not less than ten (10) years
following the end of this contract period. Additionally, records or documents
involving matters that are the subject of any litigation, claim, financial
management review or audit shall be retained for a period of not less than ten (10)
years from the end of this contract period, following the termination or
completion of the litigation, claim, financial management review or audit or
disposition of real property and equipment acquired with Federal funds,
whichever is later. This retention requirement also applies to records or
documents related to recoveries of all overpayments from the contractor to a
provider including recoveries of overpayments due to fraud, waste, or abuse.
Participant Access and Disclosure
Participants shall have access to their records in accordance with applicable state
or federal law. The Contractor shall use best efforts to assist a participant, his/her
legal decision maker, and others designated by the participant to obtain records
within ten (10) business days of the request. The Contractor shall identify an
individual who can assist the participant and his/her legal decision maker in
obtaining records. Participants have the right to approve or refuse the release of
confidential information, except when such release is authorized by law. If the
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records request is unable to be fulfilled due to lack of Contractor access to the
reports requested, the request shall be immediately referred to the Department.
Provision of Records
The Contractor shall make participant’s medical, claims, cost share, and/or long-
term care records as well as all pertinent and sufficient information relating to the
management of each participant’s records available and readily accessible to the
Department upon request. The Contractor shall provide this information to the
Department at no charge. The Contractor shall also have procedures to provide
copies of records promptly to other providers for the management of the
participant’s medical, claims, cost share, and/or long-term care, and the
appropriate exchange of information among the Contractors and other providers
receiving referrals, as necessary.
Participant-Employer Information Requests
Acting as employer agent, the FEA must respond to all requests for information
on behalf of the participant employer in an accurate and timely manner:
The FEA will promptly handle all requests for information including
participant-hired worker wages and workers compensation information
(WCI).
The FEA will assist the participant with WCI appeals, unemployment
compensation-related requests, and inquiries as requested by the
participant employer, the participant-hired worker, or by the State.
The FEA will work with the Department of Revenue and the Department
of Workforce Development, as necessary, on wage-related or other
questions.
Civil Rights Compliance and Affirmative Action Plan Requirements
All Contractors must comply with the Department’s Affirmative Action/Civil Rights
Compliance requirements at https://www.dhs.wisconsin.gov/publications/p0/p00164.pdf.
Compliance Requirements
All Contractors must comply with the Department’s Affirmative Action/Civil Rights
Compliance requirements at https://www.dhs.wisconsin.gov/civil-rights/index.htm.
Affirmative Action Plan
As required by Wisconsin’s Contract Compliance Law, Wis. Stat. § 16.765, the
contractor must agree to equal employment and affirmative action policies and
practices in its employment programs:
The Contractor agrees to make every reasonable effort to develop a balance in
either its total workforce or in the project-related workforce that is based on a
ratio of work hours performed by handicapped persons, minorities, and women
except that, if the department finds that the Contractor is allocating its workforce
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in a manner which circumvents the intent of this section, the Department may
require the Contractor to attempt to create a balance in its total workforce. The
balance shall be at least proportional to the percentage of minorities and women
present in the relevant labor markets based on data prepared by the Department of
Industry, Labor and Human Relations, the Office of Federal Contract Compliance
Programs, or by another appropriate governmental entity. In the absence of any
reliable data, the percentage for qualified handicapped persons shall be at least
2% for whom the Contractor must make a reasonable accommodation.
The Contractor must submit an Affirmative Action Plan within fifteen (15)
working days of the signed contract for certification. Exemptions exist, and are
noted in the Instructions for Contractors posted on the following website:
http://vendornet.state.wi.us/vendornet/contract/contcom.asp.
The Contractor must submit its Affirmative Action Plan or request for exemption
from filing an Affirmative Action Plan to:
Department of Health Services
Division of Enterprise Services
Bureau of Strategic Sourcing
Affirmative Action Plan/CRC Coordinator
1 West Wilson Street, Room 665
P.O. Box 7850
Madison, WI 53707
Civil Rights Compliance (CRC)
As required by Wis. Stat. § 16.765, in connection with the performance of work
under this contract and the accompanying contract, the Contractor agrees not to
discriminate against any employee or applicant for employment because of age,
race, religion, color, handicap, sex, physical condition, developmental disability
as defined in Wis. Stat. § 51.01 (5), sexual orientation or national origin. This
provision shall include, but not be limited to, the following: employment,
upgrading, demotion, or transfer; recruitment or recruitment advertising; layoff or
termination; rates of pay or other forms of compensation; and selection for
training; including apprenticeship. The Contractor further agrees to take
affirmative action to ensure equal employment opportunities. The Contractor
agrees to post in conspicuous places, available for employees and applicants for
employment, notices to be provided by the contracting officer setting forth the
provisions of the nondiscrimination clause.
In accordance with the provisions of Title VI of the Civil Rights Act of 1964
(nondiscrimination on the basis of race, color, national origin), Section 504 of the
Rehabilitation Act of 1973 (nondiscrimination on the basis of disability), the Age
Discrimination Act of 1975 (nondiscrimination on the basis of age), regulations of
the U.S. Department of Health and Human Services issued pursuant to these three
statutes at Title 45 Code of Federal Regulations Parts 80, 84, and 91, the
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Contractor shall not exclude, deny benefits to, or otherwise discriminate against
any person on the grounds of race, color, national origin, disability, or age in
admission to, participation in, or receipt of the services and benefits under any of
its programs and activities, and in staff and employee assignments to participants,
whether carried out by the Contractor directly or through a sub-contractor or any
other entity with which the Contractor arranges to carry out its programs and
activities.
Additionally in accordance with Section 1557 of the Patient Protection and
Affordable Care Act of 2010, 42 U.S.C. § 18116, and rules promulgated to
implement Section 1557 (81 Fed. Reg. 31376 et. Seq. (May 18, 2016) (amending
45 C.F.R. Part 92 to implement Section 1557)), the Contractor shall not exclude,
deny benefits to, or otherwise discriminate against any person on the basis of sex
in admission to, participation in, or receipt of the services and benefits under any
of its health programs and activities, and in staff and employee assignments,
whether carried out by the Contractor directly or through a subcontractor or any
other entity with which the Contractor arranges to carry out its programs and
activities.
The Contractor must file a Civil Rights Compliance Letter of Assurance (CRC
LOA) within fifteen (15) working days of the effective date of the Contract. If the
Contractor employs fifty (50) or more employees and receives at least $50,000 in
funding, the Contractor must complete a Civil Rights Compliance Plan (CRC
Plan). The current Civil Rights Compliance Requirements and all appendices for
the current Civil Rights Compliance period, are hereby incorporated by reference
into this Contract and are enforceable as if restated herein in their entirety. The
Civil Rights Compliance Requirements, including the template and instructions
for the CRC Plan, can be found at https://www.dhs.wisconsin.gov/civil-
rights/requirements.htm or by contacting:
Department of Health Services
Civil Rights Compliance
Attn: Attorney Laura Varriale
1 West Wilson Street, Room 651
P.O. Box 7850
Madison, WI 53707-7850
Telephone: (608) 266-1258 (Voice)
711 or 1-800-947-3529 (TTY)
Fax: (608) 267-1434
Email: [email protected]
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The CRC Plan must be kept on file by the Contractor and made available upon
request to any representative of DHS.
Civil Rights Compliance Letters of Assurances should be sent to:
Department of Health Services
Division of Enterprise Services
Bureau of Strategic Sourcing
Affirmative Action Plan/CRC Coordinator
1 West Wilson Street, Room 672
P.O. Box 7850
Madison, WI 53707
-or-
The Contractor agrees to cooperate with DHS in any complaint investigations,
monitoring, or enforcement related to civil rights compliance of the Contractor or
its Subcontractor under this Agreement.
Cultural Competency
Contactors shall include cultural diversity training, encourage, and foster cultural
competency among staff. The Contractor shall incorporate in its policies,
administration, and service practice the values of honoring participants’ beliefs,
being sensitive to cultural diversity including participants with limited English
proficiency and diverse cultural and ethnic backgrounds, and fostering in staff
attitudes and interpersonal communication styles which include participants’
cultural backgrounds. Policy statements on these topics shall be communicated to
any subcontractors.
Policy and Procedure Manual
The Contractor must maintain an internal policy and procedure manual consistent
with DHS-communicated policy, procedures, and work instructions.
DHS reserves the right to request a copy of a portion thereof, or the manual in its
entirety for review and ongoing oversight. The Department further reserves the
right to request other policies and procedures, as deemed necessary.
Specific topics that are essential to the ICA Policy and Procedures Manual, at
minimum, include:
a. IRIS Consultant staff orientation and training requirements;
b. Functional screener staff orientation and training requirements
c. Ongoing training requirements for Consultants and Functional screeners;
d. Internal process for transition between IRIS contractors and adult
programs such as Family Care, Family Care Partnership, and PACE;
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e. The Department case management system (WISITS) training, resources,
and best practices;
f. Methodology for plan development and updates;
g. Process for identifying budget mismanagement and the fraud allegation
review and assessment process (FARA);
h. Monitoring of participant spending and budget amendment/one-time
expense guidelines;
i. Reporting and monitoring of participant cost share and financial
eligibility;
j. Conflicts of Interest regarding personnel, participants, and service
providers;
k. Critical Incident Reporting protocols, including the identification, referral
and follow up in instances of referral for Adults at Risk or in need of
Protective Services;
l. Vulnerable High Risk protocol;
m. Issuance, tracking, and resolution of Notices of Action;
n. Process for preparation and representation at State Fair Hearings;
o. Record Review Remediation procedures;
p. Request for records from participants, legal decision makers, ombudsman,
and other agencies;
q. Identification, notification, risk assessment, and monitoring of HIPAA
Breaches, security incidents, and unauthorized disclosures of PII, PHI, and
other confidential information;
r. IT Guidelines and Requirements;
s. Methodology for addressing, tracking, and resolving complaints and
grievance;
t. Fiscal policies and procedures; and
u. Process for updating policies and procedures when federal, state, or
program changes.
Specific topics that are essential to the FEA Policy and Procedures Manual, at
minimum, include:
a. FEA staff orientation and training requirements;
b. FICA overpayments and refunds process, including remittance of refunds
to the Department Deposit Account;
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c. Accounting procedures related to Medicaid cost share collection,
including the procedures when payment involves checks returned for
insufficient funds;
d. Procedures related to worker wage payment exceptions, denial, or
adjustment;
e. Communication plans describing how and when the FEA will inform the
ICA of the need to follow up with participant employers and participant-
hired workers;
f. Implementation of Department case management system (WISITS)
changes for FEA personnel, as it relates to the FEA’s internal system(s);
g. FEA internal monitoring controls;
h. Document retention and destruction policy;
i. Workers compensation policy and process;
j. Process describing how only participants and participant-hired workers
that meet all minimum qualifications are compensated for services
rendered;
k. FEA transfer policy and process;
l. Identification, notification, risk assessment, and monitoring of HIPAA
Breaches, security incidents, and unauthorized disclosures of PII, PHI, and
other confidential information;
m. Resolution of complaints and grievances;
n. Fiscal policies and procedures; and
o. Process for updating policies and procedures when federal, state, or
program changes.
ICA-Specific Staff Expectations
The ICA should at a minimum have the following roles:
IRIS Consultant(s),
Long-term Care Functional Screener, and
Long-term Care Functional Screen Liaison.
The ICA shall designate one member of their staff to act as the Tribal Liaison.
The Tribal Liaison will serve as the main point of contact between the ICA and
the Department and the ICA and each tribe for all tribal issues. The ICA must
provide contact information for the Tribal Liaison to the Department and to each
tribe in Wisconsin
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IRIS Consultant Expectations
IRIS Consultants must meet the following criteria:
Option 1:
Possess a minimum of a Bachelor’s degree in social work,
psychology, human services, counseling, nursing, special
education, or a closely related field.
Have one year of supervised experience working with seniors
and/or people living with disabilities.
Complete all required IRIS orientation and training courses with
the ICA.
Pass a nationwide caregiver criminal history screening pursuant to
DHS’s policy (http://www.dhs.wisconsin.gov/caregiver/).
OR
Option 2:
Have a minimum of four years of direct experience related to the
delivery of social services to seniors and/or people living with
disabilities and long-term care needs in community settings.
Complete all required IRIS orientation and training courses with
the ICA.
Pass a nationwide caregiver criminal history screening pursuant to
DHS’s policy (http://www.dhs.wisconsin.gov/caregiver/).
IRIS Consultant-specific Training
The IRIS consultant agency is responsible for developing all training material
content;
The IRIS consultant-training curriculum must include, but should not be limited
to:
An overview of the IRIS program, including the history of the IRIS
program, the structure of the program, budget and employer authority, the
relationship between IRIS partners, processes of enrollment, processes of
program participation, and processes of disenrollment.
An overview of self-determination, including the five principles of self-
determination and the six domains of self-determination.
Critical incident reporting
Person-centered plan development, including the development of
outcomes and supports according to the DHS IRIS Policy Manual (P-
00708) and IRIS Work Instructions (P-00708A).
Plan Approval
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Annual financial eligibility requirements and how medical remedial is
factored into financial eligibility.
Documentation requirements.
Conflict of interest, fraud, and other program integrity concerns.
IRIS Self-Directed Personal Care (SDPC).
Long-Term Care Functional Screen (LTCFS)
Record review remediation.
The Department case management system (WISITS).
Participant-hired worker onboarding, paperwork, authorizations, and
participant responsibilities thereof.
Approved waiver services and supports, including supports paid for using
IRIS funds and the limitations regarding who can provide those supports
and services
Risk assessment and management, including identifying and helping the
participant mitigate risks, including challenging behaviors, medical
treatment, falls, environmental hazards, egress issues, and others
Needs assessments, including how to assist the participant in identifying
their strengths and areas where they need assistance from natural
supports, supports from other funding sources, and supports funded by
IRIS
Complaints, appeals, and grievances, including supporting a participant
to file a grievance or an appeal, the existing processes, the roles of IRIS
partners, and how to complete the appropriate paperwork
Budget issues, including how to request additional funds for a one-time
expense, addressing a participant who is overspending, and effectively
monitoring and helping a participant manage their budget
Other training as requested by DHS
Long-term Care Functional Screener Expectations
ICAs must be able to provide participants with ongoing and annual
redetermination Long-Term Care Functional Screens (LTCFS). The LTCFS
determines functional eligibility for Medicaid waiver programs. Screeners must
meet qualifications that ensure knowledge of long-term care needs to ensure
reliable and consistent administration of LTCFS.
ICAs must become certified screening agencies by registering with DHS.
Long-Term Care Functional screeners shall:
Be a representative of an ICA with an official function in
determining functional eligibility.
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Have a license to practice as a registered nurse in Wisconsin
pursuant to Wis. Stat. § 441.06, or a Bachelor of Arts or Science
degree or more advanced degree in a health or human services
related field (e.g. social work, rehabilitation, psychology), and a
minimum of one year of experience working with at least one of
the target populations.
Successfully complete the online screener certification training
course(s) and become certified as a functional screener by the
Department. Information on the online web class can be found at:
https://wss.ccdet.uwosh.edu/stc/dhsfunctscreen.
Successfully complete all mandatory certification courses, exams,
refresher courses, and continuing skills testing, as required by
DHS.
Certified Screener Documentation
Each ICA shall maintain documentation of compliance with the
requirements and make documentation available to the Department upon
request.
Administration of the Screening Program
Listing of Screeners
Each ICA shall maintain an accurate, complete, and up-to-date list
of staff that perform functional screens, as well as certificates
documenting that each LTCFS screener has passed the required
certification course.
Communications
Each ICA that administers functional screens shall ensure that each
screener is able to receive communications from the Department’s
functional screen listserv(s)
(https://public.govdelivery.com/accounts/WIDHS/subscriber/new?t
opic_id=WIDHS_45).
Mentoring
Each ICA that employs newly certified screeners shall have a
formal process for mentoring new screeners (that is providing them
with close supervision, on-the-job training, and feedback) for at
least six months.
This shall be described in the Contractors internal policy and
procedures documents and shall be made available to DHS upon
request. Each ICA will include the process for new screeners to:
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Observe an experienced screener administering a screen;
a) Complete practice screens on a paper version of the
LTCFS;
b) Be observed by an experienced screener while
completing first screens or to have his/her screens
reviewed by an experienced screener; and
c) Have the opportunity for discussion and feedback as
a result of those observations or reviews.
The ICA’s functional screeners may also be IRIS consultants.
Monitoring Long-Term Care Functional Screens
The ICA shall adopt written standards and procedures to govern quality
management for its functional screening activities and will upon request submit
those that describe:
The ICA methods employed to monitor the accuracy, completeness, and
timeliness of annual and change-in-condition screens completed by the
ICA;
The criteria employed to evaluate the accuracy, completeness, and
timeliness of annual and change-in-condition screens submitted by the
ICA;
The process by which changes in condition are communicated to
screeners; and
The most recent results of the quality management monitoring of
functional screen activities.
Long-term Care Functional Screen Liaison Expectations
Each ICA shall designate at least one staff person as “Screen Liaison” to work
with the Department in respect to issues involving the screens done by the ICA.
This person must be a certified functional screener and, at Department determined
intervals, successfully pass the required continuing skills testing. This person’s
current contact information must be provided to the Department. Screeners shall
be instructed to contact the Screen Liaison with questions when they need
guidance or clarification on the screen instructions, and shall contact the Screen
Liaison whenever a completed screen leads to an unexpected result in terms of
eligibility or level of care;
The duties of the Screen Liaison are to:
Provide screeners with guidance when possible, or contact the
Department’s Functional Screen Staff for resolution;
Consult with the Department or its designee on all screens that obtain an
unexpected result or that are especially difficult to complete accurately;
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Oversee new screener mentoring program and train new screeners as listed
in 8.b.;
Following the Department’s quality review of functional screens, the
screen liaison will meet with the screener to discuss the results.
Subsequently, the screener will make any needed corrections/changes to
the screen using established DHS procedures.
In regular staff meetings or in individual meetings with the screeners, to
discuss/resolve any screening problems identified as a result of continued
skills testing. The screener(s) will follow any recommendations related to
improving knowledge or skills in the problem area(s).
Review and respond to any quality assurance issues detected by DHS or
its designee and implement any improvement projects or correction plans
required by DHS to ensure the accuracy and thoroughness of the screens
performed by the ICA.
Act as the contact person for all communications between the Department
or its designee relating to functional screens and the screening program;
Ensure that all local screeners have received listserv communications and
updates from the Department;
Act as the contact person other counties/agencies can contact when they
need a screen transferred;
Act as the contact person for technical issues such as screen security and
screener access;
Consult with the ADRC when the ICA re-determines level of care for a
newly enrolled participant or a newly enrolled participant is found to be
functionally ineligible or eligibility changes to a non-nursing home level
of care within six months of the submission of the most recent pre-
enrollment screen. Review and compare the screens and attempt to resolve
differences. Contact the Department or its designee if differences cannot
be resolved.
Either through the screeners’ supervisor or through the Screen Liaison, or
both, provide ongoing oversight to ensure that all screeners:
Follow the most current version of the WI Long Term Care
Functional Screen Instructions and all updates issued by the
Department, including technical assistance documents and
frequently asked questions. These are available and maintained on
the Department’s website at:
https://www.dhs.wisconsin.gov/functionalscreen/ltcfs/instr
uctions.htm.
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Meet all other training requirements as specified by the
Department.
Long-term Care Functional Screener & Liaison Training
New Hire Training – Screeners
The Department has resources available to supplement ICA
training for screeners at:
https://www.dhs.wisconsin.gov/functionalscreen/index.htm
Screeners shall receive and review paper copies of the most recent
functional screen clinical instructions and functional screen form,
diagnosis cue sheet, and other pertinent material.
Screeners must pass the online certification course.
Once certification is received, screeners shall work with the ICA
screen liaison to obtain a Wisconsin Log-on ID and Functional
Screen Security Clearance.
Newly hired screeners shall receive the following training from the
screen liaison or an experienced screener:
a) Instruction on procedures for obtaining verification of
diagnosis and health-related services.
b) Getting a completed screen entered on the functional screen
website.
c) Making changes/corrections on a functional screen.
Ongoing and as needed, the screener shall consult with the screen
liaison regarding questions related to the proper completion of the
functional screen, interpretation of instructions, using the related
tools, etc.
Ongoing Training/Mentoring Methods include:
i. Consultation with the screen liaison on any questions related to
how to properly complete the functional screen, interpret
directions, use the related tools, etc.
ii. The screener will use a registered nurse (RN) through the IRIS
SDPC nurse consultation service for questions regarding health-
related services, medications, and diagnosis.
iii. Participate in regular staff meetings where information about the
functional screen received from DHS, the Functional Screen
GovDelivery messages, DHS memos, Q&A documents, and other
sources is shared and discussed.
iv. Identification of how the accuracy, completeness, and timeliness of
annual and change-in-condition screens submitted by screeners
will be monitored;
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v. Identification of the methods that will be employed to improve
screener competency given the findings of the monitoring
Continuing Skills Testing
The ICA shall require all of its certified screeners to participate in
continuing-skills testing required by the Department. The Department
requires each screener to pass a test of continuing knowledge and skills at
least once every two years in order to maintain their certification. The ICA
will:
Ensure the participation of all certified screeners in any
continuing-skills training that is required by the Department.
Administer continuing-skills testing as required by the Department
in accordance with instructions provided by the Department at the
time of testing.
