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.
DHS 10.55(1)(k) (k) Determination of temporary ineligibility for the family care benefit resulting from divestment of assets under s. DHS 10.32 (1) (i).
DHS 10.55(1m) (1m) Exception to right to fair hearing. An enrollee does not have a right to a fair hearing under sub. (1), if the sole issue is a federal or state law requiring an automatic change adversely affecting some or all enrollees and the enrollee does not dispute that he or she falls within the category of enrollees to be affected by the change.
DHS 10.55(2) (2) Limited right to fair hearing. An enrollee may contest, through fair hearing, any decision, omission or action of a CMO other than those specified under sub. (1) (d) to (f) only if a CMO grievance decision under s. DHS 10.53 (2) (a) or a CMO grievance decision under s. DHS 10.53 (2) (a) or a department review under s. DHS 10.54 has failed to resolve the matter to the satisfaction of the enrollee within the time period approved by the department in s. DHS 10.53 (2) (b) or specified under s. DHS 10.54 (2).
DHS 10.55(3) (3) Requesting a fair hearing. A client shall request a fair hearing within 45 days after receipt of notice of a decision in a contested matter, or after a resource center or CMO has failed to respond within timeframes specified by this chapter or the department. Receipt of notice is presumed within 5 days of the date the notice was mailed. A client shall file his or her request for a fair hearing in writing with the division of hearings and appeals in the department of administration. A hearing request shall be considered filed on the date of actual receipt by the division of hearings and appeals, or the date of the postmark, whichever is earlier. A request filed by facsimile is complete upon transmission. If the request is filed by facsimile transmission and such transmission is completed between 5 p.m. and midnight, one day shall be added to the prescribed period. If a client asks the department, a county agency, a resource center or CMO for assistance in writing a fair hearing request, the department, resource center or CMO shall provide that assistance.
DHS 10.55 Note Note: A hearing request can be submitted by mail or hand-delivered to the Division of Hearings and Appeals, at 505 University Ave., Room 201, Madison, WI 53705-5400, or faxed to the Division at (608) 264-9885. The Division's telephone number is (608) 266-3096.
DHS 10.55(4) (4) Department concurrent review of fair hearing requests.
DHS 10.55(4)(a)(a) When the division of hearings and appeals receives a request for a fair hearing under this chapter, it shall set the date for the hearing in accordance with ch. HA 3 and notify the department that it has received the request.
DHS 10.55(4)(b) (b) When a client has requested a fair hearing under sub. (1) (d) to (g), the department shall concurrently review and investigate the facts surrounding the client's request using the process established under s. DHS 10.54 in an attempt to resolve the problem informally.
DHS 10.55(5) (5) Fair hearing procedures.
DHS 10.55(5)(a)(a) The division of hearings and appeals shall conduct a fair hearing pursuant to this section in accordance with ch. HA 3, in response to each fair hearing requested unless, prior to the scheduled hearing date, any of the following occurs:
DHS 10.55(5)(a)1. 1. The client withdraws the request in writing.
DHS 10.55(5)(a)2. 2. The contested matter is resolved under sub. (4).
DHS 10.55(5)(a)3. 3. In the case of an enrollee grievance against a CMO, the person voluntarily disenrolls from the CMO.
DHS 10.55(5)(a)4. 4. The petitioner has abandoned the hearing request. The division of hearings and appeals shall determine that abandonment has occurred when the petitioner, without good cause, fails to appear personally or by representative at the time and place set for the hearing. Abandonment may also be deemed to have occurred when the petitioner or the authorized representative fails to respond within a reasonable time to correspondence from the division regarding the hearing.
DHS 10.55(5)(a)5. 5. An informal resolution is proposed that is acceptable to the client, and the client agrees, in writing, to the resolution or withdraws the request for fair hearing.
DHS 10.55(5)(a)6. 6. An informal resolution acceptable to the client appears imminent to all parties, and the client requests rescheduling of the fair hearing. If the informal resolution that was anticipated is, in fact, not acceptable to the client, a new hearing date shall be set promptly.
DHS 10.55(5)(b) (b) In accordance with ch. HA 3, the division of hearings and appeals:
DHS 10.55(5)(b)1. 1. Shall consider and apply all standards and requirements of this chapter.
DHS 10.55(5)(b)2. 2. Shall issue a decision within 90 days of the date of receipt of the request for fair hearing.
DHS 10.55(5)(b)3. 3. May dismiss the petition if the client does not appear at a scheduled hearing and does not contact the division of hearings and appeals with good cause for postponement.
DHS 10.55(5)(c) (c) An applicant for or recipient of medical assistance is not entitled to a hearing concerning the identical dispute or matter under both this section and 42 CFR 431.200 to 431.246.
DHS 10.55 History History: Cr. Register, October, 2000, No. 538, eff. 11-1-00; CR 04-040: am. (1) (a), (2), and (4) (b) Register November 2004 No. 587, eff. 12-1-04; corrections in (1) (i) and (j) made under s. 13.92 (4) (b) 7., Stats., Register November 2008 No. 635; CR 09-003: am. (1), cr. (1m) Register November 2009 No. 647, eff. 12-1-09.
DHS 10.56 DHS 10.56 Continuation of services.
