RECIPIENT RIGHTS AND DUTIES
Prudent buyer limitations.
Second opinion program.
Ch. DHS 104 Note
Chapter HSS 104 was renumbered Chapter HFS 104 under s. 13.93 (2m) (b) 1., Stats., and corrections made under s. 13.93 (2m) (b) 7., Stats., Register, January, 1997, No. 493
. Chapter HFS 104 was renumbered to chapter DHS 104 under s. 13.92 (4) (b) 1., Stats., and corrections made under s. 13.92 (4) (b) 7, Stats., Register December 2008 No. 636
No applicant for or recipient of medical assistance (MA) may be excluded from participation in MA or denied benefits or otherwise be subjected to discrimination under MA for reasons which violate Title VI of the civil rights act of 1964, as amended, 42 USC 200d
et seq., and the implementing regulations, 45 CFR Part 80
(2) Rights of handicapped persons.
No otherwise qualified handicapped individual may, solely by reason of handicap, be excluded from the participation in MA, be denied benefits of MA or be subjected to discrimination under MA.
DHS 104.01 Note
See s. 504 of the rehabilitation act of 1973, as amended, 29 USC 794
, and the implementing regulations, 45 CFR Part 84
(3) Confidentiality of medical information.
Information about recipients shall be confidential in accordance with ss. 146.81
, Stats. No privilege exists under MA regarding communications or disclosures of information requested by appropriate federal or state agencies or their authorized agents concerning the extent or kind of services provided recipients under the program. The disclosure by a provider of these communications or medical records, made in good faith under the requirements of this program, shall not create any civil liability or provide any basis for criminal actions for unprofessional conduct.
DHS 104.01(4)(a)(a) Selection of a provider.
The department or agency shall maintain a current list of certified providers and shall assist eligible persons in securing appropriate care.
(c) Right to fair hearing.
A recipient who believes the recipient's freedom of choice of provider has been denied or impaired unfairly may request a fair hearing within 45 days of the department's action.
(d) Nursing home admission.
Free choice of a skilled nursing or intermediate care facility shall be limited so as to provide only care which is necessary to meet the medical and nursing needs of the recipient. A pre-admission screening assessment shall take place to determine appropriate service needs.
(e) Non-covered services.
A recipient's participation in MA does not preclude the recipient's right to seek and pay for services not covered by the program.
(f) Case management services.
Only recipients in the target populations designated by the department in s. DHS 107.32 (1) (a)
2 may choose case management services. Receipt of case management services does not restrict a recipient's right to receive other MA services from any certified provider.
(g) Presumptive eligibility determination.
A recipient who requests a determination of presumptive eligibility to receive MA services shall file an application only with a qualified provider designated by the department and certified under s. DHS 103.11
Applicants and recipients have the right to a fair hearing in accordance with procedures set out in this subsection when aggrieved by action or inaction of the agency or the department. This subsection does not apply to actions taken by a PRO.
Every applicant or recipient shall be informed in writing at the time of application for MA and at the time of any action affecting the recipient's claim of the right to a fair hearing, of the manner by which a fair hearing may be obtained and of the right to be represented or to represent self at such a fair hearing.
The applicant or recipient shall be provided reasonable time, not to exceed 45 days, in which to appeal an agency action. The department shall take prompt, definitive, and final administrative action within 90 days of the date of the request for a hearing.
No fair hearing is required when the sole issue being petitioned involves an automatic grant adjustment or change which affects an entire class of recipients and is the result of a change in state or federal law.
(b) Purpose of hearing.
The purpose of the fair hearing is to allow a recipient to appeal department actions which result in the denial, discontinuation, termination, suspension or reduction of the recipient's MA benefits. The fair hearing process is not intended for recipients who wish to lodge complaints against providers concerning quality of services received, nor is it intended for recipients who wish to institute legal proceedings against providers. Recipients' complaints about quality of care should be lodged with the appropriate channels established for this purpose, to include but not limited to provider peer review organizations, consumer advocacy organizations, regulatory agencies and the courts.
After the department has received a recipient's request for a fair hearing and has set the date for the hearing, the department shall review and investigate the facts surrounding the recipient's request for fair hearing in an attempt to resolve the problem informally.
If before the hearing date an informal resolution is proposed and is acceptable to the recipient, the recipient may withdraw the request for fair hearing.
If before the fair hearing date the concurrent review results in a proposed informal resolution not acceptable to the recipient, the fair hearing shall proceed as scheduled.
If the concurrent review has not resolved the recipient's complaint satisfactorily by the fair hearing date but an informal resolution acceptable to the recipient appears imminent to all parties, the hearing may be dropped without prejudice and resumed at a later date. However, if the informal resolution proposed by the department is not acceptable to the recipient, the recipient may proceed with a fair hearing and a new hearing date shall be set promptly.
If before the fair hearing date the concurrent review has not been initiated, the fair hearing shall proceed as scheduled.
(d) Absence of petitioner.
If the recipient does not appear at a scheduled hearing and does not contact the department of administration's division of hearings and appeals with good cause for postponement, the hearing examiner may dismiss the petition.
(6) Coverage while out-of-state.
Medical assistance shall be furnished under any of the following circumstances to recipients who are Wisconsin residents but absent from the state provided that they are within the United States, Canada or Mexico:
When the health of the recipient would be endangered if the care and services were postponed until the recipient returned to Wisconsin;
When the recipient's health would be endangered if the recipient undertook travel to return to Wisconsin; or
When prior authorization has been granted for provision of a non-emergency service, except that prior authorization is not required for non-emergency services provided to Wisconsin recipients by border status providers certified by the Wisconsin MA program.