Cooperate with the Department in planning and carrying out
remedial action if the results of the continuing-skills testing
indicate performance of any individual screener or group of
screeners is below performance standards set for the test result,
including retesting if the Department believes retesting to be
necessary.
Participant Materials
Participant materials are defined in Article I, Definitions. Participant materials
shall be accurate, readily accessible, appropriate for, and easily understood by the
Contractor target population. All materials produced and/or used by the ICAs and
FEAs must be understandable and readable for the average participant and reflect
sensitivity to the diverse cultures served. The Contractor must make all reasonable
efforts to locate and use culturally appropriate material. Materials shall take into
account individuals who are visually limited or who are limited English
proficient.
Participant materials shall be available to participants in paper form, unless
electronic materials are available, the participant or the participant’s legal
decision maker prefers electronic materials, and the electronic materials meet the
requirements in section 2 below.
All materials produced and/or used by the Contractor must:
Use easily understood language and format.
Use a font size no smaller than 12 point.
Be available in alternate formats and through the provision of auxiliary
aids and services upon request and at no cost.
The Contractor may provide participants with materials using electronic media
only if all of the following requirements are met:
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Permission to Receive Materials Electronically
i. Contractor must have obtained the participant’s consent to receive
materials electronically. This can be gathered either on paper (and
uploaded to the participant’s WISITS record) or can be provided
over the phone, but in this instance, the Contractor must document
this approval in a case note within the participant’s record in the
Department’s case management system (WISITS).
ii. Contractor must have safeguards in place to ensure delivery of
electronic materials is in compliance with confidentiality laws,
and:
Participants must be able to opt out of receiving electronic
communications upon request.
Participant contact information must be current and materials
are sent timely, with important materials identified in a way
that participants understand their importance.
Contractor must have a process for mailing of hard copies when electronic
communications are undeliverable.
The format is readily accessible;
i. The information is placed in a location on the Contractor’s website
that is prominent;
ii. The information is provided in an electronic form which can be
electronically retained and printed;
iii. The participant is informed that the information is available in
paper form without charge upon request and the Contractor
provides it upon request within five (5) business days.
Materials for marketing/outreach and for health-promotion or wellness
information produced by the Contractor must be appropriate for its target
population and reflect sensitivity to the diverse cultures served.
If the Contractor uses material produced by other entities, the Contractor
must review these materials for appropriateness to its target population
and for sensitivity to the diverse cultures served.
Educational materials (e.g., health, safety, fall prevention, etc.) prepared
by the Contractor or by their contracted providers and sent to the
Contractor’s other participants do not require the Department’s approval,
unless there is specific mention of Medicaid or IRIS. Educational
materials prepared by outside entities do not require Department approval.
The Contractor shall have all participant materials approved by the
Department before distribution. The Department will review participant
materials within thirty (30) calendar days of receipt.
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Marketing/Outreach Plans and Materials
The Contractor agrees to engage only in marketing/outreach activities and
distribute only those materials that are pre-approved in writing, as outlined in this
section; marketing/outreach and marketing/outreach materials are fully defined in
Section II, Definitions.
Marketing/outreach materials are defined, in part, as any communication, from
the Contractor to an individual who is not being provided services from the
Contractor, which can reasonably be interpreted as intended to influence the
participant to choose their ICA or FEA, or to not choose another ICA or FEA.
This further includes materials and presentations to community participants,
participants, stakeholders, non-profit organizations, professional conferences, etc.
on topics related to the IRIS Program.
Marketing/Outreach
If the Contractor engages in marketing/outreach activities, a plan describing those
activities must be approved in writing by the Department before the plan is
implemented.
Requirements and Approvals
The Contractor shall submit to the Department for approval all
marketing/outreach materials prior to printing, presenting, or disseminating the
materials. Existing marketing/outreach materials that are being updated must also
be resubmitted for approval.
The Contractor must ensure that participants and potential participants
receive accurate oral and written information sufficient to make informed
choices.
The Department will review all marketing/outreach plans materials in a
manner which does not unduly restrict or inhibit the Contractor’s
marketing/outreach plans and materials, and which considers the entire
content and use of the marketing/outreach materials and activities.
Issues identified by the Department will be reviewed with the Contractor.
The Contractor will be asked to make the appropriate revisions and
resubmit the document for approval. The Department will not approve any
materials it deems confusing, fraudulent, or misleading, or that do not
accurately reflect the scope, philosophy of the program.
Timeline for Department approval - The Department will review
marketing materials within thirty (30) calendar days of receipt.
Contractor agreement to abide by marketing and distribution criteria
The Contractor agrees to engage only in marketing activities and distribute
only those marketing materials that are pre-approved in writing.
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All activities must not be intended to target or exclude a specific target
population or subgroup of individuals.
Participant Usability
All marketing/outreach materials must be easily understood and readable for the
average participant by utilizing plain language (https://www.plainlanguage.gov/).
Social Media Practices
Any social media postings referencing the IRIS program or the Contractor’s role
in said program must be pre-approved by the Department.
Prohibited Practices
The following marketing/outreach practices are prohibited:
Practices that are discriminatory.
Practices that seek to influence enrollment in conjunction with the sale or
offering of any other service or product.
Direct and indirect cold calls, either door-to-door, email, telephone or text,
or other cold-call marketing activity;
Practices that reveal PII or PHI of an IRIS participant without expressed
written approval by the participant.
Activities and materials that could mislead, confuse, or defraud
participants or potential participants, or otherwise misrepresent the
Contractor, its marketing representatives, the Department, or CMS.
Statements that would be considered inaccurate, false, or misleading
include, but are not limited to any assertion or statement (whether written
or oral) that:
i. The participant must choose the Contractor in order to obtain
benefits or in order to not lose benefits;
ii. The Contractor is endorsed by CMS, the federal or state
government, or other similar entity;
iii. Practices that are reasonably expected to have the effect of denying
or discouraging enrollment; or
iv. Practices to influence the recipient to either choose their
Contractor or not choose another Contractor.
Marketing/outreach activities that have not received written approval from
the Department.
Sanctions
The Contractor that fails to abide by these marketing/outreach requirements may
be subject to any and all sanctions identified herein. In determining any sanctions,
the Department will take into consideration any past unfair marketing/outreach
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practices, the nature of the current problem and the specific implications on the
health and well-being of the enrolled participant(s).
Websites
The Contractor is expected to maintain a current and up-to-date website
providing information regarding their agency.
Website must have a participant-friendly design with written materials in
plain language (https://www.plainlanguage.gov/) English.
All web content must be approved by the Department prior to
deployment.
The Contractor should aim for the written content on their websites
to be at a 6
th
grade reading level, with a best practice that alternate
formats be available (e.g. large print, languages other than
English).
If the Contractor’s IRIS-specific website is embedded within their parent
organization’s website, accessible plain language information and
resources about IRIS must be present and available from that parent
organization’s home page. The Contractor is expected to provide a link on
their agency website to the Department of Health Service’s IRIS Program
website: https://www.dhs.wisconsin.gov/iris/index.htm.
The Contractor is expected to provide a link on their agency website to the
IRIS Self-Directed Personal Care website maintained by the Department:
https://www.dhs.wisconsin.gov/iris/sdpc.htm.
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V. Eligibility
Individual Eligibility Requirements
Per 42 CFR 442.302(b-c), all participants must meet and continue to maintain
functional, financial, and non-financial eligibility requirements. Policies on
eligibility requirements for individuals seeking participation in IRIS are
summarized below:
Age and Target Group
An individual must be at least 18 years of age and fall within one of the following
target groups: frail elder, physical disability, or intellectual/developmental
disability.
Medicaid Eligibility
An individual must be eligible for full-benefit Medicaid, as described in Chapter
21.2 of the Medicaid Eligibility Handbook
(http://www.emhandbooks.wisconsin.gov/meh-ebd/meh.htm). Eligibility for
Medicaid is verified using the Department’s ForwardHealth interChange system;
participants enrolled in limited-benefit Medicaid plans are not eligible to be
enrolled in IRIS. Resources and a quick reference document are available upon
request or logging into interChange for Contractors to identify full-benefit
Medicaid programs using current Med Stat codes in the interChange system.
Functional Eligibility
Functional eligibility for IRIS and all adult long-term care programs is determined
using the Long-Term Care Functional Screen. Individuals must have a level of
care assignment that would allow admission to a nursing home or an Intermediate
Care Facility for Individuals with Intellectual Disabilities (ICF-IID). The long-
term care eligibility condition must be expected to last more than 12 months.
Need for Services
Persons who have been determined to meet the financial and functional eligibility
criteria for waiver participants, but who do not have an assessed need for waiver
services, are not eligible for Medicaid using the special IRIS program eligibility
criteria (42 CFR § 435.217(c)). The Centers for Medicare and Medicaid Services
defines “reasonable need” as follows:
“In order for an individual to be determined to need waiver [IRIS] services, an
individual must require (a) the provision of at least one HCBS waiver service, as
documented in the service plan, and (b) the provision of HCBS waiver services
occurs at least monthly or, if the need for services is less than monthly, the
participant requires regular monthly monitoring which must be documented in the
service plan.”
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Residency and Eligible Living Arrangements
An individual must be a resident of the State of Wisconsin, and reside in an
eligible living setting. While the arrangements below are generally permitted,
there are some restrictions. For example, IRIS program funds may not be used to
pay for community-based residential facilities (CBRFs), and many residential care
apartment complexes (RCACs) may not admit persons who have a legal decision
maker. Individuals seeking enrollment in the IRIS program may be residing in
one of the ineligible settings listed below at the time of application. However,
final eligibility cannot be established and services through the IRIS program may
not begin until the person lives in an eligible setting.
Eligible living arrangements include:
A house, apartment, condominium, or other private residence;
A rooming/boarding house;
A certified Adult Family Home (1-2 bed);
A licensed Adult Family Home (3-4 bed);
A certified RCAC.
Ineligible living arrangements include, but are not limited to:
A hospital, nursing home, or institution for mental disease (IMD);
An ICF-IDD or any of the state centers for people with
developmental disabilities;
A jail, prison, or other correctional facility; and
A registered RCAC, as this is a private pay-only facility.
Temporary Living Arrangements
In transitional situations, a participant may reside in a hotel, motel,
homeless shelter, or other type of transitional housing. These are permitted
living arrangements. All other eligibility requirements continue to apply
including Wisconsin residency.
The IC is responsible for evaluating health and safety, as well as
monitoring the participant’s progress towards permanent residence.
Short Term Institutional Stays
IRIS participants admitted to a nursing home or hospital on a short-term
basis for acute care or rehabilitation will not disrupt eligibility for
enrollment in IRIS. IRIS funded services must be suspended while the
person is in this short-term setting. The participant is required to report
any institutional stay to the ICA. Providers cannot bill for services to the
participant while they are in suspended status.
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If the stay becomes permanent, it will result in a voluntary disenrollment.
Any institutional stay that exceeds 90 days will result in disenrollment.
Incarceration
IRIS services must be suspended while the participant is incarcerated until
such time as they are released or disenrolled, as detailed herein. If a
participant is incarcerated in a jail, prison, or other correctional facility for
30 days or more, the ICA will initiate disenrollment from the IRIS
program, since this is not an eligible living arrangement.
Re-enrollment
Individuals who are disenrolled may re-enroll into the IRIS program, if
found eligible for the program, unless they were disenrolled for
substantiated fraud or have failed to pay cost share arrearages (so long as
they remain unpaid).
Separation from Eligibility Determination
Under the conflict of interest policy, the Contractor must ensure that there is
separation from the initial eligibility determination and enrollment counseling
functions.
IRIS is competitive for Contractors; no contractor is automatically afforded any
number of participants in a specific region.
Cost Share Collection, Monitoring, and Reporting
Participants may be required to pay a monthly cost share in order to be eligible for
Medicaid. Cost share could apply to participants in any IRIS-allowable living
setting. The participant’s local/county income maintenance agency is responsible
for determining the participant’s cost share. Information regarding cost share can
be found in ForwardHealth interChange and the CARES system. Cost share is
imposed on participants in accordance with 42 C.F.R. § 435.726 and is not
prorated for partial months.
The FEA is responsible for the ongoing monitoring of the cost share payments of
its participants, ensuring that the information is up-to-date and accurate.
The ICA must ensure that cost share information assessed by Income
Maintenance is entered accurately in the Department’s case management system
(WISITS)
The ICA is responsible for assisting a participant with the determination of
medical/remedial expenses, as necessary. Reporting changes to the income
maintenance agency is the responsibility of the participant.
The FEA is responsible for collecting participant’s monthly cost share payments,
subject to the following Department policies and procedures:
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The ICA will send the initial notice (F-01556) to any participant who has a
cost share.
Statements are sent after payments are received, and no later than the 10
th
of each month.
The FEA will send a statement each month to participants reflecting the
current status and at least three months of their cost share payment history,
with a clear indication of whether they are in arrears or overpaid.
i. Cost share overpayments shall be remit from the FEA’s private
funds and repaid to the FEA using the Reimbursement file.
The FEA is responsible for collecting participant’s monthly cost share payments,
subject to the following Department policies and procedures:
The ICA will send the initial notice (F-01556A) to any participant who has
a cost share.
Statements are sent after payments are received, and no later than the 10
th
of each month.
The FEA will send a statement each month to participants reflecting the
current status and at least three months of their cost share payment history,
with a clear indication of whether they are in arrears or overpaid.
i. Cost share overpayments shall be remit from the FEA’s private
funds and repaid to the FEA using the Reimbursement file.
ii. Cost share overpayments should be repaid in full to participants
within 30 days of identifying the need for repayment.
Room and Board
Residential settings where waiver services are furnished to the participant, other
than the personal home of the participant, are required to break out the
participant's obligation for room and board from the cost of allowable waiver
services using the following methodology prescribed by the Department. The
participant uses his or her own resources to pay for their room and board
obligation.
1. Determining the Participant's Room and Board Obligation (effective
1/1/2023)
The participant's room and board obligation is the lesser of:
a. The prior calendar year's HUD FMR rental amounts, based on residential
type by county, plus the prior calendar year's maximum Supplemental
Nutrition Assistance Allocation for one person; or
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i. HUD FMR amounts: HUD FMR rents are set at the 40% percentile
of surveyed rental costs reflecting modest but reasonable housing,
include utilities, vary by county and apartment size, and are
updated yearly: https://www.huduser.gov/portal/datasets/fmr.html
ii. SNAP allocation:
https://www.dhs.wisconsin.gov/foodshare/fpl.htm
b. The participant's available income for room and board using procedures
specified by the Department.
Round HUD FMR, SNAP allocation, and participant's available income down to
the nearest dollar. Use the prior calendar year's efficiency rent for owner-occupied
Adult Family Homes, the one bedroom rent for corporate-operated Adult Family
Homes and Licensed Community-Based Residential Facilities, and the two-
bedroom rent for Residential Care Apartment Complexes. Use the HUD FMR
amount for the county where the member lives. For a participant residing in a
shared room, divide the HUD FMR by two and add the maximum SNAP
allocation.
c. To calculate the amount of income the participant has available for room
and board, the following calculations must be used:
Deduct from the participant's gross monthly income:
i. Health insurance premiums, defined in MEH 28.6.4.4;
ii. Discretionary income allowance of $100 for basic living expenses;
iii. Spousal income allocation, defined in MEH 18.6;
iv. Income used for supporting others, defined in MEH 15.7.2.1;
v. Expenses associated with establishing and maintaining a
guardianship, defined in MEH 15.7.2.3;
vi. Court ordered fees and payments, defined in MEH 15.7.2.3;
vii. Garnishments;
viii. Deductions from unearned income, including IRS and SSA
paybacks;
ix. Medical and remedial expenses, defined in MEH 15.7.3; and State
and federal income taxes.
2. Determining the Participant’s Available Income
The available income the participant has to pay for room and board, is determined
using procedures specified by the Department. The room and board obligation
calculation is not pro-rated for partial months.
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3. Sharing Information with Income Maintenance
The ICA shall inform the income maintenance agency of the room portion of the
participant’s room and board obligation. The room portion is always the
participant’s obligation minus the maximum SNAP allocation (which is the board
portion).That information may be used by income maintenance to determine any
allowable excess housing costs that may reduce the participant’s cost-share.
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VI. Enrollment & Orientation
ADRC Referral Process
When a participant chooses IRIS, the ADRC representative will provide the
participant with the program information. This material is provided to the ADRCs
by DHS to ensure consistency across all ADRCs.
Contractors must work with DHS to have informational materials approved and
available to ADRCs about their agency.
Once the participant chooses an ICA and FEA, the ADRC representative
facilitates the referral process by submitting a referral packet to the ICA the
participant has chosen. Immediately upon creating the participant’s record in the
Department’s case management system (WISITS), the ICA must notify the FEA
of the referral.
IRIS participants are allowed to request a change of IRIS consultant agency and
fiscal employer agent at any time.
Contractors are required to assist participants, other Contractors, the Department,
and/or other agencies, with efficient, accurate, and unbiased transfers between
agencies.
Contractors must adhere to documented IRIS Program Policies and Work
Instructions regarding transfers.
ICA Transfers
If an IRIS participant or their legal decision maker wants to change ICAs,
the ICA is responsible for directing the participant or their legal decision
maker to their local ADRC to initiate that change.
FEA Transfers
The initial FEA will provide the new FEA with all necessary information
regarding the participant and will ensure the participant’s successful
transfer between FEAs.
Participants may request to transfer FEAs at any time, transfers will take
effect at the beginning of each quarter (e.g. January 1, April 1, July 1, and
October 1).
Voluntary Enrollment
Enrollment in the IRIS program is a voluntary decision on the part of the
applicant who is determined to be eligible. The Department does not guarantee
any minimum enrollment level. Individuals must make the choice to enroll in
IRIS, over other adult long-term care programs; the choice to enroll is verified by
the signature of the participant (or their legal decision maker) on an enrollment
form provided by the Department.
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Service Timeline Expectations
The Enrollment and Orientation period is intended to take place 1-60 days from
the referral date, to include the following required actions and deadlines:
Welcome Call 3 business days from referral date
IRIS Consultant Selection 3 business days from welcome call
IRIS Consultant Auto-assign 4 business days from welcome call
Initial Enrollment &
Orientation Visit
14 calendar days from referral date
ISSP Plan – Completed 30 calendar days from initial visit
Implementation of ISSP Plan
–
Completed and Approved
45 calendar days from initial visit
Transition Visit
On or before 55 - 60 calendar days from
welcome call
Transition to participant-
selected level of IRIS
Consultant involvement
On or before 61
calendar days from referral
date
Date of annual plan
submission/approval
Prior to current plan year end
Enrollment and Orientation Services
ICAs are responsible for enrolling participants in the program as well as providing
orientation services. Orientation includes an introduction to the participant’s role
and responsibility in the IRIS program and development of the Individualized
Support and Services Plan (ISSP).
Welcome Call & IRIS Consultant Selection
The ICA will enter the referral into the Department case management
system (WISITS) within one business day.
The ICA will contact the individual within three business days after
receiving the participant’s referral packet to assist the participant in
choosing a consultant.
The ICA should obtain information from the participant about
special needs or preferences and, in turn, provide the participant
with at least three available consultants who are most suited to
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meet the participant’s specified needs and provide IRIS consultant
biographies, in the DHS required format.
If the participant prefers to have a consultant chosen on his or her
behalf, then the participant is assigned an IRIS consultant during
this welcome call based on information provided by the participant
to the ICA.
If the participant does not identify a preferred consultant within
three business days of the welcome call, then on the fourth
business day, the ICA will notify the participant of the agency-
selected consultant and notify the participant they can change
consultants at any time, and for any reason. The ICA will advise
the participant of the procedure to change consultants at this time.
In addition to IRIS consultant selection, the welcome call will
include a brief overview of the immediate next steps and the steps
of the enrollment and orientation phase. After the welcome call,
the appropriate ICA representative will schedule the initial
enrollment and orientation meeting between the IRIS consultant
and the participant.
Enrollment and Orientation Meeting
The enrollment and orientation meeting must be conducted within 14 calendar
days from the referral date. The details of the meeting must also be documented in
the Department case management system (WISITS) within 2 business days.
During this meeting, the consultant shall, at minimum:
Provide a review of the annual functional and financial eligibility
requirements, and the role of the participant in maintaining their eligibility
for Medicaid and IRIS.
Provide the participant with the amount of their IRIS individual budget
allocation.
Provide a printed copy of the IRIS Participant Handbook (P-01008) to the
participant.
Discuss the required ICA service levels, including the reasons for and the
process by which DHS may require an increase in ICA services, such as
with a vulnerable high-risk designation.
Provide information related to the ISSP, including allowable goods and
services, planning tools, and available community resources.
Ensure the participant understands that they must be available to speak
with and/or meet with their IRIS consultant.
Discuss the benefits, responsibilities, and alternatives to serving as the
employer of record (e.g. hiring a vendor).
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Review the IRIS consultant’s contact information, contact information for
the participant’s chosen ICA and FEA, and contact information for the
IRIS Call Center.
This information should be documented in front of the Participant
Education Manual, and updated throughout the year, as needed
when there are changes in consultant or Contractor.
The contact information for the IRIS Call Center shall be pointed
out in the IRIS Participant Handbook.
i. A review of additional required documentation for enrollment and obtain
requisite participant signatures, as required by IRIS Policy.
Individual Support and Service Plan Development
IRIS consultants are required to provide the tools, resources, and information to
assist the participant in making informed planning decisions about long-term care
services and supports. The participant-identified outcomes lead to the
development of an Individual Support and Service Plan (ISSP), based on the
participant’s assessed long-term care needs.
