DHS 10.56 Continuation of services
DHS 73.01 Authority and purpose
DHS 73.02 Applicability
DHS 73.05 Reimbursement for community options program case plans
DHS 73.10 Individual hardship exceptions to limits on funding for CBRF care
DHS 90.06 County administrative agency designation and responsibilities
DHS 104.01 Recipient rights
DHS 105.17 Personal care rights3.
Policies proposed to be included in the rule2019 Wisconsin Act 9 made changes which require the Department to bring associated rules into compliance, including:
modifying the availability and timing of the fair hearing process for certain community-based Medical Assistance programs and services;
defining managed care organization decisions, omissions, or actions;
requiring members to first file grievances with managed care organizations, and limiting members’ ability to contest managed care organizations’ grievance decisions with the Department;
removing the Community Options Program as a Medical Assistance program;
eliminating regional long-term care advisory committees;
requiring each aging and disability resource center governing board to review the number and types of grievances and appeals related to the aging and disability resource center; and
modifying aging and disability resource center provisions to reflect availability statewide.4.
Analysis of policy alternativeThere are no reasonable alternatives to the proposed rulemaking. The rules must be altered and expanded to bring current rules into compliance with the Act.
5.
Statutory authority for the rulea.
Explanation of authority to promulgate the proposed ruleThe Department’s authority to promulgate the proposed rules is provided in s.46.03 (25), s. 46.288 (3), and 49.45 (10), Stats. b.
Statute/s that authorize/s the promulgation of the proposed ruleUNIFORM REGULATION AND LICENSING. The department shall promulgate rules to establish licensing and program compliance standards for care and residential facilities, hospitals, hotels, restaurants and the vending of food and beverages after due consideration of the relationship of a licensing code to other related licensing codes, the need for uniform administration, the need to maximize the use of federal funds and the need to encourage the development and operation of needed facilities statewide. In establishing licensing standards designed to ensure that the facility qualifies for federal financial participation, the department shall establish federal regulations as the base requirement. The department may promulgate such additional health and safety standards as it determines to be in the public interest.
Rule−making. The department shall promulgate as rules all of the following:
Procedures and standards for procedures for s. 46.287 (2), including time frames for action by a resource center or a care management organization on a contested matter. RULE−MAKING POWERS AND DUTIES. The department is authorized to promulgate such rules as are consistent with its duties in administering medical assistance. The department shall promulgate a rule defining the term “part−time intermittent care” for the purpose of s. 49.46. c.
Statute/s or rule/s that will affect the proposed rule or be affected by it
Section 46.27, 2017 Stats.6.
Estimates of the amount of time that state employees will spend to develop the rule and other necessary resourcesThe 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
Members receiving certain community-based Medical Assistance programs and services
Providers providing certain community-based Medical Assistance programs and services
Medical Assistance managed care organizations
Medical Assistance managed care organization external quality review organization
Aging and disability resource centers and related governing boards
Department of Administration, Division of Hearings and Appeals
Disability Rights Wisconsin, Family Care and IRIS Ombudsman Program
Board on Aging and Long Term Care, Ombudsman Program8.
Summary and preliminary comparison of any existing or proposed federal regulation that is intended to address the activities to be regulated by the rule42 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.”
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