SS 062-20

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2019 Wisconsin Act 9 Sections 448, 477, and 478

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DHS 10

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DHS 73

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DHS 90

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DHS 104

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DHS 105

6.

Estimates of the amount of time that state employees will spend to develop the rule and other necessary resources

The estimated time for state employees to develop the rule is 2,080 hours.

7.

Description of all of the entities that may be affected by the rule, including any local governmental units, businesses, economic sectors, or public utility ratepayers who may reasonably be anticipated to be affected by the rule

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Members receiving certain community-based Medical Assistance programs and services

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Providers providing certain community-based Medical Assistance programs and services

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Medical Assistance managed care organizations

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Medical Assistance managed care organization external quality review organization

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Aging and disability resource centers and related governing boards

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Department of Administration, Division of Hearings and Appeals

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Disability Rights Wisconsin, Family Care and IRIS Ombudsman Program

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Board on Aging and Long Term Care, Ombudsman Program

8.

Summary and preliminary comparison of any existing or proposed federal regulation that is intended to address the activities to be regulated by the rule

42 CFR Part 431 Subpart E sets forth federal regulation of fair hearing for Medical Assistance applicants and recipients. Under 42 CFR § 431.200, states must “provide an opportunity for a fair hearing to any person whose claim for assistance is denied or not acted upon promptly.” Under 42 CFR § 431.205(d), the hearing system must meet established due process standards. Additionally 42 CFR § 431.242(f) establishes the rights of applicants and recipients to request an expedited fair hearing. 42 CFR § 431.244(f) establishes a timeline for hearing stating that states must “ordinarily” take “final administrative action” within 90 days of a request for a fair hearing and identifies exceptions to this timeline.

42 CFR Part 438 Subpart F sets forth federal regulation of the appeal and grievance system for Medical Assistance managed care plans. 42 CFR § 438.400 defines adverse benefit determinations and grievances. Under 42 CFR § 438.408(f)(1), a member “may request a State fair hearing only after receiving notice under § 438.408 that the adverse benefit determination is upheld” or when the managed care organization “fails to adhere to the notice and timing requirements in § 438.408” in which case the member “is deemed to have exhausted the [managed care organization’s] appeals process.” Under 42 CFR § 438.408, a member “must request a State fair hearing no later than 120 calendar days from the of the [managed care organization’s] notice of resolution.”

9.

Anticipated economic impact, locally or statewide

The Department anticipates the proposed rule may have a moderate economic impact.

10.

Agency contacts

Laura Brauer

Division of Medicaid Services

608.266.5368

[e-mail]