IRIS consultants discuss with the participant their desired outcomes and the
assistance or services that the participant needs to address their long-term care
need in order to reach those outcomes. IRIS consultants support the participant to
identify supports, services, and goods which address identified outcomes specific
to the participant’s disability or qualifying condition, to ensure community-based
services prevent the need for institutional-based services. Supports, services, and
goods can be any combination of natural supports, services paid for by other
funding sources, as well as services and supports funded through the IRIS
individual budget allocation.
Plan development is done in accordance with the IRIS participant’s identified
long-term care needs and outcomes. Based on this, the ICA selected by the person
must:
Assist the participant in completing all required and/or applicable
assessments, including but not limited to, risk, behavior, and needs
assessments.
Utilize discussion with the participant regarding long-term care needs and
life goals, all assessments, LTCFS, available medical records, and other
available pertinent information to assist the participant in identifying
participant-centered outcomes.
Assist the participant to identify natural supports and other resources
outside the IRIS program that may assist in meeting his or her needs.
Assist in the identification of long-term care strategies to accomplish their
desired outcomes.
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The ICA is responsible for the review and approval of the ISSP in
accordance with IRIS Program Policy (P-00708) and IRIS Work
Instructions (P-00708A).
The IC is responsible for completing the ISSP within 30 days of the
enrollment and orientation meeting. If delays arise, the ICA shall notify
and work with the Department towards a timely resolution, as necessary.
The IC is responsible for monitoring the plan.
The IC is responsible for ensuring that the ISSP for each participant
includes the following:
The participant’s person-centered outcomes, and the method by
which progress towards meeting this outcome will be measured.
The services and supports, covered by natural supports, other
funding sources, and the IRIS program.
Behavior support plans and restrictive measures applications in
accordance with DHS policy and the IRIS policy.
The 24-hour emergency backup and preparedness plan for services
that ensure the health and safety of participants, per IRIS policy.
Mitigation of any issues of conflict of interest.
Any required cost share or medical remedial costs.
Service Authorizations
Each IC must ensure appropriate service authorizations are in place for
each service or support on the participant’s ISSP, at usual and customary
rates.
Each service authorization must include:
Participant name
Provider/employee name
Start date
End date
Unit of measure for the service or support
Frequency of the service or support
Cost per unit of service or support
Orientation Service Level Expectations
All new or re-enrolled IRIS participants are required to receive the orientation
service level for the initial 90 days after plan implementation. The orientation
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service level requires the ICA to maintain contact with the participant to ensure
that the participant builds a basic foundation and understanding of:
Policy and procedures of the IRIS program
The participant’s role and responsibilities within the IRIS program;
The process to get help, as needed; and
A clear understanding of the ICA’s role and responsibilities.
An Orientation and Enrollment Checklist is available for IRIS consultants to
utilize during the first 90 days of enrollment to ensure that all required topics of
discussion are addressed.
Participants are welcome to contact the orientation consultant or IRIS consultant
as often as needed and the consultant will address their concerns and questions.
The minimum requirements for the ICA, during the orientation service level
phase, include:
A biweekly phone conversation with the IRIS participant to discuss any
questions, concerns, and experiences with the IRIS program.
Monthly, in-person conversations with the IRIS participant to discuss any
questions, concerns, and experiences with the IRIS program.
At least one in-person conversation with the participant, in the IRIS
participant’s residence.
Provide a printed copy of the IRIS Participant Handbook (P-01008) to the
participant.
Participant Education Manual
Review of all chapters and content in the IRIS Participant
Education Manual (P-01704) and requisite completion of IRIS
Participant Education Manual – Acknowledgement (F-01947).
All topics included in the manual must be reviewed with the
participant during orientation.
Completion of the Budget Amendment Education Participant
Education form (if applicable) (F-01205B).
Completion of the One-Time Expense Participant Education form
(if applicable) (F-01205C).
A review of the processes and paperwork for hiring and terminating
participant-hired workers and vendors. This should include an explanation
of requirements related to completion and submission of timesheets.
A review of the processes and paperwork for hiring guardians and other
legal representatives as participant-hired workers.
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A discussion regarding compliance with IRIS Program policy and possible
disenrollment consequences.
Provision of participant training to include an understanding of
requirements to act as an employer for participant-hired workers,
including the obligation to train, supervise, and/or terminate workers.
A review of the complaints, grievances, and appeals process, including
related resources. This review should include contacts specific to the
Contractor, as well as the third party Contractors, such as the EQRO or
ombudsman.
Disenrollment
The ICA shall comply with the following requirements and use Department
issued forms related to disenrollment.
Processing Disenrollments
The disenrollment plan, developed in collaboration with the ADRC and income
maintenance agency, shall be the agreement between entities for the accurate
processing of disenrollments. The enrollment plan shall ensure:
That the ICA is not directly involved in processing disenrollments
although the ICA shall provide information relating to eligibility to the
income maintenance agency;
That enrollments and disenrollments are accurately entered in
ForwardHealth interChange so that correct monthly rate of service
payments are made to the ICA and FEA;
That timely processing occurs, in order to ensure that participants who
disenroll have timely access to any Medicaid fee-for-service benefits for
which they may be eligible, and to reduce administrative costs to the ICA,
FEA, and other service providers for claims processing; and
That disenrollments are accurately entered in the Department case
management system (WISITS) so that correct monthly rate of service
payments are made to the ICA and FEA.
Contractor Influence Prohibited
Neither the ICA, nor the FEA, shall counsel or otherwise influence a participant
due to his/her life situation (e.g., homelessness, increased need for supervision) or
condition in such a way as to encourage disenrollment.
Types of Disenrollment
Participant-Requested/Voluntary Disenrollment
All participants have the right to disenroll from the ICA, FEA, and the
IRIS program without cause at any time.
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If a participant expresses a desire to disenroll from IRIS, the ICA shall
provide the participant with contact information for their local ADRC; and
with the participant’s approval, may make a referral to the ADRC for
options counseling. If the participant chooses to disenroll, the participant
will indicate a preferred date for disenrollment. The date of voluntary
disenrollment cannot be earlier than the date the individual last received
services authorized by the ICA.
The ADRC will notify the ICA that the participant is no longer requesting
services and the participant’s preferred date for disenrollment as soon as
possible, but this notification will be no later than one (1) business day
following the participant’s decision to disenroll. The ADRC will process
the disenrollment.
Disenrollment Due to Loss of Eligibility
The participant will be disenrolled if he/she loses eligibility. The ICA is
required to notify the income maintenance agency when it becomes aware
of a change in a participant’s situation or condition that might result in
loss of eligibility.
Participants lose eligibility when the participant:
Fails to meet functional eligibility requirements;
Fails to meet financial eligibility requirements;
Fails to pay, or to make satisfactory arrangements to pay, any cost
share amount due to the FEA pursuant to IRIS Policy;
Initiates a move out of the State of Wisconsin;
If the participant moves into a geographic service region not served
by the ICA, the ICA shall assist the participant with a transfer to an
ICA serving the region in which they are relocating within
Wisconsin.
Is incarcerated as an inmate in a public institution;
Is relocated to a nursing home or hospice facility for long-term or
permanent care;
A participant age 21-64 is admitted to an Institution for Mental
Disease (IMD) for longer than 90 days, or
Dies.
ICA-Requested Disenrollment with Cause
When requested by the ICA, a participant may be disenrolled in
accordance with the IRIS Policy Manual and Work Instructions, if:
The ICA is unable to assure the participant’s health and safety.
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The participant failed to complete a functional screen or sign their
ISSP.
The participant is no longer accepting services.
The participant has been found to have mismanaged or abused
their employer authority or budget authority.
The participant is out of compliance with IRIS Policy.
The ICA may not request a disenrollment if the participant exhibits
uncooperative or disruptive behavior that results from his/her
special needs with the following exception:
a) Due to the participant’s uncooperative or disruptive
behavior, the participant’s continued enrollment in the IRIS
program seriously impairs the ICA’s ability to verify health
and safety of the participant or others.
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VII. Consulting Services
Service Levels
DHS requires cost-neutral consulting models. The Contractor agency will already
have provided clear descriptions of the roles of each type of consultant in the
certification application.
All ICAs will collaborate with the IRIS participant throughout their participation
in the program, to resolve any issues that may arise in which the participant needs
assistance, such as changes in service plan, change in living environment, and
provider or employee conflicts.
ICAs have the option of utilizing IRIS consultants and/or orientation consultants
in the orientation phase, when familiarizing the participant with program
responsibilities and requirements.
Regardless of the model under which the ICA operates, the ICA must ensure
participants receive the correct level of consulting services.
After the orientation phase, the participant and the IRIS consultant must have a
conversation discussing the participant’s level of confidence, comprehension, and
security in self-directing their long-term care support needs within the IRIS
program.
The orientation consultant or IRIS consultant may offer their assessment
of the participant’s orientation to the program.
If, after this conversation, the participant requests, or it is mutually agreed
upon, that the orientation level continue as they become familiar with the
IRIS program, then the ICA is required to extend this service level an
additional 90 days.
ICAs should note that participant life events including, but not limited to, a
change in condition, seeking employment, moving, plan updates and
amendments, and new or changing employees, are all considered naturally
occurring life events and part of the standard ICA service delivery model required
of all ICAs.
The ICA must uniquely adjust the level of service required for each participant.
Competency Standards for IRIS Consultants
The ICA shall utilize the competency standards cited below when hiring and
training their consultants. The ICA shall provide or arrange for training to assure
that ICA employees meet competency standards in the following areas:
Knowledge of long-term care services and supports, IRIS program governing
documents (e.g., policy and work instructions), and available IRIS-funded
services and supports.
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Knowledge of the principles of self-direction, self-determination, person-centered
planning, budget authority, employer authority, and Medicaid eligibility;
Knowledge, experience, and understanding of working with IRIS target group
populations and the customer service-driven role the consultant plays with regards
to self-direction and empowerment;
Knowledge of IRIS fiscal employer agents’ roles and responsibilities;
Monitor the health and safety of IRIS participants through the identification of
risks and concerns, completion of critical incident reporting, and supporting
participants after said incidents to ensure risks have been mitigated;
Capacity to create and maintain thorough, unbiased, accurate, well-written, and
timely records and case notes related to each participant for whom the consultant
is responsible;
Ability to educate participants on program responsibilities, as well as act as a
resource on an ongoing basis regarding program policy and the completion of
necessary forms;
Ability to work with agency peers, partner agencies, fiscal employer agents, and
Department staff, as necessary, in a professional, collaborative, problem-solving
driven atmosphere;
Possess interpersonal skills, display professionalism, and take accountability for
the responsibilities of an IRIS consultant; and
Core professional competencies, such as the abilities to:
Manage time effectively and multitask,
Identify and gather key information through active listening and effective
communication,
Problem solve and assist with the implemented solution(s),
Use proper grammar, spelling, proof reading, and other written
communication skills in their interactions and recordkeeping,
Utilize basic computer functions surrounding the internet and word
processing, with the capacity to learn the WISITS system, and
Complete mathematical calculations, as necessary, with regard to
participant budget and expenses.
Ongoing Service Level Requirements
The ICA service levels described herein are required for all IRIS participants to
ensure proper orientation to the IRIS Program and ongoing consultant service
level in the program. However, ongoing consultant services provide a level of
service to a participant unique to their personal preferences and needs to
maximize self-direction in the IRIS Program. The participant and the ICA develop
an appropriate level of consultant services to achieve the participant’s long-term
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care outcomes. Regardless of the service level developed, the participant may
initiate as many contacts as needed.
Activities occurring during ongoing consultant services include plan updates,
annual recertification of functional eligibility by LTCFS screeners, annual
completion of financial eligibility, completion of any change of condition
assessments, resolving day-to-day issues, and supporting the participant’s long-
term care needs and outcomes be met through the IRIS Program.
Minimum Service Requirements
The ongoing level of service is the minimum service level required for all
program participants after completion of the orientation phase. The minimum ICA
service requirements, during the ongoing service level, include:
Monthly phone conversation with the participant, either telephonic or live
video contact.
A minimum of one in-person visit quarterly.
Annually, a minimum of one in-person visit must take place in the
participant’s home.
Respond to all inquiries and requests made by the participant in a timely
manner, regardless of the participant’s chosen level of IRIS consultant
involvement.
Completion of the annual plan review per IRIS Policy and Work
Instructions.
Completion of individual support and service plan updates when
applicable.
Ensuring that all services on the plan are being implemented to meet the
participant’s long-term care needs.
Annual Participant Education Manual Review
Review of all chapters and content in the IRIS Participant
Education Manual (P-01704) and requisite completion of IRIS
Participant Education Manual – Acknowledgement (F-01947).
Completion of the Budget Amendment Education Participant
Education form (F-01205B), if applicable.
Completion of the One-Time Expense Participant Education form
(F-01205C), if applicable.
Completion of the annual functional screen redetermination.
i. Functional Eligibility Redetermination
Once enrolled, the ICA is responsible to assure that all participants
have a current and accurate level of care as determined by the
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Long-Term Care Functional Screen. This includes, at minimum, an
annual re-determination of level of care. It may also include a post-
enrollment redetermination shortly after enrollment or a
redetermination necessitated by a change in the participant’s
condition.
ii. Post-Enrollment Re-Determination
The ICA may re-determine level of care for a new participant
shortly after enrollment if the ICA believes that different or
additional information has emerged as a result of the initial plan
development.
The ICA shall consult with the ADRC if the ICA re-determines
level of care for a newly enrolled participant or when a newly
enrolled participant is found to be functionally ineligible or
eligibility changes to a non-nursing home level of care within six
(6) months of the submission of the most recent pre-enrollment
screen. The ICA shall review and compare the screens, attempt to
resolve the differences, and contact the Department or its designee
if differences cannot be resolved.
iii. Annual Re-Determination
An annual re-determination of level of care shall be completed
within 365 days of the most recent functional screen. If the level of
care re-determination is not complete in the designed timeframe,
the ICA is required to inform the income maintenance agency of
the lack of functional eligibility determination. Participants will
lose eligibility if the redetermination is not done timely.
iv. Change of Condition Re-Determination
A re-determination of level of care should be done whenever a
participant’s situation or condition changes significantly.
Ongoing Service Level Requirements
In conjunction with the ICA service level requirements, IRIS consultants (ICs) are
responsible for providing a unique level of ICA services to ensure participants
effectively self-directed their services, based on their assessed needs, and that
they understand their responsibilities. The services ICs must provide include, but
are not limited to:
Discuss assessed needs and life goals, all assessments, functional screen
results, available medical records, and other available pertinent
information to support participants in the identification of participant-
centered outcomes.
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Assist in the development, implementation, and updating of the ISSP to
ensure access to goods, services, supports, and to enhance success with
self-direction.
Ensure ISSP for each participant includes the following:
The participant’s long-term care outcomes and purpose for
requesting the good or service, as well as the method by which
progress towards meeting this outcome will be measured.
The services and supports covered by natural supports, other
funding sources, and the IRIS program to address the needs and
outcomes of the participant as determined through an assessment
and person-centered planning process.
The 24-hour emergency backup plan for services that affect the
health and safety of participants.
Signatures are required for any plan changes. Per Wis. Stat. § 137.11(8) an
“electronic signature” means an “electronic sound, symbol or process
attached to or logically associated with a record and executed or adopted
by a person with the intent to sign the record.”
Assist the participant with quality assurance activities.
Assist the participant in ensuring all services and supports are arranged, to
include completion of all hire required paperwork, to begin in conjunction
with the ISSP service authorization dates.
Ensure the participant’s requirements for training of participant-hired
worker(s)/service provider(s) are documented in the IRIS Participant
Education Manual: Acknowledgement.
Process requests for additional funding for either a one-time expense or a
budget amendment, and justification for payment above the range of rates
is completed and submitted as needed and in the format prescribed in the
Department case management system (WISITS) or SharePoint.
Assist the participant in managing the service plan budget by reviewing
their budget statement.
Monitor, report, and address issues of budget mismanagement and/or
abuse, conflict of interest, and health and safety issues.
Assist the participant and legal decision maker to develop and implement
any behavior support plans and restrictive measures applications in
accordance with DHS policy and the Wisconsin Restrictive Measures
Protocol.
Provide ongoing oversight of the participant’s understanding of acting as
an employer, the IC may also provide guidance, feedback, and act as a
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resource to the IRIS participant, as it relates to PHW-related functions.
However, ICs are not a supervisor for participant-hired workers.
Assist the participant to arrange for participant-specific training of the
participant-hired worker(s)/service provider(s) in circumstances where the
participant is unable to provide the training.
Use provided Departmental reports and resources to ensure the participant
understands and completes requirements for functional (LTCFS) and
financial eligibility on an annual basis.
In the event of a change of condition, assist the participant in arranging to
have an updated LTCFS.
Assist in the mitigation of any issues of conflict of interest.
Ensure participants understand their responsibility regarding cost share, if
applicable.
Report all critical incidents according to policy.
Make referrals to Adult Protective Services agencies, as needed, to address
immediate or ongoing health and safety concerns.
Understand the role of the SDPC registered nurse(s) with regard to
oversight, nurse consultation, and participant health and safety.
Assist DHS in implementing DHS’s defined employment initiatives by
assisting participants with employment needs and collecting data from
participants as requested by DHS.
Refer participants who are seeking to transfer ICA to their local ADRC.
Regularly provide information on IRIS Program changes or updates.
The IC is responsible for routinely discussing multiple aspects of the
participant’s plan and ongoing enrollment in the IRIS Program.
Monthly Discussion Requirements
All discussions with participants must be documented in concise detail in
the participant’s case notes, within the Department’s case management
system (WISITS).
The monthly contact with the participant must be either telephonically or
by live video. Communications by email or text do not meet the monthly
contact requirements.
Topics of conversation for monthly contact shall include, but are not
limited to:
A review and documentation of progress on implementation of the
ISSP.
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Documentation of any usage and effectiveness of the 24-hour
emergency backup plan.
A review budget spending patterns, including an analysis of any
over- and under-utilization of services.
Assessment of the quality of services, access to supports, and
functionality of goods in accordance with the quality assurance
section of the ISSP and any applicable IRIS service standards.
A review of any incidents or events impacting the participant’s
health, welfare, or ability to fully access and utilize support as
identified in the ISSP.
A review any conflict of interest issues and any health or safety
issues.
The progress towards achieving outcomes, including employment
if applicable.
Other concerns or challenges as noted by the participant or legal decision
maker.
Accuracy of Information
The ICA shall not knowingly misrepresent or knowingly falsify any information
in the participant’s record, including but not limited to the LTCFS, the ISSP, or
the case notes. The ICA shall also verify the information is obtained from or
about the individual with the individual’s medical, educational, and other records
as appropriate to ensure its accuracy.
Increased Service Levels
Certain actions or activities involving the IRIS participant may demonstrate the
need for an increased ICA service level. DHS has an obligation to ensure the
health and safety of IRIS participants, while ensuring the highest quality of
service and integrity of the IRIS program. If any of the following circumstances
occur, an increased level of consulting service from the ICA will be required:
Evidence of abuse or neglect,
Two or more related critical incidents in a rolling 12-month period,
Evidence of budget mismanagement or abuse,
Evidence of employer authority mismanagement or abuse,
Routine and consistent errors in timesheet reporting and submission,
40-hour health and safety monitoring, as defined in IRIS Policy and IRIS
Work Instructions,
Meeting the criteria defined herein as a vulnerable high-risk participant.
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The definition of vulnerable/high risk, as defined in Definitions, is
a participant who is dependent on a single caregiver, or two or
more caregivers all of whom are related to the participant or all of
whom are related to one another, to provide or arrange for the
provision of nutrition, fluids, or medical treatment that is necessary
to sustain life and to whom at least one of the following applies:
Is nonverbal and unable to communicate feelings or
preferences; or
Is unable to make decisions independently; or
Is clinically complex, requiring a variety of skilled
services or high utilization of medical equipment; or
Is medically frail.
If a participant meets the criteria as a vulnerable high-risk
participant (VHRP), the ICA shall implement additional oversight
including all of the following:
Every other month in-person visits with the participant.
In-person visits in the participant’s home once every 6
months, which may be combined with the every other
month in-person visit.
At a minimum once per year and when there is a change in
condition of the participant, ICs must document in the Department
case management system (WISITS) that a VHRP determination
has been completed for the participant. If the participant has been
determined to be VHRP, the ICs must complete the VHRP
Determination Form (F-02879) and upload it into the Department
case management system (WISITS). The VHRP Determination
Form (F02879) must be completed at a minimum twice per year or
when there is a change in condition of the participant.
Increase in Service Level
If one of the circumstances noted above occurs, then the ICA is responsible for
explaining to the participant the reason for increased consulting services.
DHS will work with the ICA and the participant to develop a level of service
appropriate to address and potentially resolve the situation. In certain
circumstances, DHS may mandate an increased level of ICA services.
All increases in service level require the following information:
A description of the circumstances requiring the increased level of
ICA services, including type, frequency, and severity of the
identified circumstances.
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The number of monthly or weekly phone conversations to address
the identified issue.
The number of monthly or weekly face-to-face conversations to
address the identified issue.
The proposed duration of the recommended increased level of ICA
services.
A description of the other solutions attempted to address and
resolve the circumstances and a notation that those attempts were
unsuccessful.
Participant Provider Service Agreement Language
The ICA must ensure participants have a participant provider service agreement
with all required providers for all agency provided services. The participant
provider service agreement shall be in writing; shall include the provisions of this
subsection; shall only include approved waiver services and supports paid for
using IRIS funds; and shall include and comply with any general requirements of
this contract that are appropriate to the service. All amendments to the provider
agreements shall be in writing and signed and dated by both the provider and the
participant.
Requirements
Except for specific areas inapplicable in a specific participant provider service
agreement, at a minimum, a participant provider service agreement shall include,
but is not limited to, the following requirements:
Participant Provider Service Agreement
The participant and provider entering into the agreement are clearly
defined.
Service(s)
The participant provider service agreement clearly delineates the scope of
service(s) being provided, arranged, or coordinated by the provider.
Compensation
The participant provider service agreement specifies rate(s) for purchasing
service(s) from the provider.
Term and Termination
The participant provider service agreement specifies the start date of the
participant provider service agreement and the means to renew, terminate
and renegotiate. The participant provider service agreement specifies the
participant’s ability to terminate and suspend the participant provider
service agreement based on quality deficiencies.
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Nothing herein shall impair the right of either party to terminate a
service(s) contract as otherwise specified therein.
Participant Incidents
The participant shall require its providers to identify, respond to,
document, and report participant incidents as required in IRIS policy.
Notices
The participant provider service agreement specifies a means and a contact
person for each party for purposes related to the participant provider
service agreement (e.g., interpretations, provider agreement termination).
Certification and Licensure
The provider agrees to provide applicable licensure, certification and
accreditation status upon request of the ICA and/or FEA and to comply
with all applicable regulations.
Sanctions/Criminal Investigations
The provider must notify the participant of any sanctions imposed by a
governmental regulatory agency and /or regarding any criminal
investigations(s) involving the provider.
Cooperation with Investigations
To the extent permitted by law, the provider agreement shall require the
provider to fully cooperate with any participant-related investigation
conducted by APS, the Department, the Federal Department of Health and
Human Services, CMS, law enforcement, or any other legally authorized
investigative entity.
Required Providers
Participants shall have a written participant provider service agreement with all
required providers for all agency provided services. Providers of the following
IRIS waiver services are required providers:
Adult Day Care
Daily Living Skills Training
Day Services
Prevocational Services
Respite
Supported Employment - Individual
Nursing Services
Consultative Clinical and Therapeutic Services for Caregivers
Consumer Education and Training
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Counseling and Therapeutic Services
Housing Counseling
Interpreter Services
Residential Services (1-2 Bed AFH)
Residential Services (Other)
Support Broker Services
Supported Employment - Group
Supportive Home Care
Training Services for Unpaid Caregivers
Vocational and Futures Planning
Elder Adults/Adults at Risk Agencies and Adult Protective Services
Contractors shall make reasonable efforts to ensure that their participants are free
from abuse, neglect, self-neglect and exploitation.
Policies and Procedures
Contractors shall have policies, procedures, protocols, and training to ensure that
staff:
Are able to recognize the signs of abuse, neglect, self-neglect, and
exploitation as defined in Wis. Stats. §§ 46.90 and 55.01.
Identify participants who may be at risk of abuse, self-neglect and
exploitation and in need of elder adult/adult-at-risk or adult protective
services (EA/AAR/APS).
Report incidents involving participant abuse, neglect, self-neglect and
exploitation as provided in Wis. Stats. § 46.90(4)(ar) and §
55.043(1m)(br).
Refer participants at risk or in need of services to the appropriate
EA/AAR/APS agency.
Notify the Department by documenting incidents in SharePoint and/or the
Department case management system (WISITS), per work instructions.
Only ICAs are responsible for documenting incidents, but FEAs, if
identifying concerns, should relay them to the appropriate IC as soon as
possible.
Update the participant’s plan, as needed, to balance participant needs for
safety, protection, physical health, and freedom from harm with overall
quality of live and individual choice.
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Follow-up to ensure that participant’s needs are addressed on an ongoing
basis.
Memorandum of Understanding (MOU)
ICAs must have a signed MOU with all APS agencies within their regions. The
ICA shall notify the Department if an agency with whom they have a MOU is
non-compliant.
IRIS Consultant Capacity Expectations
ICAs shall ensure that the number of participants assigned to each IRIS consultant
does not exceed the consultant’s capacity to provide the highest quality of
consulting services.
The ICA must ensure that all required consultant functions are met and
adequate time exists to provide the necessary ICA services, unique to each
participant.
The number of participants for each consultant shall be determined by the
ICA based on the skill level of the consultant and the unique needs of the
individual participant.
The ratio of consultant to participants must not exceed 1:50.
Self-Directed Personal Care
The Department contracts with an agency for IRIS self-directed personal care
(SDPC) oversight and nurse consultation services. Contractors are responsible for
adhering to the IRIS Policy and Work Instructions dedicated to IRIS SDPC, as
well as the following specific expectations.
ICAs are responsible for:
Training all new personnel initially and again annually on the IRIS SDPC
option using the curriculum developed by the SDPC Oversight.
Adding SDPC Prior Authorization to the Individual Support and Service
Plan (ISSP) and stop any authorizations within 48 hours of disenrollment
from IRIS SDPC services.
Utilize the IRIS Self-Directed Personal Care Guide, provided by the
oversight agency, to ensure participants qualify for IRIS SDPC prior to
making a referral. A registered nurse at the oversight agency will complete
the Personal Care Screening Tool to determine a participant’s personal
care hours if they are deemed eligible.
Ensuring that the hours ordered by the physician and authorized by IRIS
SDPC agency match the amount indicated on the plan.
Informing the nurse consultant when a long-term care functional screen is
completed and identifies skilled nursing care.
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Making collateral contact with the IRIS SDPC registered nurse when
completing the long-term care functional screen (LTCFS) for participants
with IRIS SDPC (or MAPC) to verify changes to ADLS. This also ensures
that the LTCFS is tied to the PCST if a change in personal care hours and
cares may be impacted.
Informing the SDPC Registered Nurse (RN) when any of the following
occur:
Health-related critical incident report is completed;
Participant relocates;
A health-related risk agreement is identified or completed;
Health-related program integrity issues;
Skilled services in the home;
Institutionalization (e.g., hospital, nursing home, prison, etc.);
Participant is traveling out of state;
Participant dies;
Participant has experienced a change in guardian or legal
representative;
Participant has been issued a Notice of Action for disenrollment;
Participant has no workers;
Adult Protective Services has been engaged/contacted;
Participant has disenrolled from the program; or
Any other health and safety issues that would impact services or
care.
Completing the IRIS Self-Directed Personal Care Disclosure Statement
(F-01258), when applicable per IRIS Policy.
FEAs are responsible for:
Ensuring that all personal care services being paid to workers are only for
those participants enrolled in IRIS SDPC. FEAs should look at the
certification period and any holds in place to ensure that IRIS SDPC
remains current and authorized.
Paying only for those hours that are authorized.
Crosschecking to ensure there is a valid authorization prior to payment.
Ensuring that no IRIS SDPC RNs or representatives are paid for providing
IRIS SDPC services.
Discharge Planning
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If a participant is being discharged from a hospital or other institution, that agency
or institution’s discharge planner needs to work directly with the participant or
legal decision maker. Neither IRIS consultants, nor IRIS SDPC RNs are tasked
with case coordination for participant discharge. Neither ICs, nor IRIS SDPC RNs
should take on the duties of discharge planning, but rather are responsible for
supporting the participant or their legal decision maker to supply needed
information regarding resources as it relates to their plan. For example, if a person
requires outpatient transportation, the IC may assist with identifying
transportation resources to fit their needs; if IRIS SDPC workers needed to be
trained on new cares after discharge, the IRIS SDPC RN will need to follow up
for reassessment for personal cares.
Contractors with questions or seeking additional clarification are encouraged to
contact the IRIS RN Nurse Consultant ([email protected]).
Nurse Consultation
Nurse consultation is available to all ICAs regarding any participant in IRIS, not
just those receiving IRIS SDPC services. In addition to providing consultation on
individuals, nurse consultation may be used for trainings and other projects.
Contact with the nurse consultant should be made by the IRIS consultant agency
or their personnel, not by the participant, their guardian, family, or legal decision
maker. Nurse consultation services can be accessed by emailing:
irisnurseconsultant@wisconsin-iris.com.
Reasons for Individual Consultation
Individual consultation and discharge planning cares assessment
when a person is being discharged from an institutional setting,
such as a state operated facility, behavioral health unit, nursing
home (SNF), hospital or other institution to a community setting
and is deemed medically fragile or complex.
All Private Duty Nursing Cases (nurses in independent practice or
home health) are reviewed by the nurse consultant prior to putting
any other waiver services on an ISSP.
Before enrolling someone with complex medical concerns to best
determine if all skilled cares are covered and the plan is safe.
Examples would be anyone on a mechanical vent, receiving IV
therapy, TPN, is in a semi-vegetative or vegetative state, or any
other complex situation.
Cases when individuals are asking for an adjustment to their IRIS
budget related to medical staffing or specialized equipment that is
not customary.
Request to add any nursing tasks/services to a plan (in the waiver
the SDPC Agency Staff must prior authorize Nursing Services).
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Situations where a person is wanting to forgo medical care that is
ordered by a physician. Those enrolled in IRIS SDPC are handled
by the IRIS SDPC RN; those outside of IRIS SDPC should come
to the nurse consultant for review.
Consult with ICs on issues a person may have as they go through
the dementia or hospice process.
Ideas in care delivery that are needed “outside the box” in relation
to provision of “medically necessary” cares. Examples may
include consultation in obtaining a special lift, extra-large hospital
bed, access to a clinic or provider, or complex care needs.
Determining a “safe plan” as it relates to medical issues (e.g.,
refusing cares, wound issues, self-neglect, travel out of state,
refusing to see a physician).
Interpretation of labs, medical tests, or medical orders.
Assistance in finding MA services for home care, in home
assessments, etc.
Examples of ICA Consultation for Trainings or Projects
ICA trainings on skilled care and HRS table.
Standard Precautions, Communicable Diseases (for ICA staff, not
participant caregivers).
Medical Considerations within Target Groups.
Dual Eligible, SSI Managed Care, Medicare Managed Care
Projects.
Nurse delegation, skilled nursing, and scope of practice.
Training on common medical issues (diabetes, hypertension, fall
prevention, etc.)
Training on various disabilities (spinal cord injuries, multiple
sclerosis, dementia, etc.)
Pre-qualification estimates for personal care.
Limitations in Consultation
Individual consultation where a RN or physician are already
managing a case.
Individual consultation where medical advice or diagnosis is being
sought.
Requests for nursing/health physical assessment (card service).
Performing any hands-on nursing task or service (card service).
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Supplying written order for a medical service (no prescriptive
authority).
Psychiatric-related consultations (card service).
Wound care consultation (card service).
One-on-one participant, guardian, or health care power of attorney
consultation or education (covered by MAPC and SDPC or other
FFS provider).
Individual medication consultation.
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VIII. Fiscal Employer Agent Services
General Expectations
FEAs are responsible for all financial transactions on the participant’s behalf,
including but not limited to paying for goods and services, processing payroll for
hired workers and processing agency provider (non-participant hired worker)
invoices.
In general, FEAs must:
Document the participant-provider relationship;
File all required reports with the Internal Revenue Service (IRS) and Wisconsin
Department of Revenue (DOR) according to standard deadlines; and
Utilize the DHS case management system (WISITS).
Payroll and Claim System Requirements
The FEA must have a system that can process payroll and vendor claims. This
system must:
Maintain a record of every payment made to every service provider per
participant;
Records must be delineated and capable of identifying all payments paid
to a single provider, regardless of participant
Utilize the conventional rounding method of to the nearest penny (two decimal
points);
Extract authorization data daily; and
Automatically detect duplicate payments.
Bank Accounts
Each FEA will have access to two bank accounts, a deposit and disbursement
account. The FEA is responsible for adhering to the following expectations for
both accounts:
Monthly reconciliation of bank accounts and bank statements;
Notify the Department and US Bank of any employee who had access to
the account that is no longer employed by the FEA by close of business on
the employee’s last day;
Issue positive pay exception (i.e., manual checks) reports, authorized by
two staff, daily to US Bank and DHS designee, as needed;
The maximum dollar threshold of a single transaction will be $25,000; and
Daily monitoring of account activity.
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Deposit Account
The FEA deposits funds owed to the Department into the deposit account.
No participant or provider shall deposit funds directly into the account.
The FEA will not withdraw from the deposit account.
A universal payment identification code (UPIC) will be assigned to the FEA’s
deposit account to be used when funds are deposited (direct deposit/AC) into the
account.
The code must be provided or US bank will reject the deposit.
Disbursement Account
The Department makes funds available to the FEA to pay service providers in the
disbursement account.
The FEA will not make a deposit into the disbursement account.
Account Reconciliation
The FEA is responsible for reconciling both accounts. The FEA must:
Reconcile the previous month’s transactions of each account.
Use the DHS-approved IRIS Bank Reconciliation spreadsheets. Separate
spreadsheets are available for each account.
Submit the reconciled statements and all related documentation according to the
‘Instructions’ tab on the spreadsheet.
Hold Harmless Agreement
The FEA will hold the Department harmless for a payment issued in error to a
provider, participant-hired worker, or individual provider.
The FEA will be responsible to recouping funds in instances of an overpayment
or disbursing additional funds in instances of underpayment.
The FEA must notify the Department as soon as the error is discovered.
Federal Employee Identification Number (FEIN)
The FEA may only pay providers that have a current FEIN. Two exceptions exist;
the FEA may pay a provider without an FEIN:
If the FEA has verified the information required to obtain a FEIN, and verifies
that the information will be submitted to the Internal Revenue Service within
fourteen calendar days; and
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When the FEA has a protocol in place to retroactively correct all tax issues that
may occur as a result of payroll being issued to participant-hired workers prior to
the FEA receiving the provider’s FEIN from the Internal Revenue Service (IRS).
After the initial payment, providers are expected to provide their FEIN number to the
FEA, which can be verified through the Internal Revenue Service verification line.
Workers’ Compensation Payments
Workers Compensation Coverage
The FEA is required to pay 100% Workers’ Compensation coverage for
all participant-hired workers in the IRIS program.
Reimbursement for the costs of Workers’ Compensation paid on behalf of
the participants will be invoiced to DHS on a monthly basis by the FEA as
a percentage of gross wages.
The percentage invoiced by the FEA will be determined by written
agreement between the FEA and DHS.
FEAs must submit documentation evidencing the existence of
required coverage and the percentage of gross wage payment rate
that the FEA’s Workers’ Compensation carrier provides to cover
the population.
Workers’ Compensation Coverage Invoicing and Reconciliation
The FEA shall submit a monthly invoice to DHS with the amount of the
actual Workers’ Compensation coverage cost at the lesser of the actual
carrier invoice or the percentage previously specified by the 10th of each
month.
i. The invoice should include the actual carrier invoice or clear
documentation to support the invoiced amount to DHS to
demonstrate the number of workers, total payroll cost, and rate.
ii. The invoice should be submitted to the fiscal oversight mailbox at
iii. Adjustments or corrections to a prior month amount should be
included in the next monthly invoice with specific identification
and calculation of the adjustment or correction.
DHS will perform validation and reconciliation against the payroll file
submissions included in the FEA claim files, the actual carrier invoices,
and the agreed upon reimbursement percentage.
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FEAs must submit annual Workers’ Compensation audit results from their
carrier to support DHS reconciliation process.
i. Refunds resulting from the annual Workers’ Compensation audit
should be reflected as adjustments in the next monthly Workers’
Compensation invoice submitted to DHS.
ii. The FEA is not permitted to profit from the Workers’
Compensation provisions.
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IX. Service Providers
Service Provider Setup
The participant must choose a service provider who is willing and qualified to
provide IRIS-funded services. Qualification requirements vary based on type of
service provider. See the IRIS Service Definition Manual for service provider-
specific requirements.
The FEA must approve a service provider’s qualifications prior to the service
provider rendering services and receiving payment.
Although it is the responsibility of the FEA to verify and approve qualifications of
service providers, the ICA and participant play key roles in timely set up in the
program.
The FEA must maintain records that meet or exceed the following criteria:
All storage and disposal of paper and electronic employee and employer
records must meet or exceed state and federal confidentiality laws and
HIPAA compliance standards.
All paper and electronic documentation must be maintained for a
minimum of ten years.
Service Provider Onboarding Packets
The FEA is responsible for creating an onboarding packet with the information
required to be a service provider for the program.
This must include forms under Section 3504 of the Department of
Treasury’s Internal Revenue Service Code.
All forms necessary for each packet can be found in Appendix III.
Different onboarding packets shall be developed for each type of service provider:
participant-employers, participant-hired workers, individual providers, and
provider agencies. The packets for each group must be identical and contain the
same Department, Internal Revenue Service, and/or agency-specific documents.
Changes to the contents of the packet must be approved by the Department prior
to distribution. This is referred to as the FEA’s DHS-approved onboarding packet,
which consists of the program-required forms and any FEA-specific forms.
The FEA shall provide to each ICA the DHS-approved onboarding packets in a
printable electronic form.
The FEA is permitted, and encouraged, to provide the packet on their IRIS-
specific website.
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The ICA is responsible for submitting completed onboarding packets to the FEA,
if involved in the process. Note: Participant, participant-hired worker, or vendor
can submit documentation directly to the FEA.
The FEA must receive, verify, and archive documentation and records. The
capabilities must include at a minimum:
Electronic acceptance of all relevant paperwork; and
Submission of all necessary documentation to the appropriate taxing or
government authority in a manner that is accurate and timely.
The FEA must upload the entire onboarding packet into the DHS case
management system (WISITS), which must include the WI Medicaid Provider
Agreement and where applicable, the signed IRIS Participant Provider Service
Agreement.
This may require setting up the service provider as a new service provider in the
system.
The FEA must notify the participant, service provider, and the IRIS consultant
when a service provider is approved (or qualified); a service provider is approved
when all of the applicable paperwork is completed and filed and the service
provider’s credentials have been verified, if required. This notification must
include the following:
The date the provider is authorized to provide services.
The service(s) the provider is authorized to provide.
The unit of measure for each authorized service.
The cost of each unit of measure for each authorized service.
Payments to Service Providers
The FEA is responsible for processing payments to service providers according to
program policy. The Department is the funder and the FEA is the processor.
The FEA may only pay service providers via pay card or direct deposit.
Payments may not be made with paper checks without Department
approval.
If the FEA is given approval to pay via paper check, the paper check must
be made on the FEA’s business check stock. No checks should be issued
on DHS check stock.
Timesheets and Invoices/Claims
The FEA must be able to receive and process paper and/or electronic
timesheets and invoice/claims. The FEA may also utilize an online time
reporting system.
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The FEA must pay only what is documented on the timesheet or
invoice/claim.
Pended Timesheets and Invoices/Claims
If there is an inconsistency during verification of the timesheets, invoices,
or claims, the FEA must:
i. Pend payment of the timesheet or claim until the error is corrected;
ii. Document and ensure documentation is available for the ICA. The
FEA is responsible for follow-up and resolution;
iii. Track issue through resolution;
a) Notify the provider of the pended timesheet or claim within
five business days from the date it became pended and provide
directions on how to resubmit.
The FEA is required to report pended timesheets and claims to the
Department upon request. Information should include:
i. Service
ii. Reason for pended claim
iii. Claims pended
iv. Claims resubmitted
v. Pended claims resolved
Garnishments, Levies, and Liens
The FEA must process garnishments, levies, and liens according to state and
federal rules.
Employment-related Taxes
The FEA is responsible for:
Withholding and filing federal, state, and local taxes, quarterly, in
aggregate, using FEA’s separate FEIN and Internal Revenue Form 941 in
accordance with Internal Revenue Proc. 70-06 and proposed notice 2003.
Making tax payments to appropriate tax authorities;
Process all returned payments in accordance with Wisconsin rules on
property abandonment; and
Ensure participants and their providers are being paid in accordance with
all applicable Federal, State, and local Laws.
The FEA must ensure payments are compliant with:
Social Security, Medicare, and Unemployment tax withholding rules on
family participant employees; and
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The Fair Labor Standards Act (including exemption criteria) as well as
any other state, federal, and local wage and hour rules.
Other state’s rules and regulations, if applicable.
The FEA must indicate on the payment the service(s) and participant(s). If it is
not possible to include this information on the direct deposit, the FEA must
provide a supplement statement to the provider with this information.
Funding File Spreadsheet
DHS releases WI Medicaid funds into the disbursement account for the
FEA to disburse to service providers, according to the amounts specified
on the funding file spreadsheet submitted to the Department.
The FEA must submit payment data via the funding file spreadsheet to the
Department weekly by the Department specified deadline.
The FEA must adhere to the ‘Instructions’ tab on the spreadsheet for data
formatting requirements and submission deadlines.
The FEA may not attempt to withdraw funds from the disbursement
account in advance of the settlement date. Premature withdrawal of funds
will result in an overdraft, which includes banking fees that may be passed
along to the FEA.
The FEA must receive Department approval prior to paying a single
provider any amount over $120,000 in a pay cycle. Payments at or
exceeding this amount may not be broken down into multiple payments by
the FEA to circumvent this requirement.
Pay periods for participant hired workers alternate by payroll (P) and
vendor (V) as specified by the schedule issued by the Department.
However, vendors are allowed to be paid on payroll weeks, and vice-
versa.
The schedule indicates pay cycles when the funding file date is irregular
due to a holiday. The FEA is expected to plan for and be able to meet
adjusted timelines.
Outstanding Checks
The FEA must track and provide an outstanding/aging check report to the DHS
designee by the 15
th
day of each month. Information regarding check aging can be
found in the funding file template.
