Medicaid: Provider-Controlled Settings
Overview
The Wisconsin Department of Health Services (DHS) is working to make sure services provided in residential settings are safe, consistent, and follow program rules. Community Supported Living (CSL) is a way services can be provided in a person’s home. DHS has created a form to help managed care organizations (MCOs) and IRIS consultant agencies (ICAs) determine when a setting is provider-controlled and therefore must be licensed or certified to continue receiving Medicaid funding.
What is daily supportive home care?
Daily supportive home care (SHC) occurs when a person lives in their own home or apartment and receives services based on their individual needs.
- The person typically holds their own lease.
- Services are flexible and support independence.
- Supports may include things like SHC coordination or on-call help.
SHC is not a separate Medicaid service or benefit. Services must still follow existing program rules.
What is a provider-controlled setting?
A provider-controlled setting is a residential setting where services are provided beyond room and board, and the provider or property owner has control or influence over the setting.
A setting may be provider-controlled if:
- The provider owns or leases the home.
- The provider has a financial relationship with the property owner.
- The setting owner or provider influences which service providers a person can use.
Determining a provider-controlled setting
DHS is implementing a standard process so MCOs and ICAs can identify provider-controlled settings.
MCOs and ICAs will:
- Ask questions about the setting.
- Review documents, such as leases.
- Use a standard determination form.
- Determine whether the setting is provider controlled.
This process will be used across programs, including:
- Family Care
- Family Care Partnership
- IRIS (Include, Respect, I Self-Direct)
- Program of All-Inclusive Care for the Elderly (PACE)
What does this mean for members and participants?
This process is intended to:
- Protect a member's and participant's right to choose their provider.
- Make sure housing is not tied to a specific provider.
- Ensure services are safe and meet program requirements.
MCO staff or IRIS consultants may:
- Ask members questions about their living situation.
- Request documents, such as the lease.
- Talk about next steps if changes are needed.
What does this mean for providers?
Providers should:
- Review how their services are delivered in residential settings.
- Be aware of how provider-controlled is defined.
- Be prepared to participate in the evaluation process.
If a setting is determined to be provider-controlled, providers must take steps to meet licensing or certification requirements in order to continue receiving Medicaid funding. Your MCO and ICA will provide information about next steps.
What happens if a setting is provider-controlled?
If a setting is determined to be provider-controlled:
- The provider must start the process to become licensed or certified as an adult family home.
- This process must begin within 30 days of the determination.
- If the provider does not start this process, they will not be able to continue providing services.
- Medicaid payment for services will stop, and contracts may be impacted.
Questions and answers
General
A provider-controlled setting is a residential setting which needs to be certified or licensed to receive Medicaid funding.
A provider-controlled setting has a resident or residents who are not related to the provider or property owner, who reside and receive support and services above the level of room and board, and where one of the following applies:
- The provider has a direct or indirect financial relationship with the property owner, but does not lease or own the property.
- The property owner has influence over which service providers the resident uses.
- The provider holds the lease or title to the home.
If SHC is provided in a provider-controlled setting, then the setting needs to be licensed or certified.
The process to identify provider-controlled settings will be done in:
- Family Care
- Family Care Partnership
- IRIS
- PACE
MCO staff and IRIS consultants will use a standardized Provider-Controlled Setting Determination, F-03447 (Word) form. The form will have them ask questions and possibly request documents from members or participants and providers. MCO staff and IRIS consultants may meet members or participants and providers at the residence or ask questions over the phone.
The Provider-Controlled Setting Determination, F-03447 (Word) form is a list of questions, considerations, and guidance from DHS. The form is designed to help MCO and ICA staff evaluate whether a residence is a provider-controlled setting that needs to be licensed or certified.
MCO staff and IRIS consultants will complete the form by asking questions to the provider and the member or participant and/or their legal decision maker.
For providers
If you operate or own a residential setting and it meets the definition of a provider-controlled setting, then you will need to be licensed or certified.
You will need to start the process of being licensed or certified within 30 days of the determination by the MCO or IRIS consultant.
- Information on how to become a licensed 1-2 bed adult family home is available at Medicaid Standards for Certified 1-2 Bed Adult Family Homes.
- Information on how to become a certified 3-4 bed adult family home is available at Adult Family Homes: Opening an Adult Family Home.
If you don’t become licensed or certified, you will not get paid by Medicaid for services provided to the member or participant. The MCO may terminate their contract with you and the ICA will end service authorizations.
In order to remain an SHC provider, the participant or member must:
- Have their own lease with the setting owner and no services beyond typical shared amenities are provided by the setting owner.
- Own their own unit in a shared community.
- Have services above room and board, such as dressing, assisting with medication, and bathing, independently arranged by the resident and resident has full choice of the service provider.
- Not share any services with another individual.
A provider-controlled setting determination is not appealable. A provider can appeal an MCO’s decision to end their contract at the MCO level.
Questions related to the provider-controlled determination process should be directed to the MCO or ICA conducting the evaluation.
Resources
- Provider-Controlled Setting Determination, F-03447 (Word)
- IRIS Provider-Controlled Setting Determination Rules and Process (PDF)
- Provider-Controlled Setting Alignment Project Presentation (PDF)
- Information on becoming a licensed or certified Adult Family Home:
Questions?
If you have questions about this process: