DHS 10.54(3) (3) Department review process for fair hearings. 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 (3), the department shall conduct an informal 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; CR 22-026: am. (1), (2) (title), cr. (2e) to (2v), am. (3) Register May 2023 No. 809, eff. 6-1-23.

DHS 10.55 DHS 10.55 Fair hearing.

DHS 10.55(1) (1) Right to fair hearing in resource center and county agency adverse benefit determinations. Except as limited in sub. (3) and s. DHS 10.62 (4), a client may contest any of the following adverse benefit determinations by filing, within 45 days of receipt of notice of the adverse benefit determination, a written request for a hearing to the division of hearings and appeals:

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(1g) (1g) Right to a fair hearing. Except as limited in subs. (1m), (2) and (3), an enrollee may contest any of the following adverse benefit determinations by filing, within 90 days of the failure of a care management organization to act on a contested adverse benefit determination within the time frame specified under s. DHS 10.53 (2) (e) or within 90 days after receipt of notice of a decision upholding the adverse benefit determination, a written request for a hearing to the division of hearings and appeals:

DHS 10.55(1g)(a) (a) Denial of functional eligibility under s. DHS 10.33 as a result of the care management organization’s administration of the long-term care functional screen, including a change from a nursing home level of care to a non-nursing home level of care.

DHS 10.55(1g)(b) (b) Failure of a CMO to provide timely services and support items that are included in the plan of care.

DHS 10.55(1g)(c) (c) Denial or limited authorization of a requested service, including determinations based on type or level of service, requirements or medical necessity, appropriateness, setting, or effectiveness of a covered benefit.

DHS 10.55(1g)(d) (d) Reduction, suspension or termination of services to support items in the enrollee’s service plan, except when either of the following apply:

DHS 10.55(1g)(d)1. 1. The reduction, suspension or termination was agreed to by the enrollee.

DHS 10.55(1g)(d)2. 2. The reduced, suspended or terminated service or support was only authorized for a limited amount or duration and that amount or duration has been completed.

DHS 10.55(1g)(e) (e) Denial, in whole or in part, of payment for a service.

DHS 10.55(1g)(f) (f) Failure of a CMO to act within the timeframes provided in 42 CFR 438.408(b)(1) and (2) regarding the standard resolution of grievances and appeals.

DHS 10.55(1g)(g) (g) Denial of an enrollee’s request to dispute financial liability, including copayments, premiums, deductibles, coinsurance, other cost sharing, and other enrollee financial liabilities.

DHS 10.55(1g)(h) (h) Denial of an enrollee, who is a resident of a rural area with only one CMO, to obtain services outside the CMO’s network of contracted providers.

DHS 10.55(1g)(i) (i) An individualized service plan that is unacceptable to the enrollee because any of the following apply:

DHS 10.55(1g)(i)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(1g)(i)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(1g)(i)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(1g)(j) (j) Termination of the family care benefit.

DHS 10.55(1g)(k) (k) 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(1g)(L) (L) Recovery of incorrectly paid family care benefit payments as provided under s. DHS 108.03 (3).

DHS 10.55(1g)(m) (m) Hardship waivers, as provided in s. DHS 108.02 (12) (e), and placement of liens as provided in ch. HA 3.

DHS 10.55(1g)(n) (n) 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. (1g), 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 they fall within the category of enrollees to be affected by the change.