(7) Free choice of family planning method.
Recipients eligible for family planning services and supplies shall have freedom of choice of family planning method so that a recipient may choose in accordance with the dictates of conscience and shall neither be coerced nor pressured into choosing any particular method of family planning.
(8) Continuation of benefits to community care organization clients.
Recipients who were eligible for or receiving services from any of the local community care organization (CCO) projects in La Crosse county, Barron county, or Milwaukee county, in April 1976, shall be allowed to continue to receive any of the CCO services and these services shall be reimbursed under MA.
(9) Right to information concerning program policy. DHS 104.01(9)(a)(a) Program manuals.
Recipients may examine program manuals and policy issuances which affect the public, including rules and regulations governing eligibility, need and amount of assistance, recipients' rights and responsibilities and services covered under MA, at the department's state or regional offices, or an agency's offices, during regular office hours.
Except when changes in the law require automatic grant adjustments for classes of recipients, in every instance in which the department intends to discontinue, terminate, suspend or reduce a recipient's eligibility for MA or coverage of services to a general class of recipients, the department shall send a written notice to the recipient's last known address at least by the minimum time period required under 42 USC 601-613
and before the date upon which the action would become effective, informing the recipient of the following:
The circumstances under which assistance will be continued if a hearing is requested.
The department shall mail the individual written notice to be received no later than the date of intended action under any of the following circumstances:
The department receives a clear written statement signed by a recipient that states the recipient no longer wishes assistance, or that gives information which requires termination or reduction of assistance, and the recipient has indicated, in writing, that the recipient understands that the consequence of supplying the information will be termination or reduction of assistance;
The recipient has been admitted or committed to an institution and further payments to the recipient do not qualify for federal financial participation under the state plan for MA;
The recipient has been placed in skilled nursing care, intermediate care or long-term hospitalization;
The recipient's whereabouts are unknown and departmental mail directed to the recipient has been returned by the post office indicating no known forwarding address;
A recipient has been accepted for assistance in a new jurisdiction and that fact has been established by the jurisdiction previously providing assistance;
An AFDC child is removed from the home as a result of judicial determination or voluntarily placed in foster care by a legal guardian;
A change in level of medical care is prescribed by the recipient's physician;
The recipient has received service during a period of ineligibility and the department is preparing to take recovery action, pursuant to s. DHS 108.03 (3)
(10) Right to prompt decisions and assistance.
Applicants have the right to prompt decisions on their applications. Eligibility decisions shall be made within 30 days of the date the application was signed. For individuals applying as disabled, where medical examination reports, determination of disability, and other additional medical and administrative information is necessary for the decision, eligibility decisions shall be made not more than 60 days after the date the application was signed. Health care shall be furnished promptly to eligible recipients without any delay attributable to the department's administrative process and shall be continued as needed until the individual is found ineligible.
(11) Right to request return of payments made for covered services during period of retroactive eligibility.
If a person has paid all or part of the cost of health care services received and then becomes a recipient of MA benefits with retroactive eligibility for those covered services for which the recipient has previously made payment, then the recipient has the right to notify the certified provider of the retroactive eligibility period. At that time the certified provider shall submit claims to MA for covered services provided to the recipient during the retroactive period. Upon the provider's receipt of the MA payment, the provider shall reimburse the recipient for the lesser of the amount received from MA or the amount paid by recipient or other person, minus any relevant copayment. In no case may the department reimburse the recipient directly.
Recipients of MA are liable for payment of any copayment or deductible amount established by the department pursuant to s. 49.45 (18)
, Stats., for the cost of a service, except as provided in this subsection. The recipient shall pay the copayment or deductible to the provider of service. Copayments or deductibles are not required:
From recipients who are members of a health maintenance organization or other prepaid plan for those services provided by the HMO or PHP;
For services furnished to pregnant women if the services relate to the pregnancy, or to any medical condition which may complicate the pregnancy when it can be determined from the claim submitted that the recipient was pregnant;
For emergency hospital and ambulance services and emergency services related to the relief of dental pain;
For transportation services provided through or paid for by a county social services department;
For home health services or for home nursing services if a home health agency is not available;
For outpatient psychotherapy services received over 15 hours or $500, whichever comes first, during one calendar year;
For occupational, physical or speech therapy services received exceeding 30 hours or $1,500 for any one therapy, whichever occurs first, during one calendar year;
If the recipient uses one pharmacy or pharmacist as his or her sole provider of prescription drugs, the monthly amount of copayment a recipient is required to pay may not exceed $5.
(b) Freedom from having to pay for services covered by MA.
Recipients may not be held liable by certified providers for covered services and items furnished under the MA program, except for copayments or deductibles under par. (a)
, if the patient identifies himself or herself as an MA recipient and shows the provider the MA identification card.
DHS 104.01 Note
Note: Recipients seeking nonemergency services from noncertified providers are liable for all charges, unless the services were authorized by the department prior to service delivery.
(c) Prior authorization of services.
When a service must be authorized by the department in order to be covered, the recipient may not be held liable by the certified provider unless the prior authorization was denied by the department and the recipient was informed of the recipient's personal liability before provision of the service. In that case the recipient may request a fair hearing. Negligence on the part of the certified provider in the prior authorization process shall not result in recipient liability.