Timesheets for Participant-Hired Workers
The FEA must process and make payment when a timesheet is approved by the
employer (i.e., IRIS participant or guardian) for services. This does not include
payment for self-directed personal care services.
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FEAs should report payments that exceed the authorization to the ICA per the
reporting procedures and standards.
Payments to Self-Directed Personal Care Worker
SDPC is a service that requires physician-orders and prior authorization. This
means the payment may not exceed the weekly-authorized amount.
The FEA may not pay beyond the total weekly authorized amount.
Employment-related Tax Reporting
The FEA is responsible for filing taxes according to WI Department of Revenue
and IRS rules.
The FEA is responsible for filing other state taxes, if applicable.
The FEA must report to the Department receipt of any tax refunds prior to
depositing refund into the Deposit Account.
The FEA must have written policies and procedures that document:
Refunding over-collected FICA to applicable individual employers and
employees and for maintaining documentation in the participant-hired
worker’s record;
Refunding over-collected FICA to the Department and for maintaining
documentation in the FEA’s records.
Reimbursement File
The FEA may encounter a situation when it needs to issue a direct payment with
its own monies.
To be reimbursed, the FEA is expected to submit this information via the
Department reimbursement file spreadsheet with backup documentation for all
transactions.
The Reimbursement file may be necessary for any of the following reasons:
Payments to agency providers by paper check;
Garnishment payments paid by paper check;
Cost share reimbursement payments; or
Refund payments.
The FEA must adhere to the ‘Instructions’ tab on the spreadsheet for data
formatting requirements and submission deadlines.
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Claims Adjudication
The FEA must provide prompt and accurate processing of claims from receipt to
payment, or denial, and not accumulate an excessive claims inventory or aged
claims.
Provider claims shall be processed at 98% financial accuracy.
FEA shall measure and monitor the correctness of IRIS payments quarterly and
make those reports available to the Department upon request.
There is an obligation to pay approved claims is responsible for compliance with
the Department of Labor regulations.
When receiving a provider agency invoice or claim, the FEA must:
Validate the service is on the authorization;
Validate the provider is an approved provider and set up in the Department
case management system (WISITS);
Validate the unit frequency matches the authorization (i.e., daily, hourly,
each, etc.)
Validate the service was rendered during the authorized period;
Validate the codes and applicable modifiers match the authorization;
Validate the rate does not exceed the authorized amount;
Validate the claim does not exceed the authorized amount;
Pay only up to the authorized amount;
Reject any claims that do not have a service authorization;
Reject any claims that do not have an authorized provider; and
Refer the claims that exceed the authorized amount to the ICA each
payment cycle, and the IC will be responsible for working with the
participant and the agency.
The FEA must make claim payments:
Within 30 calendar days of receipt from a provider, or
Within 14 calendar days of receipt of notice or validation that a claim has
been corrected when there was a hold on processing the payment.
The FEA shall monitor the timeliness of payments and adjustments monthly and
make pended claim and claim adjudication reports available to the Department
upon request.
A vendor/agency should not be paid above that amount authorized.
A signed MA Provider Agreement is required for all vendors.
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Ineligible Service Providers
1. In implementing this section the FEA shall check at least monthly the federal
DHHS OIG List of Excluded Individuals /Entities (LEIE), the Social Security
Administration’s Death Master File, the National Plan and Provider Enumeration
System (NPPES), and the System for Award Management (SAM), as required by
42 C.F.R. § 455.436, as well as any other databases that may be required by the
federal DHSS or the Department. Referenced to the “Act” iin this section refers to
the Social Security Act.
2.
Upon verification of an ineligible entity or individual, the FEA shall take
immediate action to:
a.
Exclude from further remuneration and begin the process of collecting
overpayments, if applicable.
b.
Notify the Department within ten (10) days of discovery the identity of
each ineligible provider and other details enumerated under subsection 4.
Disclosure of Excluded Individuals or Entities, below.
Individuals or organizations may be found ineligible under one or more of the
categories herein.
3. Ineligibility
Entities which could be excluded under Section 1128 (b) (8) of the Social
Security Act are entities in which a person: (1) who is an officer, director, agent
or managing employee of the entity; (2) who has a direct or indirect ownership or
controlling interest of five percent or more in the entity; (3) who has beneficial
ownership or controlling interest of five percent or more in the entity; or (4) who
was described in (2) or (3) but is no longer so described because of a transfer of
ownership or control interest to an immediate family member or a member of the
household (as defined in 1128(j)(1) and 1128(j)(2)) in anticipation of (or
following) a conviction, assessment, or exclusion has:
Been convicted of the following crimes:
i. Program related crimes, such as, any criminal offense related to the
delivery of an item or service under title XVIII or under any State
health care program (see Section 1128 (a) (1) of the Act);
ii. Patient abuse, such as, criminal offense relating to abuse or neglect
of patients in connection with the delivery of health care (see
Section 1128 (a) (2) of the Act);
iii. Fraud, such as, a state or federal crime involving fraud, theft,
embezzlement, breach of fiduciary responsibility, or other financial
misconduct in connection with the delivery of health care or
involving an act or omission in a program operated by or financed
in whole or part by federal, state or local government (see Section
1128 (b) (1) of the Social Security Act);
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iv. Obstruction of an investigation or audit, such as, conviction under
state or federal law of interference or obstruction of any
investigation or audit related to any criminal offense described
directly above (see Section 1128 (b) (2) of the Act); or,
v. Offenses relating to controlled substances, such as, conviction of a
state or federal crime relating to the manufacture, distribution,
prescription or dispensing of a controlled substance (see Section
1128 (b) (3) of the Act).
Been excluded from participation in Medicare or a state health care
program.
A state health care program means a Medicaid program or any state
program receiving funds under Title V or Title XX of the Act. (See
Section 1128 (h) of the Act.) Been excluded, debarred, suspended,
otherwise excluded, or is an affiliate (as defined in such Act) of a person
described above from participating in procurement activities under the
Federal Acquisition Regulation or from participating in non-procurement
activities under regulations issued pursuant to Executive Order No. 12549
or under guidelines implementing such order.
Been assessed a civil monetary penalty under Section 1128A or 1129 of
the Act.
Civil monetary penalties can be imposed on individual providers, as well
as on provider organizations, agencies, or other entities by the federal
Department of Health and Human Services Office of Inspector General.
Section 1128A authorizes their use in case of false or fraudulent submittal
of claims for payment, and certain other violations of payment practice
standards. (See Section 1128 (b) (8) (B) (ii) of the Act.)
4. Contractual Relations
Entities which have a direct or indirect substantial contractual relationship with an
individual or entity listed above in Article H.1. Substantial contractual
relationship is defined as any contractual relationship which provides for one or
more of the following services:
The administration, management, or provision of medical or long-term
care services;
The establishment of policies pertaining to the administration,
management, or provision of medical or long-term care services; or
The provision of operational support for the administration, management,
or provision of medical or long-term care services.
5. Excluded from Participation in Medicaid
Entities which employ, contract with, or contract through any individual or entity
that is excluded from participation in Medicaid under Section 1128 or 1128A of
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and <<Name of ICA or FEA>>
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the Act, for the provision (directly or indirectly) of health care, utilization review,
medical social work or administrative services. For the services listed, the FEA
shall exclude from contracting with any entity which employs, contracts with, or
contracts through an entity which has been excluded from participation in
Medicaid by the Secretary under the authority of Section 1128 or 1128A of the
Act.
The FEA attests by signing this contract that it excludes from participation in the
FEA all individuals and organizations which could be included in any of the
above categories.
6. Disclosure of Excluded Individuals or Entities
Within ten days (1) the FEA shall disclose to the Department any individual or
entity described herein. This disclosure shall be made to
The disclosure shall include the following information:
a. The name, address, phone number, Social Security number/Employer
Identification number and operating status/ownership structure (sole
proprietor, LLC, Inc., etc.) of the individual or organization;
b. The type of relationship and a description of the individual or entity’s role
(for example, provider and service type or employee and classification);
c. The initial date of the relationship, if existing;
d. The name of the database that was searched, the date on which the search
was conducted and the findings of the search;
e. A description of the action(s) taken to exclude the individual or entity
from participation in IRIS.
7. Foreign Entity Exclusion
Pursuant to 42 C.F.R. § 438.602(i), the State is prohibited from contracting with
an ICA or FEA located outside of the United States. DHS contracts are rendered
null and void in the event an ICA or FEA moves outside of the United States.
Home and Community-Based Settings Requirements Compliance
Participants shall use only a licensed or certified residential provider or operating
non-residential setting in which adult day care, prevocational, day services, or
group supported employment services are provided, if the setting has been
determined by the certification agency or the Department to be in compliance
with the home and community based setting requirements under 42 C.F.R. §
441.301(c)(4) or is a non-residential setting pending determination of compliance
by the Department. An exception to this requirement is a setting that was
operating prior to March 17, 2014 that is subject to heightened scrutiny and is
awaiting a determination of compliance from CMS.
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Wisconsin Department of Health Services, Division of Medicaid Services
and <<Name of ICA or FEA>>
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X. Information Technology/System Requirements
The IRIS program utilizes a case management system (WISITS) which provides
standardized operational functionality for all Contractors. The case management
system (WISITS) is the system of record for participant documentation including
but not limited to, ISSPs, service authorizations, provider document, program
enrollment, case notes, contacts, addresses, and the storage of program required
documents. The case management system (WISITS) is a web-based application
that utilizes role-based permissions and organizational hierarchies to ensure that
Contractors have access to information that they have a business need to access.
Any information stored outside of, the Department case management system
(WISITS) on the Contractor’s network or internal information systems must
comply with HIPAA, including all pertinent regulations (45 CFR Parts 160 and
164) issued by the U.S. Department of Health and Human Services, as well as
security, and data retention requirements identified below. The CMS standard
acceptable risk safeguards (https://www.cms.gov/Research-Statistics-Data-and-
Systems/CMS-Information-Technology/CIO-Directives-and-Policies/CIO-IT-
Policy-Library-Items/STANDARD-ARS-Acceptable-Risk-Safeguards.html) and
the standard for encryption of computing devices and information
(https://www.cms.gov/Research-Statistics-Data-and-Systems/CMS-Information-
Technology/InformationSecurity/Info-Security-Library-Items/HHS-Standard-for-
Encryption-of-Computing-Devices-and-Information.html) documents are
available online, with greater detail, for Contractor reference on increased
safeguards.
Contractors are responsible for having at least one designated IT Security
Officer/Chief Information Security Officer responsible for documenting and
addressing the security requirements specified in this section. This staff is
required to review and submit to the Department case management system
(WISITS) access requests. This staff must ensure all staff have the appropriate
roles and permissions and inform DHS if there is an inappropriate level of access.
This staff is responsible for ensuring that each system user account is associated
to a specific individualized email account that is provided and owned by the
Contractor.
General Requirements
General Security Provisions
Contractor agrees that they will implement administrative, physical, and technical
safeguards to protect all DHS data that are no less rigorous than accepted industry
best practices, including but not limited to, National Institute of Standards and
Technology (NIST), Federal Information Security Management Act (FISMA),
Health Information Technology for Economic and Clinical Health (HITECH) Act,
ISO/IEC 27001 Series, Information Technology Library (ITIL), Control
Contract for IRIS Program between the
Wisconsin Department of Health Services, Division of Medicaid Services
and <<Name of ICA or FEA>>
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Objectives for Information and related Technology (COBIT), Payment Card
Industry Data Security Standard (PCI-DSS) or other applicable industry standards
for information security.
All new user set-up forms for the Department case management system (WISITS)
or SharePoint, as well as user termination emails shall be submitted to the
WISITS system administration inbox:
DHSWISITS.SystemAdmin@dhs.wisconsin.gov.
The Contractor must submit a completed WISITS– Request for User Setup
(F-01578) form for each new user. DHS processes the account setup and
will inform the agency’s security officer of its completion.
When a Contractor’s staff with access to the Department case management
system (WISITS) ends their relationship with the contracted agency, the
security officer must inform of this date and DHS will process the
deactivation with as much advanced notice as possible.
Contractor must submit a completed SharePoint – Request for User Setup
(F-01578A) for each new user.
Contractors must complete the relevant Conflict of Interest (F-01310)
disclosure forms prior to submitting access requests to any systems owned
or operated by the Department, including but not limited to SharePoint,
the Department case management system (WISITS), ForwardHealth
interChange, CARES, or FSIA.
Contractors are responsible to maintain a list of all individuals possessing
any access to SharePoint, the Department case management system
(WISITS), ForwardHealth interChange, CARES, or FSIA, to ensure
appropriate termination of access upon resignation or termination of
personnel. At any point the Contractor can request a list from DHS of their
current user accounts for these systems.
The Contractor must ensure that all employees requested access to these
systems have completed the appropriate onboarding training required by
the Department prior to requesting access. This includes but is not limited
to: HIPAA initial and annual training. Additionally, each new employee
must have a personal, agency-owned email address and phone prior to
requesting access.
Contractor Systems
Contractors must be capable of and willing to grant viewing access or provide
guided demonstrations to Department staff, as necessary, for the purpose of
recertification, security compliance, and/or the Department case management
system (WISITS) utilization and compatibility. Contractor must be able to
provide and/or demonstrate their data security and encryption methods at the
request of DHS.
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Governance
Contractors, and any subcontractors thereof, are expected to abide by all
applicable policies, procedures, standards and guidelines (PPSG) set-forth by
DHS. These PPSGs will be provided to the Contractor upon initial certification,
and any new PPSGs or changes will be communicated by DHS.
Data Security and Encryption
Contractor agrees to preserve the confidentiality, integrity, and availability of
DHS data with administrative, physical, and technical measures to conform to
industry best practices, as reiterated below. Maintenance of the environment the
Contractor interfaces, manages or has access to, in addition to the Contractor’s
environment, must apply timely applications of patches, fixes and updates to
operating systems and applications..
All data stored and/or transmitted by the vendor must be encrypted. All
encryption, hashing and signing modules used must be certified by NIST
to FIPS 140-2 standards or better.
All devices utilized by and issued to personnel, whether laptops, cell
phones, iPads, or tablets, must be encrypted and password protected.
Once data has been extracted from DHS systems, including the
Department case management system (WISITS), it is the responsibility of
the Contractor to manage and maintain said data and the secure access of
the data.
All training materials created by Contractors must use de-identified data or
appropriately redact any personally identifiable data or protected health
information.
Contracted agencies must have documentation of their internal data
management plan and policy which must be made available at the request
of DHS.
Infrastructure and Network Security
The vendor shall maintain network security at all times, and at a minimum
perform the following actions;
Firewall provisioning
Intrusion detection
Regularly scheduled vulnerability scanning and assessments
Additionally, the vendor agrees to maintain network security that
conforms to industry best practices as mentioned herein.
Password Protection
Staff passwords should be a minimum of 8 characters, with at least one
capitalized letter, one number, and one special symbol.
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Staff shall be required to change passwords regularly, at least once every
three to six months.
Passwords should be changed regularly, at minimum once every three to
six months.
Staff must not share their passwords with others and they should not
automatically save passwords on websites or browsers for their work
computers.
Passwords should never be written down on paper, post it notes, or
notebooks and/or hidden in or around a staff work computer.
Contractors may invest in encrypted password storage programs for staff,
such as Password Safe, which can be installed on staff computers to safely
retain passwords.
Controls must be implemented to protect sensitive information that is sent
via email.
Email and any attachments that contain sensitive information when
transmitted inside and outside of the Contractor’s premises shall be
encrypted when possible.
Password protection of files is recommended to add an additional
layer of data protection but shall not be used in lieu of encryption
solutions.
Encrypted emails may or may not encrypt documents attached to
said emails. As such, attachments on encrypted emails should have
an additional layer of security, such as password protection.
Passwords and/or encryption keys shall not be included in the same
email that contains sensitive information
Application Security
Any Contractors, who on behalf of the Department of Health Services (DHS)
develop, work with, update, or deliver source code or code to DHS shall provide
annual secure code training to all personnel supporting DHS. Additionally, source
code development outside the contiguous United States is strictly prohibited.
In particular, Contractor staff, particularly the IT Security Officer, shall be
proficient and knowledgeable in the OWSAP Top 10 and/or SANS Top 25
vulnerabilities and their appropriate remediation techniques.
Governance and Privacy
Contractors must, at minimum:
Appoint or hire personnel to be accountable for developing, implementing, and
maintaining an organization-wide governance and privacy program to ensure
compliance with all applicable laws and regulations regarding the collection, use,
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and <<Name of ICA or FEA>>
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maintenance, sharing, and disposal of PII and PHI by programs and information
systems.
Monitor federal privacy laws and policy for changes that affect the privacy
program.
Develop a strategic operational privacy plan for implementing applicable privacy
controls, policies, and procedures.
Develop and implement a Privacy Incident and Breach Response Plan; provide an
organized and effective response to privacy incidents and breaches in accordance
with the Business Associate Agreement.
Develop, disseminate, and implement operational privacy policies and procedures
that govern the appropriate privacy and security controls for programs,
information systems, or technologies involving PII and PHI; and
Update privacy plan, policies, and procedures, as required to address changing
requirements, no less than every two years.
Document and implement a privacy risk management process that assesses
privacy risk to individuals resulting from the collection, sharing, storing,
transmitting, use, and disposal of PII and PHI. This assessment plan shall be
conducted for information systems programs, electronic information collections,
or other activities that pose a privacy risk.
Establish privacy roles, responsibilities, and access requirements for ICAs / FEAs
and service providers.
Keep an accurate accounting of disclosures of information held in each system of
records under its control, specifically those provided in records requests,
including:
Date, nature, and purpose of each disclosure of a record; and
Name and address of the person or agency to which the disclosure was
made.
Provide means, where feasible and appropriate, for individuals to authorize the
collection, use, maintaining, and sharing of PII and/or PHI prior to its collection.
Provide plain language education with individuals ensure they understand the
consequences of decisions to approve or decline the authorization of the
collection, use, dissemination, and retention of PII and PHI.
Obtain consent, where feasible and appropriate, from individuals prior to any new
uses or disclosure of previously collected PII or PHI.
Provide participants the ability to have access to their PII maintained in the
information system.
Provide a process for individuals to have inaccurate, incomplete, or out-of-date
PII maintained by the organization corrected or amended, as appropriate.
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and <<Name of ICA or FEA>>
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Implement a process for receiving and responding to complaints, grievances,
concerns, or questions from individuals about the organizational privacy
practices.
Disaster Recovery Plan
Contractors that own and/or operate their own systems housing IRIS data,
especially fiscal employer agents, are required to have a disaster recovery plan to
address, at a minimum, the following:
Verification of adequate back-up and recovery systems in compliance with
federal and state rules and regulations.
Communication plan for critical personnel, key stakeholders, and business
partners.
Periodic back-up which is adequate and secure for all computer software
and operating programs; databases; files; and system operations, and user
documentation (e.g. electronic, non-electronic, incremental, full).
Full and complete backup copies of all data and software.
Verification that back-up copies are stored in a secure off-site location and
tests are routinely performed on back-up copies.
Policies and procedures for purging outdated backup data.
Plan that supports the immediate restoration and recovery of lost or
corrupted data or software resulting from the event of a disaster.
Identification of a back-up processing capability at a distant remote site(s)
from the primary site(s) such that normal business processes and services
can continue in the event of a disaster or major hardware problem at the
primary site(s).
All Contractors are required to have policies and procedures to ensure the
preservation documentation of a participant’s safety and wellbeing in the event of
a disruption or disaster.
Disaster Recovery Plans must be reviewed and approved by the Department as a
part of the annual site visit and/or recertification process.
WISITS: The Department Case management system (WISITS)
All Contractors must use the Department case management system (WISITS) to
access IRIS participant data, generate reports, and maintain/document information
related to participants, participant-hired workers, and service providers/vendors.
In utilizing the Department case management system (WISITS), ICAs must be
capable of meeting the core IT functions related to:
Service level requirements;
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and <<Name of ICA or FEA>>
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Enrollment, Disenrollment, Suspension, and Orientation requirements;
Plan Development requirements;
Service Authorization requirements;
Ongoing consultant service requirements;
Participant records and documentation requirements; and
Agency program integrity and quality management requirements.
Utilizing the Department case management system (WISITS), as well as their
internal system, FEAs must be capable of meeting the core IT functions related to:
Participant/consultant access requirements;
Employer setup, records, and documentation requirements;
Participant-hired worker records and documentation requirements;
Extraction and uploading of authorization and expenditure data;
Tax withholdings;
FEA payroll processing and wage payment requirements;
Provider claims adjudication requirements;
FEA reporting requirements
FEAs are required to have at least one staff available and in attendance for
monthly teleconference meetings for the Long-Term Care Technical Workgroup.
FEAs will further ensure that at least one appropriately knowledgeable staff is in
attendance at all meetings initiated by the Department related to the Department
case management system (WISITS).
WISITS does not contain payroll or claims processing functionality, it does not
determine tax-withholding information, and is not the system of record for
documenting this information. These are the responsibility of the FEA. Any
information stored outside of the Department case management system (WISITS)
on the FEA’s network or internal system must meet the security and HIPAA-
compliance requirements identified in this section. With regard to these
responsibilities, FEAs must:
Have the ability to extract and download the eligibility, enrollment, and
authorization file from the Department case management system
(WISITS). The authorization number, as documented in the Department
case management system (WISITS), should match the authorization
number input into the FEA’s internal system and the DHS Encounter
system.