DHS 10.56(1)(1)Request for continuation of services. Prior to reducing or terminating services under the family care benefit, a CMO shall provide to the enrollee prior notification of its intent to reduce or terminate the services in accordance with s. DHS 10.52 (3). If an enrollee who has received a notice that services will be reduced or terminated files a grievance under s. DHS 10.53 (2), or requests a department review under s. DHS 10.54 or a fair hearing under s. DHS 10.55 related to the reduction or termination of services and before the effective date of the reduction or termination, the enrollee may request that the CMO continue to provide the services pending the outcome of the grievance, department review or fair hearing.
DHS 10.56(2) (2) Requirement for continuation. Except as provided in sub. (2m), a CMO may not reduce or terminate services under dispute pending the outcome of the enrollee's grievance under s. DHS 10.53 (2), department review under s. DHS 10.54 or fair hearing under s. DHS 10.55 if a request for continued benefits was made under sub. (1).
DHS 10.56(2m) (2m) Exemption from right to continuation. If the sole issue is a federal or state law requiring an automatic change adversely affecting some or all enrollees and the enrollee does not dispute that he or she falls within the category of enrollees to be affected by the change, the enrollee does not have the right to continuation of services pending the outcome of the enrollee's grievance under s. DHS 10.53 (2), department review under s. DHS 10.54, or fair hearing under s. DHS 10.55. A CMO will not receive a monthly capitated payment for such an individual and is not required to continue services in such circumstances.
DHS 10.56(3) (3) Liability for continuation of services. The enrollee shall be liable for the cost of services provided during the period in which services have been continued under this section if the outcome of the grievance, department review or fair hearing is unfavorable to the enrollee. The CMO shall notify in writing an enrollee who requests continuation of services under this section of the potential for liability under this subsection and the time period during which the enrollee will be liable. If the department or its designee determines that the person would incur a significant and substantial financial hardship as a result of repaying the cost of the services provided, the department may waive or reduce the enrollee's liability under this subsection.
DHS 10.56 History History: Cr. Register, October, 2000, No. 538, eff. 11-1-00; CR 09-003: am. (2), cr. (2m) Register November 2009 No. 647, eff. 12-1-09.
DHS 10.57 DHS 10.57 Cooperation with advocates.
DHS 10.57(1)(1)Definitions. In this section:
DHS 10.57(1)(a) (a) “Advocate" means an individual or organization whom a client has chosen to assist him or her in articulating the client's preferences, needs and decisions.
DHS 10.57(1)(b) (b) “Cooperate" means:
DHS 10.57(1)(b)1. 1. To provide any information related to the client's eligibility, entitlement, cost sharing, care planning, care management, services or service providers to the extent that the information is pertinent to matters in which the client has requested the advocate's assistance.
DHS 10.57(1)(b)2. 2. To assure that a client who requests assistance from an advocate is not subject to any form of retribution for doing so.
DHS 10.57(2) (2) Cooperation with advocates. The department and each resource center and CMO shall cooperate with any advocate selected by a client. Nothing in this section allows the unauthorized release of client information or abridges a client's right to confidentiality.
DHS 10.57 History History: Cr. Register, October, 2000, No. 538, eff. 11-1-00.
subch. VI of ch. DHS 10 Subchapter VI — Recovery of Paid Benefits
DHS 10.61 DHS 10.61 Recovery of incorrectly paid benefits. County agencies, on behalf of the department, shall recover benefits incorrectly paid under the family care benefit, whether paid on behalf of individuals eligible for medical assistance or not, according to provisions of s. 49.497, Stats., s. DHS 108.03 (3) and policies established by the department or by the department of workforce development. The amount to be recovered is the amount actually paid by a CMO on behalf of a family care enrollee.
DHS 10.61 History History: Cr. Register, October, 2000, No. 538, eff. 11-1-00; correction made under s. 13.92 (4) (b) 7., Stats., Register November 2008 No. 635.
DHS 10.62 DHS 10.62 Recovery of correctly paid benefits.
DHS 10.62(1)(1)Recovery from the estate of an enrollee. The department shall file a claim against the estate of an enrollee to recover for the costs of the family care benefits provided under s. 46.286, Stats., on and after January 1, 2000. Recoveries from the estates of all family care enrollees shall be made in accordance with the provisions in ss. 49.496 (1), (3), (6m), and (7), and 49.849, Stats., and s. DHS 108.02 (11) and (12), except as follows:
DHS 10.62(1)(a) (a) The amount to be recovered under this section shall be the actual cost of services received by an enrollee through the family care benefit as reported to the department by the CMO in which the person was enrolled.
DHS 10.62(1)(b) (b) Recovery under this section from the estate of an enrollee who was not found eligible under s. 46.286 (1) (b) 2m. a., Stats., and who did not receive services that are recoverable under s. 46.27 (7g), 49.496 (3) or 49.682, Stats., shall be treated as follows:
DHS 10.62(1)(b)1. 1. Except as provided in subd. 2., an amount of the liquid assets owned by the enrollee on the date of death, equal to the amount of countable assets that were disregarded under s. DHS 10.34 (3) (b) 2. b. or c. at the enrollee's initial eligibility determination for the family care benefit, shall be unavailable to pay the department's claim to the extent that the amount of liquid assets exceeds the amount of claims paid having a higher priority than the department's claim under s. 859.25, Stats.
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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.