DHS 10.46(4)(d) (d) Maintenance of family involvement.
DHS 10.46(4)(e) (e) Satisfactory community contact.
DHS 10.46(4)(f) (f) Access to transportation.
DHS 10.46(4)(g) (g) Choice of living arrangement.
DHS 10.46(5) (5) Cost- effectiveness. The department shall measure:
DHS 10.46(5)(a) (a) CMO cost-effectiveness in meeting member needs within available resources.
DHS 10.46(5)(b) (b) CMO financial condition.
DHS 10.46(6) (6) Cost of services. The department shall measure the cost of all department-funded health care services received by CMO enrollees.
DHS 10.46 History History: Cr. Register, October, 2000, No. 538, eff. 11-1-00; CR 04-040: am. (3) (f) Register November 2004 No. 587, eff. 12-1-04.
subch. V of ch. DHS 10 Subchapter V — Protection of Applicant, Eligible Person and Enrollee Rights
DHS 10.51 DHS 10.51 Client rights. Clients shall have the rights in family care that are outlined in the applicant information materials they receive when contacting a resource center and in the member handbook they receive prior to enrollment in a care management organization. The department shall review and approve the statement of client rights and responsibilities in each resource center's applicant information materials and in each CMO's member handbook. Client rights shall, at a minimum, include an explanation of client rights in the following areas:
DHS 10.51(1) (1) Rights of clients. Clients have the right to all of the following:
DHS 10.51(1)(a) (a) Freedom from unlawful discrimination in applying for or receiving the family care benefit.
DHS 10.51(1)(b) (b) Accuracy and confidentiality of client information.
DHS 10.51(1)(c) (c) Prompt eligibility, entitlement and cost-sharing decisions and assistance.
DHS 10.51(1)(d) (d) Access to personal, program and service system information.
DHS 10.51(1)(e) (e) Choice to enroll in a CMO, if eligible, and to disenroll at any time.
DHS 10.51(1)(f) (f) Information about and access to all services of resource centers and CMOs within standards established under this chapter to the extent that the client is eligible for such services.
DHS 10.51(1)(g) (g) Support for all clients in understanding their rights and responsibilities related to family care, including due process procedures, and in providing their comments about resource centers, CMOs and services, including through grievances, appeals and requests for department review and fair hearings. Resource centers, CMOs and county agencies under contract with the department shall assist clients to identify all rights to which they are entitled and, if multiple grievance, review or fair hearing mechanisms are available, which mechanism will best meet client needs.
DHS 10.51(1)(h) (h) Support for all clients in the exercise of any rights and available grievance and appeal procedures beyond those specified in this chapter.
DHS 10.51 Note Note: Examples of other rights and procedures available to clients include those afforded to persons who receive treatment or services for developmental disability, mental illness or substance abuse under ch. 51, Stats. and ch. DHS 94, and those afforded to persons who reside in a nursing home, community-based residential facility, adult family home or residential care apartment complex, or who receive services from a home health agency under statutes and rules of those programs.
DHS 10.51(2) (2) Rights of enrollees. Enrollees have the right to all of the following:
DHS 10.51(2)(a) (a) Support from the CMO in all of the following:
DHS 10.51(2)(a)1. 1. Self-identifying long-term care needs and appropriate family care outcomes.
DHS 10.51(2)(a)2. 2. Securing information regarding all services and supports potentially available to the enrollee through the family care benefit.
DHS 10.51(2)(a)3. 3. Actively participating in planning individualized services and making reasonable service and provider choices for achieving identified outcomes.
DHS 10.51(2)(b) (b) Receipt of services identified in the individualized service plan.
DHS 10.51(3) (3) Application of other rules and regulations. Nothing in this chapter shall limit or adversely affect the rights afforded to clients in accordance with other state or federal laws or regulations. To the extent that provisions in this chapter differ from provisions affording a client rights under other state or federal laws or regulations, the provision that does most to promote the rights of the client shall be controlling.
DHS 10.51 History History: Cr. Register, October, 2000, No. 538, eff. 11-1-00; CR 04-040: am. (1) (g) and (2) (b), cr. (1) (h) and (3), Register November 2004 No. 587, eff. 12-1-04.
DHS 10.52 DHS 10.52 Required notifications.
DHS 10.52(1)(1)Notification of general client rights and responsibilities. Each resource center, county agency and CMO shall provide clients written notification of their rights and responsibilities in accordance with timelines and other requirements established in its contract with the department in every instance in which:
DHS 10.52(1)(a) (a) The client applies for the family care benefit and is initially counseled by a resource center about the family care benefit or enrollment in a specific care management organization.
DHS 10.52(1)(b) (b) The client enrolls in a care management organization.
DHS 10.52(2) (2) Notification of eligibility or entitlement. Every applicant for the family care benefit shall be notified in writing of decisions regarding eligibility, entitlement and cost sharing requirements as required under s. DHS 10.31 (6) (b).
DHS 10.52(3) (3) Notification of intended action. Clients shall be given written notice of any intended adverse action at least 10 days prior to the date of the intended action.
DHS 10.52(3)(a) (a) Notification shall be provided as follows:
DHS 10.52(3)(a)1. 1. By the county agency in every instance in which a client's eligibility or entitlement for family care will be discontinued, terminated, suspended or reduced, or in which the client's maximum cost sharing requirement will be increased.
DHS 10.52(3)(a)2. 2. By the CMO in every instance in which the CMO intends to reduce or terminate a service or deny payment for a service.
DHS 10.52(3)(b) (b) The notification of intended action shall include an explanation of all the following, as applicable:
DHS 10.52(3)(b)1. 1. The action the county agency, resource center or CMO intends to take, including how the action will affect any service that the client currently receives.
DHS 10.52(3)(b)2. 2. The reasons for the intended action.
DHS 10.52(3)(b)3. 3. Any laws that support the action.
DHS 10.52(3)(b)4. 4. The client's right to file a grievance or appeal with the resource center, county agency or CMO, to request a department review and to request a fair hearing.
DHS 10.52(3)(b)5. 5. How to file a grievance, or request a department review or a fair hearing.
DHS 10.52(3)(b)5m. 5m. The circumstances under which expedited resolution of a grievance or appeal is available and how to request it.
DHS 10.52(3)(b)6. 6. That if the client files a grievance, he or she has a right to appear in person before the county agency, the resource center or CMO personnel assigned to resolve the grievance.
DHS 10.52(3)(b)7. 7. The circumstances under which an enrollee's current services provided through the family care benefit will be continued under s. DHS 10.56 pending the outcome of a grievance, department review or fair hearing.
DHS 10.52(3)(b)8. 8. The availability of independent advocacy services and other local organizations that might assist a client in a grievance, department review or fair hearing.
DHS 10.52(3)(b)9. 9. That the enrollee may obtain, free of charge, copies of client records relevant to the grievance, department review or fair hearing, and how to obtain the copies.
DHS 10.52(4) (4) Notification of due process and fair hearing rights. Clients shall be provided timely and adequate written notification of client rights, including the right to a fair hearing in accordance with s. DHS 10.55, an offer of assistance in preparing a written grievance or fair hearing request and information about the availability of advocacy services to assist the client. Resource centers, county agencies and care management organizations shall provide written notification of due process rights, within timelines established in department contracts, in each instance in which:
DHS 10.52(4)(a) (a) A county agency makes a determination or redetermination of eligibility for the family care benefit that results in more limited eligibility or entitlement or increased cost sharing for the client.
DHS 10.52(4)(b) (b) A CMO requests or the department approves involuntary disenrollment of an enrollee.
DHS 10.52(4)(c) (c) A CMO reduces or discontinues a service or item received by an enrollee without the enrollee's consent.
DHS 10.52(4)(d) (d) A CMO denies a service or item requested by an enrollee.
DHS 10.52(4)(e) (e) The client registers any grievance or appeal with the department, resource center, county agency, CMO or any contracted service provider.
DHS 10.52 History History: Cr. Register, October, 2000, No. 538, eff. 11-1-00; CR 04-040: am. (3) (b) 4. and (4) (a) and (e), cr. (3) (b) 5m. Register November 2004 No. 587, eff. 12-1-04.
DHS 10.53 DHS 10.53 Grievances.
DHS 10.53(1)(1)Grievance process in resource centers.
DHS 10.53(1)(a) (a) The governing board of each resource center shall approve and effectively operate a process for reviewing and resolving client grievances and appeals. The board may delegate, in writing, its responsibility for review of appeals and resolution of grievances to a committee of the resource center's senior management, provided the process ensures that the board is made aware of grievances and requests for department review and fair hearings.
DHS 10.53(1)(b) (b) The department shall review and approve a resource center's grievance and appeal process as part of its contracting with the resource center.
DHS 10.53(1)(c) (c) A resource center shall assist individuals to file and resolve grievances or appeals, including assistance with committing an oral grievance or appeal to writing.
DHS 10.53(2) (2) Grievance process in care management organizations.
DHS 10.53(2)(a)(a) The governing board of each CMO shall approve and shall effectively operate a process for reviewing and resolving client grievances and appeals. The board may delegate, in writing, its responsibility for review of complaints and resolution of grievances to a committee of the CMO's senior management, provided that the board is made aware of grievances and requests for department review and fair hearings.
DHS 10.53(2)(b) (b) The department shall review and approve a resource center's grievance and appeal process as part of its contracting with the CMO.
DHS 10.53(2)(c) (c) A CMO shall individuals to file and resolve grievances or appeals, including assistance with committing an oral grievance or appeal to writing.
DHS 10.53 History History: Cr. Register, October, 2000, No. 538, eff. 11-1-00; CR 04-040: am. (1) (a) to (c) and (2) (a) to (c) Register November 2004 No. 587, eff. 12-1-04.
DHS 10.54 DHS 10.54 Department reviews.
DHS 10.54(1)(1)General review process. The department shall establish a process for the timely review, investigation and analysis of the facts surrounding client grievances or appeals in an attempt to resolve concerns and problems informally, whenever either of the following occurs:
DHS 10.54(1)(a) (a) A client makes a grievance or appeal directly to the department.
DHS 10.54(1)(b) (b) A client requests department review of a decision arrived at through a county agency, resource center or care management organization grievance process.
DHS 10.54(2) (2) Timeliness of reviews. The department shall complete its review under sub. (1) within 20 days of receiving a request for review from a client, unless the client and the department agree to an extension for a specified period of time.
DHS 10.54(3) (3) Concurrent review process. Whenever the department receives notice from the department of administration's division of hearings and appeals that it has received a fair hearing request under s. DHS 10.55 (1) (d) to (g), the department shall use the process in sub. (1) to conduct a concurrent review in accordance with s. DHS 10.55 (4).
DHS 10.54 History History: Cr. Register, October, 2000, No. 538, eff. 11-1-00; CR 04-040: am. (1) (intro.) (a) and (3) Register November 2004 No. 587, eff. 12-1-04.
DHS 10.55 DHS 10.55 Fair hearing.
DHS 10.55(1)(1)Right to fair hearing. Except as limited in subs. (1m), (2) and (3) and s. DHS 10.62 (4), a client has a right to a fair hearing under s. 46.287, Stats. The contested matter may be a decision or action by the department, a resource center, county agency or CMO, or the failure of the department, a resource center, county agency or CMO to act on the contested matter within timeframes specified in this chapter or in the contract with the department. The following matters may be contested through a fair hearing:
DHS 10.55(1)(a) (a) Denial of eligibility under s. DHS 10.31 (6) or 10.32 (4).
DHS 10.55(1)(b) (b) Determination of cost sharing requirements under s. DHS 10.34.
DHS 10.55(1)(c) (c) Determination of entitlement under s. DHS 10.36.
DHS 10.55(1)(d) (d) Failure of a CMO to provide timely services and support items that are included in the plan of care.
DHS 10.55(1)(e) (e) Reduction of services or support items in the enrollee's individualized service plan, except in accordance with a change agreed to by the enrollee.
DHS 10.55(1)(f) (f) An individualized service plan that is unacceptable to the enrollee because any of the following apply:
DHS 10.55(1)(f)1. 1. The plan is contrary to an enrollee's wishes insofar as it requires the enrollee to live in a place that is unacceptable to the enrollee.
DHS 10.55(1)(f)2. 2. The plan does not provide sufficient care, treatment or support to meet the enrollee's needs and identified family care outcomes.
DHS 10.55(1)(f)3. 3. The plan requires the enrollee to accept care, treatment or support items that are unnecessarily restrictive or unwanted by the enrollee.
DHS 10.55 Note Note: The rights guaranteed to persons receiving treatment or services for developmental disability, mental illness or substance abuse under ch. 51, Stats., and ch. DHS 94 are also guaranteed under par. (f), and enrollees may request a fair hearing related to such matters in accordance with this section and ch. HA 3, or may choose the grievance resolution procedure under Subchapter III of ch. DHS 94 to grieve a violation of those rights, and if necessary may choose to appeal a provider or CMO grievance decision to the department of health services as specified in ss. DHS 94.42 and 94.44.
DHS 10.55(1)(g) (g) Termination of the family care benefit or involuntary disenrollment from a CMO.
DHS 10.55(1)(h) (h) Determinations of protection of income and resources of a couple for maintenance of a community spouse under s. DHS 10.35 to the extent a hearing would be available under s. 49.455 (8) (a), Stats.
DHS 10.55(1)(i) (i) Recovery of incorrectly paid family care benefit payments as provided under s. DHS 108.03 (3).
DHS 10.55(1)(j) (j) Hardship waivers, as provided in s. DHS 108.02 (12) (e), and placement of liens as provided in ch. HA 3.
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Published under s. 35.93, Stats. Updated on the first day of each month. Entire code is always current. The Register date on each page is the date the chapter was last published.