Have the ability to upload the eligibility, enrollment, and authorization file
from the Department case management system (WISITS) into the FEA’s
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payroll system in a way that allows the FEA to carry out the requirements
of this contract.
Set up participant-hired workers, providers, and individual reimbursement
providers in the Department case management system (WISITS) and
associate the provider to the correct serve type and when applicable, the
correct participant.
Functional Screen Information Access, ForwardHealth Partner Portal,
and CARES
Functional Screen Information Access (FSIA)
ICAs are responsible to maintain an accurate, complete, and up-to-date list of all
staff or contractors with approved access to the FSIA system. ICAs shall submit
to the Department requests to have a screener’s security access deactivated as
follows:
If the ICA terminates the employment of a screener, the ICA shall submit
the deactivation request within one (1) business day of the screener’s
termination.
When a screener leaves the ICA and/or no longer has a need for access to
the functional screen application, the agency shall submit the deactivation
request within three (3) business days of the departure or reassignment of
the screener.
ForwardHealth Portal – FEA Responsibilities
Contractors must maintain a current, up-to-date list of users
roles/permissions within the secure ForwardHealth Portal account to
ensure only authorized users have access to data and functions provided.
Contractors are responsible to maintain an accurate, complete, and up-to-
date list of all staff or contractors with approved access to the Portal.
Contractors shall submit to the appropriate Department staff, requests to
have security access deactivated as follows:
If the Contractor terminates the employment, the Contractor shall
submit the deactivation request within one (1) business day of the
staff participant’s termination.
When staff leave and/or no longer have a need for access to Portal, the
agency shall submit the deactivation request within three (3) business days
of the departure or reassignment.
ForwardHealth Portal – ICA Responsibilities
a. All ICAs must use the secure ForwardHealth Portal account to access data
and reports and to maintain information with the Department.
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and <<Name of ICA or FEA>>
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b. ICAs must assign and remove users’ roles/permissions in the secure
ForwardHealth Portal account within three (3) business days of the user’s
departure or reassignment to ensure only authorized users have access to
data and functions provided.
c. ICAs must ensure all users log in to the secure Waiver Agency Portal to
submit or retrieve agency or participation information that may be
sensitive and/or fall under the requirements of the Health Insurance
Portability and Accountability Act (HIPPA) regulations.
Access to CARES Data
Contractors are authorized to have limited access to, and make use of, data
found in the Client Assistance for Reemployment and Economic Support
system (CARES) operated for the Department.
Each Contractor must identify an Authorizing Agent Security Officer
specific to CARES Access requests. That individual must complete a
security officer’s form (F-00639) and submit it to their Contract Specialist
for submission and approval. The only authority granted with this form is
the authority of the designated Authorizing Agent Security Officer to
submit requests for access to CWW/CARES on behalf of their agency.
Once approved, the designated Authorizing Agent Security Officer
may submit a separate form (F-00476) to request access for them
self or any other staff at their agency to use the CARES system.
Only the designated Security Officer may submit requests for
access to:
dhscaresaccessandidenti[email protected]isconsin.go
v
When staff leave and/or no longer have a need for access to
CARES, the agency shall submit the deactivation request within
three (3) business days of the departure or reassignment.
Contractors must maintain a current, up-to-date list of users’
roles/permissions within the secure CARES account to ensure only
authorized users have access to data and functions provided. The
Department may limit the number of authorized Contractor staff
with access to the CARES system. Contractors shall submit to
dhscaresaccessandidenti[email protected]isconsin.go
v, requests to have security access deactivated as follows:
If the Contractor terminates the employment, the Contractor shall
submit the deactivation request within one (1) business day of the
staff participant’s termination.
When staff leave and/or no longer have a need for access to
CARES, the agency shall submit the deactivation request within
three (3) business days of the departure or reassignment.
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and <<Name of ICA or FEA>>
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XI. Hearings, Appeals, & Grievances
Background
Participants have the right to grieve or appeal any action or inaction of a
Contractor that the participant perceives as negatively impacting them. The
system for dealing with grievances and appeals has been designed to offer
participants different options for attempting to resolve differences.
While multiple options are available to resolve grievances and appeals,
participants are encouraged, and usually best served, to seek to directly resolve
most concerns.
The participant’s ICA is usually the best option to deal with issues directly
and expeditiously. The IRIS consultant within the ICA is the most direct
source of information and assistance.
If the grievance is related to a pended, voided, or delayed payment to a
worker or a vendor, the FEA is the most direct source of information and
assistance to deal with these issues directly and expeditiously.
When a concern cannot be resolved through direct access with the ICA or
FEA, the grievance and appeal process through the EQRO is the next most
direct source for resolving grievances.
Ombudsmen are also available to assist IRIS participants with the
resolution of grievances and appeals.
The State Fair Hearing process is the final decision-making process for the
Department in resolving participant appeals.
Definitions
As used in this section, the following terms have the indicated meanings:
An “action” is any of the following:
The denial or limited authorization of a requested service that falls within
IRIS services definitions, including the type or level of service.
The reduction, suspension, or termination of a previously authorized
service.
The denial of functional eligibility as a result of administration of the
long-term care functional screen, including a change from nursing home
level of care to non-nursing home level of care.
A denial in IRIS consultant agency transfer.
An involuntary disenrollment from the IRIS program.
Any other reason cited on Notice of Action – IRIS Program (F-01204).
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Appeal
An “appeal” is a request for a review of an “action.”
Grievance
“Grievance” is an expression of a participant’s dissatisfaction about any matter
other than an “action.” The EQRO, as the independent third party mediator,
assists participants with the referral and resolution of grievances. Ombudsman,
Disability Rights Wisconsin (age 15-59) and the Board on Aging (age 60 and
above) may work with participants to assist them with the grievance process.
Fair Hearing
A “fair hearing” means a de novo review under Ch. HA 3, Wis. Admin. Code,
before an impartial administrative law judge, of an action by the Department, a
county agency, a resource center, or an ICA.
Date of Adverse Action or Effective Date
The “Date of Adverse Action” or “Effective Date” when used in terms of
establishing the time during which a participant has a right to file an appeal means
ninety (90) calendar days from this date, which is included on notice of action
communications.
Overall Policies and Procedures for Grievances and Appeals
Each Contractor is responsible for assuring that there is staff designated and
responsible for addressing and resolving concerns raised by participants. The
Contractor must dispose of each grievance and resolve each appeal. The policies
and procedures used by the Contractor to dispose of grievances and to resolve
appeals are subject to review and approval by the Department.
Contractors must attempt to resolve issues and concerns whenever possible. When
a participant presents a grievance or appeal, the Contractors must attempt to
resolve the issue or concern through internal review, negotiation, or mediation,
whenever possible.
Functional and financial eligibility decisions and cost share calculations cannot be
reviewed by the Contractor’s internal grievance and appeal staff. The only means
by which participants can contest those decisions is through the State Fair Hearing
process.
Opportunity to Present Evidence
A participant shall have a reasonable opportunity to provide evidence, and
allegations of fact or law in writing, as well as in person, in a grievance,
independent review, or State Fair Hearing.
Provision of Case File
Contractor must ensure that the participant is aware that they have the right to
access their case file, free of charge, and be provided with a free copy of their
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case file. ‘Case file’ in this context means all documents, records and other
information relevant to the ICA’s determination or action and the participant’s
appeal of the determination or action; this includes, but is not limited to, the
participant’s WISITS document library, case notes, and SharePoint records.
Cooperation with Advocates, Mediators, and Ombudsman
Contractors must make reasonable efforts to cooperate with all advocates,
mediators, and ombudsmen that a participant has chosen to assist him or her in a
grievance or appeal.
As used here, “advocate” means any individual whom or organization that
a participant has chosen to assist in articulating his or her preferences,
needs, and decisions.
“Cooperate” means:
To provide any information related to the participant’s eligibility,
entitlement, cost sharing, budget, service plan, service
authorizations, or service providers to the extent that the
information is pertinent to matters in which the participant has
requested the advocate’s assistance.
To assure that a participant who requests assistance from an
advocate is not subject to any form of retribution for doing so.
Nothing in this section allows the unauthorized release of participant
information or abridges a participant’s right to confidentiality.
Confidentiality
Contractors shall assure the confidentiality of any participant who uses the
grievance and appeal process.
Authority and Timing of Filing of Grievances
A participant or a participant’s legal decision maker or anyone acting on the
participant’s behalf with the participant’s written permission may file a grievance
with the Contractor, the EQRO, the Ombudsmen, or the Department. Grievances
can be filed at any time.
Remand/Reversed Appeal Decision
If, following a State Fair Hearing, an Administrative Law Judge orders the
reversal of an ICA’s decision to deny, limit, reduce, or terminate services that
were not furnished during the appeal, ICA must authorize services within the
timeframe specified in the hearing decision.
a. If a State Fair Hearing reverses a decision to deny authorization of
services, and the participant received the disputed services during the
appeal, the FEA must pay for those services using the participant’s budget.
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Continuation of Benefits During an Appeal
Services shall be continued by the ICA throughout any local or State
administrative appeals in relation to the initial action if the participant
makes a timely request.
Timely Request: A request for continuing benefits will be considered
timely if it is submitted on or before the effective date in a Notice of
Action.
A participant does not have a right to continuation of benefits:
Beyond any limit in a service authorization when the limit is
reached during the course of an appeal.
When grieving adverse actions that are the result of a change in
state or federal law; however, in such a situation, a participant does
have the right to appeal whether he/she is a participant of the group
impacted by the change.
After a State Fair Hearing decision upholding the ICA’s denial,
reduction, termination, or suspension of services is issued.
After electing to withdraw an appeal.
Notice of Action
The ICA shall provide written notice of action to the participant when a decision
is made to:
Deny or limit a participant’s request to add or change a good or service;
Terminate, reduce, or suspend any currently authorized good or service;
Deny transfer between IRIS consultant agencies; or
Involuntarily disenroll from the IRIS program.
The notice of action may be mailed or hand delivered. An oral, email, text, or
other nominal reference to the information in the IRIS Policy Manual, Work
Instructions, or other materials does not meet the requirement to provide notice of
action.
ICA is required to upload a copy of any notice of action issued into WISITS and
the accompanying SharePoint Notice of Action site (until such time as this site is
no longer used).
Content of Notice of Action
a. The ICA shall use the appropriate DHS-issued notice of action form letter:
Notice of Action – Denial (F-01204A),
Notice of Action – Limit (F-01204B),
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Wisconsin Department of Health Services, Division of Medicaid Services
and <<Name of ICA or FEA>>
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Notice of Action – Reduction (F-01204C),
Notice of Action – Termination (F-01204D),
Notice of Action – Functional Eligibility (F-01204E),
Notice of Action – Denied Provider Change (F-01204F).
b. The notice of action communication must also include, at minimum,:
i. Notice of Action form (F-10204),
ii. Participant Appeal Rights (P-00679),
iii. Request for State Fair Hearing – IRIS (F-00236B), and
iv. Voluntary Withdrawal form (DHA-17).
c. The notice of action and/or the letter accompanying the notice must
include:
The date the notice is mailed or hand-delivered.
The action the ICA has taken or intends to take, including the
effective date of the action.
The reason for the action.
Any law, policy, or work instructions that support the action.
State Fair Hearing Process
The State administrative fair hearing process is governed by Wis. Stat. Ch. 227.
All communication, both verbal and written, to the administrative law judge
(ALJ) must also be sent to the participant, their legal decision maker, or attorney.
The ICA is required to represent DHS in the state fair hearing process. This
requirement is applicable when the ICA issues the Notice of Action (NOA) on
behalf of DHS or if the NOA is issued from DHS as a result of a budget
amendment request, a one-time expense request, or other termination, denial,
limitation, or reduction of service NOA.
All NOAs issued must reference the federal or state statute, Wis. Admin.
Code, the Medicaid HCBS 1915(c) IRIS Waiver, or IRIS policy that
resulted in the intended action.
DHS may assist the ICA during the preparation phase of the fair hearing
process, at their discretion.
ICA must notify DHS if a hearing decision is received that could require
further action on the part of the ICA or program.
In the event of a remanded decision from the ALJ, ICA must internally
document the steps taken to mitigate and resolve the case to the
specifications set forth in the remand.
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The Department reserves the right to attend fair hearings as part of
ongoing quality oversight and compliance
The ICA will assure that an adequately prepared representative from the ICA
participates in State Fair Hearings, if:
Any action issued by the ICA is being appealed; or
The ICA has knowledge that the issue being appealed concerns
participant’s cost share and the ICA has relevant information likely to help
the Administrative Law Judge reach a decision.
The ICA representative must be trained and prepared to:
i. Represent the ICA’s position;
ii. Explain the rationale and authority for the ICA action that is being
appealed; and
iii. Accurately reference and characterize any policies and procedures
related to the action that is being appealed.
The FEA is required to provide the DHS and/or the participant’s ICA with any
documentation requested for the Wisconsin State Fair Hearing process. This
requirement is applicable both when the ICA issues the NOA on behalf of DHS or
when the NOA is issued from DHS as a result of a budget amendment, one-time
expense, or other termination, denial, limitation, or reduction of service.
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XII. Financial Provisions
IRIS consultant agencies and fiscal employer agents shall ensure continuity of care for enrolled
participants through sound financial management systems and practices. Financial management
systems shall be sufficient to track, reconcile, report, and project the operational and financial
results of the Contractor, and support informed decision-making. Financial management
practices shall ensure the overall financial health of the organization and support the
maximization of quality services with the funds expended. All Contractors shall demonstrate the
capacity for financial solvency and stability and the ability to assume the level of financial risk
required under the contract and ensure continuity of care for enrolled participants.
Working Capital
The purpose of working capital is to provide ongoing liquid assets to manage
routine fluctuations in revenues and expenses that will occur in the normal course
of business operations.
Working capital is the difference between current assets and current liabilities.
Working capital must be maintained at a level not less than 2% of the base of
IRIS revenues.
For the purposes of initial certification, the base is defined as the projected
calendar year IRIS revenues. For an entity under contract the base is defined as
the most recent 12 months of actual IRIS revenues. If the entity has less than 12
months of IRIS revenues, the 12 month base will be calculated by annualizing
actual months of IRIS revenues.
Failure to maintain and report the working capital requirement will result in
heightened monitoring and/or fiscal corrective action as determined by DHS.
Restricted Reserve
Purpose and Requirements
The purpose of the restricted reserve is to provide continuity of services
for enrolled participants, accountability to taxpayers, and effective
program administration.
The restricted reserve provides additional liquid assets to underwrite the
risk of financial volatility due to extraordinary or unbudgeted program
expenditures.
The Contractor must maintain the required restrictive reserve in a
segregated liquid account in a financial institution.
The title of the account must include the language “IRIS Restricted
Reserves.”
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Any income or gains generated by the restricted reserve funds are to
remain within the account until the required balance is met as set forth in
the restricted reserve requirement.
Restricted reserve calculation for the Contractor will be based on a rolling basis
against the most recent 12 months of actual IRIS revenues. The most recent IRIS
revenues in year two will be the annualized revenues of the actual months under
contract. The required minimum restricted reserve balance is calculated as
follows:
8% of the first $5 million;
4% of the next $5 million;
3% of the next $10 million;
2% of the next $30 million; and
1% of any additional.
Reporting
The Contractor shall evidence satisfaction of the restricted reserve account
balance at least quarterly with the financial reporting (See Financial
Reporting 7.c).
The Contractor may be required to report on the status more frequently if
the Contractor is under heightened fiscal monitoring or under a corrective
action plan.
Failure to maintain the restricted reserve requirement will result in
heightened fiscal monitoring and/or fiscal corrective action as determined
by DHS.
Withdrawal or Disbursement
Provided the minimum balance requirement will continue to be met, or
when the Department allows, disbursements may be made from the
restricted reserve account in order to fund operating expenses
Withdrawal or disbursement from the restricted reserve account requires
prior written approval from DHS if the withdrawal or disbursement results
in a balance below the required minimum balance. Additionally,
withdrawals for a purpose other than payment of operating expenses
require prior written approval from the Department.
Disbursement Requests
The Contractor must file a plan for accessing the restricted reserve funds
with the Department at least twenty (20) calendar days prior to the
proposed effective date.
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The Contractor must obtain affirmative approval for withdrawals or
disbursements that result in a balance below the required minimum
balance.
Additionally, the Contractor must obtain approval for withdrawals for a
purpose other than payment of operating expenses.
The Department shall render decisions on requests within ten (10)
business days only after consideration of all solvency protections available
Withdrawals or disbursements that result in an account balance below the
required minimum balance will only be approved to fund working capital
or operating expenses of the Contractor on a short-term basis.
This plan must be emailed to: [email protected] and
DHSLTCFiscalO[email protected].
Plans for Replenishment of Restricted Reserves When Below Minimum
If the disbursement request results in the reserve account balance falling
below the minimum requirements, the disbursement request plan must
specify the methods and timetable the Contractor shall employ to replenish
the restricted reserve account.
If the Contractor fails to submit an acceptable replenishment plan, the
Department may deny the request for disbursement. In approving or
disapproving the plan, the Department will take into account existing or
additional solvency protections available to the Contractor.
Failure to Maintain Required Minimum Balance
In the event the Contractor fails to meet the requirements of the
replenishment plan, the Contractor will be placed under corrective action
and shall submit a plan to the Department for approval that includes an
analysis of the reasons for the shortfall and a plan for restoring the
required restricted reserve balance.
If the Contractor continues to maintain an inadequate restricted reserve
balance, the Department may decertify the Contractor and terminate this
contract.
The Department reserves the right to request an updated submission of the
completed IRIS Financial Projection Template (F-02046) at any point during the
term of the contract. Factors include, but are not limited to:
Actual IRIS participant enrollment;
Projected IRIS participant enrollment;
New or expanded lines of other business for the certified Vendor; and
Termination or reduced lines of other business for the certified Vendor.
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Fiscal oversight review finding.
Financial Reporting
The Contractor will communicate the fiscal health of the organization and
demonstrate the integrity of the financial operations consistent with the conditions
of this contract.
All financial reporting will be presented in accordance with generally accepted
accounting principles (GAAP).
Financial reporting for all entities is due to DHS within 30 calendar days of the
close of the first three (3) calendar quarters, ending March 31, June 30, and
September 30 respectively.
Calendar year-end preliminary financial reporting is due by February 28 of the
following year.
The submission of financial reporting may be required on a more frequent basis,
at the discretion of DHS.
Requests for an extension to the required reporting deadline(s) must be made prior
to the due date and include the length of extension request and a reason for the
extension request.
Quarterly Financial Reporting Document Submission Requirements:
Year-to-date (YTD) financial reporting in the IRIS Financial Reporting
Template (F-02047),
Signed Financial Statement Certification (see Appendix V),
Financial institution statement(s) evidencing the IRIS segregated
Restricted Reserve balance for the period end reporting.
Financial Reporting submissions should be made to DHS IRIS Main mailbox at:
[email protected] and to DHS Long-Term Care Fiscal Oversight at:
The Contractor and any subcontractors or providers shall make available to the
Department, the Department’s authorized agents, and appropriate representatives
of the U.S. Department of Health and Human Services any financial records of
the Contractor, subcontractors or providers which relate to the Contractor’s
capacity to bear the risk of potential financial loss, or to the services performed
and amounts paid or payable under the contract.
Annual Financial Audit
The Contractor will demonstrate annually through a financial audit performed by
an independent certified public accountant the reasonable assurance that the
Contractor’s financial statements are free from material misstatement in
accordance with GAAP. The audit report should demonstrate to DHS that the
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internal controls and related reporting systems in operation by the Contractor are
sufficient to ensure the integrity of the financial reporting systems.
Deadline for Submission of Financial Audit Report
The financial audit report and related submissions are due to the
Department by June 1 of each calendar year for the previous calendar year
(See D.3. below).
Statements should be submitted to the DHS IRIS Main mailbox at
[email protected] and to DHS Fiscal Oversight at
Requests for an extension must be made at least ten (10) calendar days
prior to the audit submission due date and include the length of extension
requested and provide a reason for the extension request.
Auditor Qualifications
The accountant or accounting firm retained by a Contractor shall furnish to the
Contractor, and the Contractor will obtain and include with the submission of the
annual audited financial report to DHS annually a CPA Qualification Letter to
attest that the accountant or accounting firm:
Is in good standing with the American Institute of Certified Public
Accountants and licensed to practice in the State of Wisconsin. Contractor
may request a variance for this requirement if they originate from an out-
of-state operation, but the auditor must be licensed to practice in the State
of your company’s base of operations.
Has not, directly or indirectly, entered into an agreement of
indemnification with respect to the audit.
Conforms to the standards of the accounting profession as contained in the
code of professional ethics of the American Institute of Certified Public
Accountants rules and regulations, code of ethics, and rules of professional
conduct of the accounting examining board, or a similar code.
Has not been convicted of fraud, bribery, a violation of the Racketeer
Influenced and Corrupt Organizations (RICO) Act, 18 USC 1961
(http://docs.legis.wisconsin.gov/document/usc/18%20USC%201961) to
1968 (
http://docs.legis.wisconsin.gov/document/usc/18%20USC%201968), as
revised, or any dishonest conduct or practices under federal or state law.
Has not been found to have violated the insurance laws or rules of this
state.
Has not demonstrated a pattern or practice of failing to detect or disclose
material information in financial reports.
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and <<Name of ICA or FEA>>
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Does not have a conflict of interest to complete the independent audit due
to a direct role, relationship, or appearance of role or relationship, with the
entity to be audited. This includes a related party relationship, previous
employment relationship of the audit firm partner, manager, or audit
fieldwork staff, or participation on the entity’s Board of Directors or other
management role, either paid or voluntary. A request for exception to this
requirement may be made to DHS in the case of unusual circumstances.
Audit Report Submission
The full audit report submission will include the following:
Comparative financial statements other than audit schedules and
reports required for the type of financial audit necessary for the
Contractor and resulting audit report and opinion.
Consolidated financial statements in a comparative format to
support full reporting for the Contractor and all related companies.
If the Contractor originates from an out-of-state company the audit
report must include a supplemental report that provides a break out
of the IRIS financial results versus other operations.
A report on the Contractor internal control environment over
financial reporting.
A report describing the system of cost allocation for shared
overhead and direct services between programs or lines of business
as required.
A supplemental financial report that demonstrates the financial
results and segregated reserves of the entity’s business for each
state program contract where the organization operates under
multiple Medicaid contracts and/or other lines of business. The
report shall be in columnar format for the various programs as
required.
Letter(s) to management as issued or written assurance that a
management letter was not issued with the audit report.
Management responses/corrective action plan for each audit issue
identified in the audit report and/or management letter.
The completed CPA audit checklist signed by the Contractor’s
designated financial officer.
Submission of the final audit results in the IRIS financial reporting
template and a signed Financial Statement Certification if the audit
resulted in adjustments to preliminary calendar year-end financial
reporting. If no adjustments to the preliminary calendar year-end
financial reporting were made it should be stated in the email
submission of the audit report submission.
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Submission of the audit reports — the audit report documents should be
submitted electronically to [email protected] and
Access to Financial Auditor’s Work Papers
When contracting with an audit firm, the Contractor shall authorize its auditor to
provide access to work papers, reports, and other materials generated during the
audit to the appropriate representatives of DHS. Such access shall include the
right to obtain the work papers and computer files, or other electronic media,
upon which records/working papers are stored in an agreed upon format.
Failure to Comply with the Requirements of this Section.
In the event that the Contractor fails to have an appropriate financial audit
performed or fails to provide a complete audit report to DHS within the
specified timeframes, in addition to applying one or more of the remedies
available under this contract, DHS may:
Conduct an audit or arrange for an independent audit of the entity
and charge the cost of completing the audit to the entity; and/or
Charge the entity for all loss of federal or state aid or for penalties
assessed to DHS because the entity did not submit a complete
financial audit report within the required timeframe.
Other Regulatory Reviews and Identified Irregularities
The Contractor will notify DHS within ten (10) business days of
notice of any reviews, investigations, decisions, and requirements
for corrective action from other state and federal regulatory
agencies, including but not limited to, the Internal Revenue
Service, Department of Workforce Development, State Department
of Revenue, or Department of Labor.
The Contractor will notify DHS within ten (10) business days of
any identified irregularities involving financial fraud from internal
or contracted operations.
Even if it is not an adverse action or audit, DHS should be made aware of
all identified reviews and/or irregularities. This includes, but is not limited
to reviews and/or irregularities identified by Wisconsin Department of
Revenue, Workforce Development (regarding unemployment
compensation), and any other regulatory authority.
Annual Financial Projections Submission
The Contractor will complete and submit the annual financial projections in the
DHS financial projections template for the next calendar year by October 15, of
each year to demonstrate the projected fiscal health of the organization and ability
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to support ongoing operations consistent with the conditions of this contract in the
next calendar year.
Annual Financial Projections Document Submission Requirements:
Year-to-date (YTD) financial reporting in the IRIS Annual Financial
Projections Template,
Financial Projections submissions should be made to the DHS Long Term
Care Fiscal Oversight at: [email protected]
Heightened Fiscal Monitoring
Heightened fiscal monitoring is based on results and information provided in the
Contractor’s financial submission or from information provided by an external
party.
Heightened monitoring will include monthly financial reporting, but is not a
formal corrective action.
The specific criteria include, but are not limited to:
Fiscal volatility;
Unplanned declining positive trends in liquidity position;
Large variances to the projected current year financial budget;
Expansion to a new region;
Significant change in the Contractor infrastructure, business; or
Other operational issues as evidenced through financial reporting or other
forms of communication, including, but not limited to, staff turnover.
The follow-up actions for the Contractor will be:
Monthly financial reporting;
Written and/or verbal communication with the Contractor to identify
issues/concerns and require specific responses with a plan, if required, to
ensure stability and improvement in the area of the identified concern.
Follow-up may include description of the underlying cause for
issues/concerns identified, submission of projections, revised policies and
procedures, monthly reporting, and may result in escalation to a corrective
action.
Fiscal Corrective Action
Fiscal corrective action criteria may include any of the following, but is not
limited to:
Contractor’s inability to achieve stability and/or provide a satisfactory
plan or other requested documentation to support a plan for stability.
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Failure to meet the working capital or restricted reserves that is not due to
a previously approved shortfall.
Identification of an operational weakness in critical processes, procedures,
or internal controls.
Sudden unexplained change in trend and/or volatility or explained change
highlighting a systemic problem in the required IRIS operations.
The follow-up actions for the initial level of fiscal corrective action will require
the following from the Contractor:
Monthly fiscal reporting.
Additional analysis of the Contractor’s business and operation, which may
lead to a targeted or full scope examination.
Performance expectations to address specific areas of required
improvement.
Submission of financial projections, analysis, and reporting to demonstrate
required results.
Submission of additional support documentation may be required, as
identified by DHS.
The mandatory intervention level requires all of the actions included in the initial
level of fiscal corrective action with the addition of specific requirements imposed
by DHS.
The criteria for mandatory intervention may include any of the following, but is
not limited to:
Aggregate percentage total of the working capital, restricted reserve and
solvency funds is negative, less than zero percent and declining without an
approved plan to recover within the required timeframe.
Failure to demonstrate correction of an identified weakness in operational
procedures or internal controls within the communicated required period.
Deteriorating trends and/or volatility over a three-month period that does
not have a satisfactory plan for correction.
Sudden failure of critical systems of organizational structure, such as IT
system failure, loss of critical financial systems/staff, other major
organizational change that is identified as causing extreme risk to the
ongoing day-to-day operations and management of the Contractor.
Contractor management is failing to comply with required corrective
action measures and/or requests.
Organizational/management culture does not support overall program
design and goals to achieve implementation of identified strategies.
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The follow-up actions for the mandatory intervention level of fiscal corrective
action will require the following from the Contractor:
Corrective action requirements formalized with identified contingencies.
Financial projections development and submission to demonstrate
achievable plan for recovery.
Site visit by DHS technical staff.
Weekly updates with Contractor management.
DHS meeting with the Contractor Board of Directors and/or parent
organization leadership (depending upon organizational structure).
Additional fiscal reporting requirements.
Actions in lesser levels are ongoing.
Contractors will be taken to the Transition and Termination level if it is
determined that the Contractor is:
Insolvent with no long-term plan for immediate recovery,
Unable to manage the day-to-day financial obligations and/or risk of
ongoing operations, and/or
Unable to identify and secure a source of capital infusion to support the
Contractor operations and infrastructure.
If the contract is to be terminated, the Contractor agrees to amend the contract to
include a provisional service agreement with identification of terms for
termination. Further, the Department will work with the Contractor and other
entities to transition participants to another Contractor-agency prior to the
effective date of termination.
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XIII. Quality Management (QM)
Department Oversight Activities
The Department provides program oversight through the following activities
a. Program Record Review;
b. Contractor Recertification Site Visit;
c. IRIS Participant Satisfaction Survey;
d. Critical Incident Review.
Program Record Review process
The Department contracts with an External Quality Review Organization (EQRO)
to manage and work directly with the contractors to complete the Program Record
Review process. The Program Record Review consists of performance indicators
derived from the performance measures identified within the 1915(c) Home and
Community Based Services (HCBS) waiver, as well as programmatic
requirements identified within this document The Program Record Review is a
review of the following:
Participant records within the Department’s centralized case management
system (WISITS) focusing on health and welfare, Individual Support and
Service Plan (ISSP) development, administrative authority and best
practice.
Compliance related to contractual requirements detailed in the IRIS
Record Review Tool (F-01496) and IRIS Record Review Instructions (P-
1014). These documents are available in SharePoint and upon request, but
are not publically published.
Contractor Recertification Site Visit
Department representatives travel to each contractors Wisconsin base of
operations to conduct the annual site visit. The site visits consists of the following
activities:
Review of contractor’s pre-submitted documentation as requested by the
Department;
Discussion regarding contractor’s current practices, procedures, policies
and methodologies related to the IRIS program;
Interview of contractor’s personnel.
IRIS Participant Satisfaction Survey
The Department will administer an IRIS Participant Satisfaction Survey annually.
The Department will survey a sample of each contractor’s participants to identify
their level of satisfaction with the contractor’s services.
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Critical Incident Review
Each contractor is responsible for completing participant incident reporting
outlined in the IRIS Policy Manual-Work Instructions (P-00708A). This process
includes a review of substantiated cases of abuse, neglect, misappropriation and
exploitation to ensure participant immediate and ongoing health and safety.
Performance Improvement Project (PIP)
Performance Improvement Projects (PIPs) are projects (identified and led
by the contractor) that positively impact participant experience in the IRIS
program. Using the IRIS Performance Improvement Project (PIP)
Proposal form (F-02832), contractors will be required to develop two PIPs
annually that are related to the improvement in the following areas:
Performance Indicators that are not 100% compliant;
Results of the Participant Satisfaction Survey;
Critical Incident Prevention;
Areas identified by the contractors that are expected to have a
positive effect on participant experience or satisfaction;
Areas specified by the Department.
PIP must clearly define the following:
Title of the PIP;
PIP implementation Date;
Outcome;
Target;
Strategy;
Deliverables;
All PIPs that are submitted in fulfillment of contract requirements must be
approved by the Department before initial project interventions are implemented.
The contractor shall submit a quarterly report to the Department regarding the
status and results of each PIP. In addition, the Department may request results of
any PIP at any time. If the contractor wishes to extend a PIP to the following year,
the contractor must submit a PIP proposal for approval. The proposal must
include the justification for continuing the PIP.
Documentation of Oversight Activities
The Department will utilize the Program Oversight Tracking document (F-
01208/F-01207) to track the oversight activities. The Program Oversight Tracking
document (F-01208/F-01207) will provide contractors with instructions in each
section that will outline the contractor’s responsibilities for each oversight
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activity. The Program Oversight Tracking document (F-01208/F-01207) will
track the following information:
Performance indicator compliance percentages;
Contractor remediation activities for performance indicators below the
CMS defined threshold;
Contractor Recertification Site Visit details;
Participant Satisfaction Survey results;
Substantiated cases of abuse, neglect, misappropriation and exploitation;
Contractor Performance Improvement Projects (PIP).
Quarterly Contractor Oversight Meeting
The Department will meet with each Contractor quarterly to discuss quality
oversight activities, and the contractor will meet with the Department in calendar
quarter four to conduct the Contractor Recertification Site Visit.
Other Contractor Responsibilities
Contractors are responsible for the completion and engagement in other areas of
the program. These areas include the following:
Critical Incident Reporting.
Critical Incident Reporting purpose is outlined in the IRIS Policy Manual
(P-00708). Business rules and critical incident reporting can be located in
the IRIS Policy Manual-Work Instructions (P-00708A).
Fraud Allegation and Review Assessment (FARA).
The FARA purpose is defined in the IRIS Policy Manual (P-00708).
Business rules and the FARA process can be located in the IRIS Policy
Manual-Work Instructions (P-00708A).
Behavior Support Plans (BSP)/ Restrictive Measures Monitoring (RM).
Behavior Support Plan and Restrictive Measures Request and Monitoring
can be located in the IRIS Policy Manual (P-00708). Business rules and
how to manage the BSP/RM processes are located in the IRIS Policy
Manual-Work Instructions (P-00708A). This responsibility is applicable to
ICAs only.
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XIV. Reporting Requirements
General ICA Reporting Expectations
Quarterly submission of updated IRIS Consultant Agency Assignments by Area
of Responsibility (F-01555).
New staff completion of the IRIS Certification Acknowledgement (F-01209) and
retention of document in employee record, of which a sample will be reviewed at
an annual site visit.
Completion the Conflict of Interest – Provider (F-01310) form for all new hires
and all staff who experience changes in employment linked with Medicaid.
Records must be retained within the employee’s file and are subject to review by
the Department upon request.
Annual submission of updated Conflict of Interest – Provider (F-01310) forms for
all new members of the agency’s governing Board of Directors, if applicable.
Monthly IRIS Consultant Agency Staffing list, to include an indication of each
consultant and screener’s supervisor, geographic service area(s), email address,
and phone number.
Annual submission of demographic data as it relates to IRIS consultant personnel,
to include but not be limited to said consultants’ race, ethnicity, language(s)
spoken, and disability status.
General FEA Reporting Expectations
Quarterly submission of an updated Fiscal Employer Agent Assignments by Area
of Responsibility (F-01555A).
Completion of the Conflict of Interest – Provider (F-01310) form for all new hires
and all staff who experience changes in employment linked with Medicaid.
Records must be retained within the employee’s file and is subject to review by
the Department upon request.
Annual submission of updated Conflict of Interest – Provider (F-01310) forms for
all new participants of the agency’s governing Board of Directors, if applicable.
Encounter Reporting
The purpose of encounter reporting is to give program administrators the ability to
submit data, in a pre-defined format, to the State of Wisconsin. The content is
used for a variety of purposes, including evaluation of service costs, monitoring
program integrity, and federal reporting.
Encounter Data – Format
The FEA shall assure participant-specific data is reported to the Department in an
encounter-data format (XML) specified by the Department and according to any
HIPAA deadlines/standards/requirements applicable to the FEAs. Claims must be
separated by target group and service code and in the DHS-prescribed encounter
reporting format.
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The Department will provide a template for FEAs to utilize in capturing
data, and FEAs are required to report on only the items identified on the
Department-provided template.
The specifications and HIPAA deadlines, standards, and requirements are
identified in documents found on the Department’s website at:
https://www.dhs.wisconsin.gov/ies/index.htm.
Encounter Data – Submission
The Encounter Reporting Submission is a monthly file submission. The
file submission is due on the thirtieth day after the end of the month, or the
first business day following the thirtieth day when the thirtieth day is not a
business day. CMS annually requires data on the percent of monthly
Encounter data submissions that were accepted and certified within 30
days. The Encounter Reporting Submission shall be reported on-line
through the LTCare IES application. DHS will provide supplemental
materials to aid with the submission of an Encounter Claim using field-by-
field description and requirements.
Any time an FEA receives state funds for rendered IRIS services, it is
required to submit the claim information into the Encounter System. FEAs
must also report cost share amounts in Encounter.
Encounter Data – Non-Compliance Resolution Process
The Department shall have the right to audit any records of the FEA and to
request any additional information. If at any time the Department determines that
the FEA has not complied with any requirement of this section, the Department
will issue a corrective action to the FEA.
Quarterly Employment Data Report
The ICA is required to report employment data for participants who have
competitive integrated employment (CIE) on a quarterly basis using a
prepopulated list of participants provided by DHS.
The ICA may choose to request employment service providers report employment
data to them. However, the ICA will be responsible for the uploading and
certification of the employment data sent to DHS.
The tool the ICA will use for employment data collection and submission of these
reports will be the Informational Exchange System (IES)
(https://ltcareies.forwardhealth.wi.gov/ltcareIES/secureLogin.html).
The IES spreadsheet will be available from the Department for ICAs on the 2
nd
Friday of the month after the quarter. ICAs are required to submit their
information to the IES six weeks after receipt of said report.
Contract for IRIS Program between the
Wisconsin Department of Health Services, Division of Medicaid Services
and <<Name of ICA or FEA>>
Page 142
Reports from the Department
Monthly Enrollment and Gross Enrollment Totals
On or around the 2
nd
day of each month DHS will generate and distribute
summary totals by email to all Contractors.
Self-Directed Personal Care Reports
On or around the 15
th
day of each month DHS will generate:
An SDPC summary report of enrollment totals, broken down by month,
for the previous twelve (12) months.
The SDPC Monthly Rate of Service Detail report, broken down by SDPC
status, with an IRIS SDPC enrollment breakdown by FEA.
Quality Assurance—SharePoint Reports
On or around the 15
th
day of each month, DHS will generate reports, using
SharePoint data. The data will focus on the previous calendar month’s
reported data, specific to critical incidents, budget amendments, and one-
time expenses.
Upon completion, these reports will be uploaded to the appropriate
“Reports” section affiliated with each ICA on SharePoint. This
information is provided prior to quarterly quality meetings with the
expectation of content having been reviewed and ICAs being responsible
for providing updates on specific incidents, identify trends, and discuss
any mitigation that is recommended or underway.
Reports to the Department
Contractors agree to furnish information from its records to the Department, and
to the Department’s authorized agents and upon request to CMS, which may be
required to administer the program.
The number and frequency of reports is subject to change based on CMS
requirements and program policy. Changes to the methodology of the data
submitted, must be sent to the Department and is subject to DHS approval.
Completed reports shall be emailed to:
[email protected], unless specified otherwise.
FEA Data Integrity and Systems Assessments
1. Health and long-term care service information from each FEA is transmitted to
the Department on a regular basis through the encounter reporting process,
utilizing the LTCare IES application. This information is used for research,
monthly rate of service calculations, and various other ad hoc applications. The
Contract for IRIS Program between the
Wisconsin Department of Health Services, Division of Medicaid Services
and <<Name of ICA or FEA>>
Page 143
accuracy of encounter data may be impacted by various systems maintained by
the FEA.
The purpose of data integrity and system assessments is to assure the data that
exist in the organizations’ originating system are accurately reflected in the data
existing in the encounter data repository, and that the repository accurately
reflects the service records present in the FEA systems. The objectives of the data
integrity and systems assessments are to verify that:
a. Claims and encounter data exist in FEA systems;
b. Data from FEA systems is presented to the State correctly;
c. Data submitted to the State accurately reflects encounters; and
d. Data that resides with the State is an accurate reflection of what exists in
the FEA system.
FEA system and data integrity assessments will be scheduled and conducted on an
as needed basis as determined by the Department. The FEA data integrity and
system assessments are specific to the IRIS processes. These assessments include
processes or activities regarding the operation of the IRIS program, the operation
of the LTCare IES application, or FEA financial systems and processes.
2. FEA Responsibilities
When an assessment is scheduled, the FEA shall:
a. Appoint a primary assessment contact person to be the Department audit
team’s contact for scheduling and reviewing assessment activities, and to
provide acceptance of the final assessment report. At the same time,
designate a back-up person who will be available to perform this function
when needed;
b. Supply ad hoc reconciliation reports as requested by the Department
assessment team within 30 calendar days of the request, using date
parameters specified by the Department’s assessment team; and
c. Comply with an onsite visit by the Department’s assessment team to make
available all relevant data in order to complete the assessment.
3. Department Responsibilities
The Department assessment team shall:
a. Contact the FEA regarding the scheduling of onsite visits at least thirty
(30) calendar days prior to the visit;
b. Develop, after completion of the assessment, an initial draft report of the
findings of the assessment and share these findings with the FEA within
thirty (30) calendar days of the visit;
c. Schedule a phone conference (or meeting, as appropriate) to discuss the
findings of the draft report within two weeks of the release of the report.
Contract for IRIS Program between the
Wisconsin Department of Health Services, Division of Medicaid Services
and <<Name of ICA or FEA>>
Page 144
Any issues regarding the report will be jointly resolved with the FEA
assessment contact; and
d. Provide a written final report to both the FEA and the Department’s
program managers within six weeks of the phone call. The assessment
report shall identify areas of compliance as well as inconsistencies found,
system or data integrity vulnerabilities, and process deficiencies that may
put system or data integrity at risk.
Contract for IRIS Program between the
Wisconsin Department of Health Services, Division of Medicaid Services
and <<Name of ICA or FEA>>
Page 145
XV. Payment to IRIS Contractors
Monthly Rate of Service (MROS)
1. Payments for services provided in accordance with the terms and conditions of the
contract and these criteria:
Effective Date:
1/1/2021
Effective Date:
7/1/2021
Effective Date:
1/1/2022
ICAs
$254.73
$237.26
$219.78
FEAs
$71.71 + SDPC
supplement
$68.25 + SDPC
supplement
$62.98 + SDPC
supplement
2. DHS will extract a claim file from the Department case management system
(WISITS). The claim file and payment will reflect eligible enrollment as of the 1
st
day of every month and will contain data pertaining to the participants reported
on. Each ICA and FEA will receive a detailed claim file related to participants
enrolled with their agency. The information on the claim file shall include, but not
limited to:
Participant’s first and last name,
Participant’s Medicaid identification (MA ID) number,
Participant’s Social Security number,
Participant’s date of birth,
Participant’s sex.
3. Payment to the ICA and FEA is a prospective payment for participants classified
with the Department case management system (WISITS) status of enrolled or
suspended (suspended status must be equal to or less than 90 days to be eligible
for payment) and with verified Medicaid eligibility on that date.
4. The claims file will be adjudicated using the Medicaid Management Information
Systems (MMIS) system’s Medicaid eligibility data.
5. FEAs must submit invoices related to Workers’ Compensation coverage to the
IRIS program by the 15th day of each month to be included on that month’s
MROS file.
6. Claims files may be adjusted, as necessary, to reflect over- or underpayments
related to participant enrollment or disenrollment. In the event of adjustment, an
adjustment explanation and participant’s MCI will be provided in the comments
of the payment directive.
7. The ICA and FEA will be paid the MROS for those participants listed as
Medicaid-eligible with matching MA IDs. DHS is required to have the MROS
claim processed and payment made within 90 days of the claim submission.
Contract for IRIS Program between the
Wisconsin Department of Health Services, Division of Medicaid Services
and <<Name of ICA or FEA>>
Page 146
8. Those participants without MA eligibility, incorrect MA IDs, or whose MA IDs
are not found in the ForwardHealth interChange system, will be listed on a report
provided to the ICA and FEA. This is known as an exception report.
9. DHS will review an exception report determine if anyone listed on the exception
report received retroactive eligibility for the month they appeared on the
exception report. If the participant received retroactive eligibility, DHS will pay
the MROS for that individual in the month the exception report was reviewed
through the reconciliation process
Suspension of Payment Based on Credible Allegation of Fraud
Requirement
The Department shall suspend the monthly rate of service (MROS) payments to
the Contractor if it determines that there is a credible allegation of fraud by the
Contractor, unless the Department determines there is good cause for not
suspending payments or for only suspending them in part, pursuant to the
requirements of 42 C.F.R. § 455.23.
Credible Allegation of Fraud
A credible allegation of fraud is, as defined in 42 C.F.R. § 455.2, one considered
by the Department to have indicia of reliability based on a careful and judicious
review by the Department of all assertions, facts, and evidence on a case-by-case
basis.
Good Cause to Not Suspend Payments
The Department shall determine whether good cause exists to not suspend
payments, to suspend them only in part, or to lift a payment suspension based on
the criteria under 42 C.F.R. § 455.23 (e) or (f). Good Cause shall exist if any of
the following apply:
Law enforcement officials request that a payment suspension not be
imposed because of a possible negative affect on an investigation;
Other available remedies more effectively or quickly protect Medicaid
funds;
The Department determines based on written evidence submitted by the
Contractor that the suspension should be removed;
Law enforcement declines to certify that a matter continues to be under
investigation; or
The Department determines that payment suspension is not in the best
interests of the Medicaid program.
Notice Requirements
The Department shall send the Contractor written notice of any suspension of
MROS payments:
Contract for IRIS Program between the
Wisconsin Department of Health Services, Division of Medicaid Services
and <<Name of ICA or FEA>>
Page 147
Timeframes
Within five (5) business days after taking such action unless
requested by a law enforcement agency to temporarily withhold
such notice; or
Within five (5) business days after taking such action if requested
in writing by law enforcement to delay the notice, which request
for delay may be renewed in writing up to twice but may not
exceed ninety (90) days.
Content – The notice shall include the following:
A statement that payments are being suspended in accordance with
42 C.F.R. § 455.23.
The general allegations as to the reason for the suspension.
A statement that the suspension is temporary and the
circumstances under which it will be ended.
If the suspension is partial, the types of services or business units
to which it applies.
The Contractor’s right to submit written evidence for consideration
by the Department. The authority for the Contractor to appeal the
suspension and the procedures for doing so can be found at Wis.
Stat. ch. 227.
Duration of Suspension
A suspension of payment will end when:
The Department or a prosecuting authority determines there is insufficient
evidence of fraud;
Legal proceedings related to the alleged fraud are completed; or
The Department determines there is good cause to terminate the
suspension.
Contract for IRIS Program between the
Wisconsin Department of Health Services, Division of Medicaid Services
and <<Name of ICA or FEA>>
Page 148
APPENDIX I. Contract Signatures
Unless earlier terminated, as provided herein, this Contract shall remain in full force and effect
until December 31, 2022.
In WITNESS WHEREOF, the State of Wisconsin and the Contractor have executed this
agreement:
Executed on behalf of Executed on behalf of
Name of Contractor Department of Health Services
Authorized Signer James D. Jones
Title Medicaid Director
Date Date
Contract for IRIS Program between the
Wisconsin Department of Health Services, Division of Medicaid Services
and <<Name of ICA or FEA>>
Page 149
APPENDIX II. Key IRIS Program Publications and Forms
Waiver and Manuals:
• 1915(c) Home and Community-Based Services Waiver
• IRIS Policy Manual, P-00708
• IRIS Work Instructions, P-00708A
• IRIS Service Definition Manual, P-07008B
• IRIS Participant Education Manual, P-01704
Enrollment Reports and Maps:
• Monthly IRIS Enrollment Snapshot
• ICAs and FEAs by Geographic Service Region, P-02029
• Active IRIS Participants by County, P-01759
• Active SDPC Participants by County, P-01758
Financial and Fiscal:
• Payroll and Vendor Schedule, P-01740
• Financial Projections Template, F-02046
• Financial Reporting Template, F-02047
• IRIS CPA Audit Checklist, F-02021
Quality Management:
• IRIS Consultant Agency Quality Management Plan, F-01208
• IRIS Consultant Agency Quality Management Plan Tracking, F-01208A
• IRIS Fiscal Employer Agent Quality Management Plan, F-01207
• IRIS Fiscal Employer Agent Quality Management Plan Tracking, F-01207A
Department Resources:
• IRIS Program Website: https://www.dhs.wisconsin.gov/iris/index.htm
Department of Health Services Forms Library
• https://www.dhs.wisconsin.gov/forms/index.htm
Department of Health Services Publications Library:
• https://www.dhs.wisconsin.gov/publications/index.htm
Contract for IRIS Program between the
Wisconsin Department of Health Services, Division of Medicaid Services
and <<Name of ICA or FEA>>
Page 150
APPENDIX III. Fiscal Employer Agent Paperwork Packet Expectations
Participant-Employer Packet
The participant-employer packet must include the following documents. All
agency-specific forms must be approved by the Department prior to distribution
and utilization.
Form Name/Number Form Title/Purpose
Internal Revenue Service
Form SS-4
Application for new or activation of existing FEIN. The
FEA verifies that an FEIN is not already assigned and
submits the application to the IRS when the participant
employer needs to obtain a FEIN.
Internal Revenue Service
Form 2678
Employer/Payer Appointment of Agent (executed by both
employer and FEA).
Internal Revenue Service
Form 8821
Tax Information Authorization. Authorizes information
exchanges between the FEA and IRS.
Guardianship or Power of
Attorney paperwork
This documentation must be uploaded and retained in the
participant’s document console. FEAs shall check the
Department case management system (WISITS) prior to
requiring said documentation from the participant.
The following additional forms shall be utilized, as needed:
FEA-Specific Direct Deposit
Authorization Form
This is optional for participants to complete. There may
be circumstances whereby participants require payment
or reimbursement.
Application for Wisconsin State
Income Tax Withholding Account
Number
The FEA submits necessary forms and obtains an
individual state tax account for each participant
employer.
Wisconsin State Unemployment Compensation related documents
Workers Compensation Insurance The FEA must arrange for Workers’ Compensation
insurance according to state rules and for each participant
employer and must maintain and manage a policy
covering all participant-hired workers employed by
participants served.
Contract for IRIS Program between the
Wisconsin Department of Health Services, Division of Medicaid Services
and <<Name of ICA or FEA>>
Page 151
Participant-Hired Workers New Employee Packet
The employee packet shall include, at minimum, the following:
Form Number Form Title
DHS F-00180C Wisconsin Medicaid Program Provider Agreement and
Acknowledgement of Terms of Participation. This form
must be signed and returned to the FEA before any
payment can be issued.
U.S. Citizenship and Immigration
Services Form I-9
Employment Eligibility Verification (and copies of
appropriate documents) necessary to validate citizenship
or other work-related authorization.
Internal Revenue Service
Form W-4
Employee’s Federal Tax Withholding Certificate. This
form determines how much tax the participant-employer
will withhold from the worker’s paycheck.
WI Department of Revenue
Form WT-4
Wisconsin Income Tax Withholding Allowance
Exemption Certificate/New Hire Reporting. This form is
used to report the hiring and allowance exemptions to the
Wisconsin Department of Workforce Development.
DHS F-01201 IRIS Participant-Hired Worker Set-Up. This form is
intended to provide demographic information on the
participant and their worker.
DHS F-01201A: IRIS Participant-Hired Worker Relationship
Identification. This form documents any relationship that
the worker has with the participant, so as to ensure that the
following tax obligations are managed correctly: Federal
Insurance Contributions Act (FICA), Federal
Unemployment Tax Act (FUTA), and State
Unemployment Tax Exemptions (see Internal Revenue
Publication 15, Circular E, Family Employees Section).
DHS F-01201C IRIS Participant Employer/Participant-Hired Worker
Agreement. This form provides demographic information
for the worker, as well as an indication as to the services
they will provide, their proposed work schedule, and the
pay rate(s) thereof.
DHS F-82064 Background Information Disclosure (BID). Completion of
this form is required under Wis. Stats. § 50.065 to ensure
worker completes a criminal and caregiver background
check.
Contract for IRIS Program between the
Wisconsin Department of Health Services, Division of Medicaid Services
and <<Name of ICA or FEA>>
Page 152
DHS F-01246 Background Information Disclosure Addendum – IRIS.
This form captures the worker’s previous residences for
consideration in the resulting background check.
FEA-Specific Payment Election
Form
Each FEA shall generate and utilize a payment election
form to ensure workers are offered the choice of pay card
or direct deposit for receipt of wages.
The following additional forms shall be utilized, as needed:
Form Number Form Title
Internal Revenue Service
Form W-9
IRS Request for Taxpayer Identification Number and
Certification.
Should the ICA incorrectly determine that the worker is
not an individual employee; the FEA refers the worker
back to the ICA for setup as an independent provider.
Internal Revenue Service
Form W-5
Earned Income Credit Advance Payment Certificate
(upon request).
Internal Revenue Service Notice
797
Possible Federal Tax Refund Due to the Earned Income
Credit (EIC).
Documentation necessary for
workers under age 18 (minors)
Ensure state rules regarding employed minor workers are
followed.
Worker benefit accounting and
health insurance forms
Establish a tracking system for all workers earning
vacation or other time off benefits as part of employment.
Verification and validation of Social Security number
Local tax employee forms, as
applicable
Completed using the Social Security Administration
(SSA) number verification service
Vendor and Individual Provider Packet
The packet for Vendors and Individual Providers shall include, but shall not be
limited to, the following:
Form Number Form Title
DHS F-01312 IRIS Provider Application.
Internal Revenue Service
Form W-9
Request for Taxpayer Identification Number and
Certification. This form is required for all providers, as
well as for any existing provider that changes their name.
DHS F-00180C Wisconsin Medicaid Program Provider Agreement and
Acknowledgement of Terms of Participant. This form
Contract for IRIS Program between the
Wisconsin Department of Health Services, Division of Medicaid Services
and <<Name of ICA or FEA>>
Page 153
must be signed and returned to the FEA before any
payment can be issued.
FEA-Specific Direct Deposit
Authorization Form
Vendors and individual providers must be strongly
encouraged, if not required, to utilize direct deposit
payments.
2. The following additional forms shall be utilized, as needed:
DHS F-82064 Background Information Disclosure, as needed, for
individual providers.
DHS F-01246 Background Information Disclosure Addendum, as
needed, for individual providers.
Copy of Liability Insurance Certificate, if required for the profession.
Copy of Professional License and/or Certificate, if required for the profession.
Copy of Driver’s license, if providing transportation.
Adult Family Home Information Form, if AFH provider with non-taxable income. This
information is required only if the AFH income is qualified to be non-taxable. The AFH is
exempt from taxes and 1099 reporting only if the AFH qualifies based on the information
provided on the form.
Contract for IRIS Program between the
Wisconsin Department of Health Services, Division of Medicaid Services
and <<Name of ICA or FEA>>
Page 154
APPENDIX IV. Data Certification
Encounter Data Certification
This certification requires the responsible party to attest that the submitted
Encounter Data is accurate, complete, and truthful to the best of their knowledge.
This is required by the IRIS program and the Department of Health Services. It is
the responsibility of the certifying party to assure the necessary internal checks,
audits, and testing procedures have been conducted to ensure the integrity of the
data.
After the FEA receives the submission status report indicating the FEA’s data has
been accepted and free of batch reject errors, certification shall be made via the
automated data certification method or, when the automated function is not
available, via the Data Certification Form. If it is necessary to use a separate
method of providing certification outside of the system, certification language
should be acquired by the Department and the completed certification form
should be emailed to: [email protected].
Financial Certification
This certification requires the responsible party to attest that the submitted
financial statement is accurate, complete, and truthful to the best of their
knowledge. This is required by the IRIS program and the Department of Health
Services. It is the responsibility of the responsible party to develop the necessary
internal checks, audits, and testing procedures to assure the integrity of the
financial statement.
Certification must be included with the submission of the financial statement to
the State to the DHS IRIS mailbox at:
[email protected] and to DHS Fiscal Oversight at:
DHSLTCFiscal[email protected].
Contract for IRIS Program between the
Wisconsin Department of Health Services, Division of Medicaid Services
and <<Name of ICA or FEA>>
Page 155
Form should be created on Contractor letterhead
FINANCIAL STATEMENT CERTIFICATION
Pursuant to the IRIS Program contract between the State of Wisconsin, Department of Health
Services, Division of Medicaid Services, and the (ICA/FEA, Choose One),
________________________ (Name of ICA/FEA), hereafter referred to as the __________
(ICA/FEA, Choose One). The __________ (ICA/FEA, Choose One) certifies that: The business
entity named on this form is a qualified provider enrolled with and authorized to participate in
the Wisconsin Medicaid program as an __________ (ICA/FEA, Choose One).
The __________ (ICA/FEA, Choose One) acknowledges that if payment is based on any
information required by the State and contained in financial statements, the data submitted must
be certified by a Chief Financial Officer, Chief Executive Officer, or a person who reports
directly to and who is authorized to sign for the Chief Financial Officer or Chief Executive
Officer.
The __________ (ICA/FEA, Choose One) hereby requests payment from the Wisconsin
Medicaid program based on any information required by the State and contained in financial
statements submitted and in so doing makes the following certification to the State of Wisconsin.
The __________ (ICA/FEA, Choose One) has reported to the State of Wisconsin for the period
of _____________ (indicate dates) all information required by the State and contained in
financial statements. The __________ (ICA/FEA, Choose One) has reviewed the information
submitted for the period listed above and I, (enter Name of Chief Financial Officer,
Chief Executive Officer or Name of person who reports directly to and who is authorized to sign
for Chief Financial Officer, Chief Executive Officer) attest that based on best knowledge,
information, and belief as of the date indicated below, all information submitted to the State of
Wisconsin in this batch is accurate, complete, and truthful. No material fact has been omitted
from this form.
I, __________ (enter Name of Chief Financial Officer, Chief Executive Officer or Name of
person who reports directly to and who is authorized to sign for Chief Financial Officer, Chief
Executive Officer) acknowledge that the information described above may directly affect the
calculation of payments to the _______ (ICA/FEA, Choose One). I understand that I may be
prosecuted under applicable federal and state laws for any false claims, statements, or
documents, or concealment of a material fact.
Signature of CFO, CEO, or delegate Date signed
____
Name and title of CFO, CEO, or delegate
Contract for IRIS Program between the
Wisconsin Department of Health Services, Division of Medicaid Services
and <<Name of ICA or FEA>>
Page 156
APPENDIX V. MATERIALS WITH SPECIFIC DUE DATES – ALL
CONTRACTORS
i.
Materials with Specific Due Dates – All Contractors
Report
Reporting Period
Due Date
Submit To
1. Year to Date Financial
Reporting
(to include completed
reporting template, signed
Financial Statement
Certification, investment/bank
statement for segregated
Restrictive Reserve account)
01/01/22 - 03/31/22 04/30/22
cc: [email protected]sconsin.gov
01/01/22 – 06/30/22 07/30/22
01/01/22 – 09/30/22 10/30/22
01/01/22 – 12/31/22 Audited 06/01/23
2. Preliminary 01/01-
12/31Financial Reporting
(to include completed
reporting template, signed
Financial Statement
Certification, investment/bank
statement for
segregated Restrictive
Reserve account)
01/01/21 – 12/31/21 02/28/22
01/01/22 – 12/31/22
02/28/23
3.1 Audited Year-End
Financial Statements*
(with the audit report, required
schedules, letters, updated
financial reporting template,
and financial statement
certification)
*see contract for comprehensive
lis t of required submission files.
01/01/21 – 12/31/21 06/01/22
cc: [email protected]sconsin.gov
01/01/22 – 12/31/22
06/01/23
3.2 Accountants Letter of
Qualifications
Same as 3.1 above
Same as 3.1
above
Same as 3.1 above
3.3 CPA Checklist
Same as 3.1 above
Same as 3.1
above
Same as 3.1 above
4. Annual Financial
Projections
1/01/2023 – 12/31/2023
10/15/2022
cc: [email protected]sconsin.gov
Contract for IRIS Program between the
Wisconsin Department of Health Services, Division of Medicaid Services
and <<Name of ICA or FEA>>
Page 157
ii. Materials with Specific Due Dates - Fiscal Employer Agent
Report
Reporting Period
Due Date
Submit To
1. Encounter Reporting
Submission and Data
Certification form, as
applicable.
12/01/21 – 12/31/21
01/30/22
DHS LTC IES:
https://ltcareies.forward
health.wi.gov/ltcareIES/
01/01/22 – 01/31/22
3/2/2022
02/01/22 – 02/28/22
03/30/22
03/01/22 – 03/31/22
04/30/22
04/01/22 – 04/30/22
05/30/22
05/01/22 – 05/31/22
06/30/22
secureLogin.html
06/01/22 – 06/30/22
07/30/22
07/01/22 – 07/31/22
08/30/22
08/01/22 – 08/31/22
09/30/22
09/01/22 – 09/30/22
10/30/22
10/01/22 – 10/31/22
11/30/22
11/01/22 – 11/30/22
12/30/22
12/01/22 – 12/31/22
01/30/23
Report
Reporting Period
Due Date
Submit To
2. Funding Files
Weekly Pay Cycles,
pursuant to the Payroll and
Vendor Schedule (
P-01740)
See
P-01740
IRIS Contract Specialist, and all
required Bureau of Fiscal Services
Staff
3. Deposit Account Bank
Reconciliation
12/01/21 – 12/31/21
01/15/22
IRIS Contract Specialist(s) and all
required Bureau of Fiscal Services
Staff
01/01/22 – 01/31/22
02/15/22
02/01/22 – 02/28/22
03/15/22
03/01/22 – 03/31/22
04/15/22
04/01/22 – 04/30/22
05/15/22
05/01/22 – 05/31/22
06/15/22
06/01/22 – 06/30/22
07/15/22
07/01/22 – 07/31/22
08/15/22
08/01/22 – 08/31/22
09/15/22
09/01/22 – 09/31/22
10/15/22
10/01/22 – 10/31/22
11/15/22
11/01/22 – 11/30/22
12/15/22
12/01/22 – 12/31/22
01/15/23
4. Disbursement Account
Bank Reconciliation
Same as 3 above
Same as 3 above
IRIS Contract Specialist(s) and all
required Bureau of Fiscal Services
Staff
5. Reimbursement Files
12/01/21 – 12/31/21
01/13/22
IRIS Contract Specialist(s) and all
required Bureau of Fiscal Services
Staff
01/01/22 – 01/31/22
02/10/22
02/01/22 – 02/28/22
03/10/22
03/01/22 – 03/31/22
04/14/22
04/01/22 – 04/30/22
05/12/22
05/01/22 – 05/31/22
06/09/22
06/01/22 – 06/30/22
07/14/22
07/01/22 – 07/31/22
08/11/22
Contract for IRIS Program between the
Wisconsin Department of Health Services, Division of Medicaid Services
and <<Name of ICA or FEA>>
Page 158
08/01/22 – 08/31/22
09/08/22
09/01/22 – 09/31/22
10/13/22
10/01/22 – 10/31/22
11/10/22
11/01/22 – 11/30/22
12/08/22
12/01/22 – 12/31/22
01/12/23
6. Cost Share Arrearage
Report
12/01/21 – 12/31/21
01/10/22
To each IRIS Consultant Agency
with impacted participants.
01/01/22 – 01/31/22
02/10/22
02/01/22 – 02/28/22
03/10/22
03/01/22 – 03/31/22
04/10/22
04/01/22 – 04/30/22
05/10/22
05/01/22 – 05/31/22
06/10/22
06/01/22 – 06/30/22
07/10/22
07/01/22 – 07/31/22
08/10/22
iii.
Materials with Specific Due Dates – IRIS Consultant Agencies
Employment
Reporting
Contract Year
Review Period
IES
Spreadsheet
from DHS
available for
ICAs
(2
nd
Friday after
the quarter)
ICA IES Info Due
to DHS
(6 weeks after
receiving
spreadsheet)
Submit To
2021
Q1 - Jan, Feb, Mar
Apr 9, 2021 May 21, 2021
DHS LTC IES:
https://ltcareies.forward
health.wi.gov/ltcareIES/
secureLogin.html
Q3 - April, May,
June
July 9, 2021 Aug 20, 2021
Q4 - July, Aug,
Sept
Oct 8, 2021 Nov 19, 2021
Q4 - Oct, Nov,
Dec
Jan 14, 2022 Feb 25, 2022
2022
Q1 - Jan, Feb, Mar
Apr 8, 2022 May 20, 2022
Q3 - April, May,
June
July 8, 2022 Aug 19, 2022
Q4 - July, Aug,
Sept
Oct 7, 2022 Nov 18, 2022
Q4 - Oct, Nov,
Dec
Jan 13, 2023 Feb 24, 2023
