DHS 10.53(2)
(2)
Grievance and appeals 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 enrollee grievances and appeals. The board may delegate, in writing, its responsibility for reviewing and resolving grievances and appeals 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 CMO's grievance and appeal process as part of its contracting with the CMO.
DHS 10.53(2)(br)
(br) The CMO shall complete its review of a grievance and issue its written decision to the enrollee within 90 days of its receipt of the grievance, unless the grievance decision timeframe is extended under the extension requirements specified in the contract with the department.
DHS 10.53(2)(c)
(c) The CMO shall inform enrollees of all of the following:
DHS 10.53(2)(c)1.
1. The circumstances under which expedited resolution of a grievance is available and how to request it.
DHS 10.53(2)(c)2.
2. The enrollee has the right to appear in person before the CMO personnel assigned to resolve a grievance, if the enrollee files the grievance.
DHS 10.53(2)(c)3.
3. The availability of independent advocacy services and other local organizations that might assist an enrollee with a grievance.
DHS 10.53(2)(c)4.
4. The enrollee may obtain, free of charge, copies of enrollee records relevant to the grievance and how to obtain the copies.
DHS 10.53(2)(d)
(d) A CMO shall assist enrollees with filing grievances with the CMO. If an enrollee is dissatisfied with the CMO's grievance decision, or the CMO fails to render a grievance decision within the timeframe specified under par.
(br), a CMO shall assist the individual with requesting a department review of the grievance under s.
DHS 10.54.
DHS 10.53(2)(dm)
(dm) An enrollee must request department review within 45 days of the date on the grievance decision.
DHS 10.53(2)(e)
(e) The CMO shall complete its review of an appeal and issue its written decision to the enrollee within 30 days of its receipt of the appeal, unless the appeal decision timeframe is extended under the extension requirements specified in the contract with the department.
DHS 10.53(2)(f)
(f) A CMO shall assist enrollees with filing appeals with the CMO. If the enrollee is dissatisfied with the CMO's appeal decision, or the CMO fails to render an appeal decision within the timeframe specified under sub.
(2) (e), a CMO shall assist the individual with requesting a fair hearing with the division of hearings and appeals under s.
DHS 10.55.
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;
CR 22-026: am. (title), (1) (a), (b), renum. (1) (c) to (1) (c) (intro.) and am., cr. (1) (c) 1. to 4., (d) to (f), (1m), am. (2) (title), (a), (b), cr. (2) (bg), (br), r. and recr. (2) (c), cr. (2) (d) to (f)
Register May 2023 No. 809, eff. 6-1-23; correction in (2) (d), (f) made under s.
35.17, Stats.,correction in numbering of (2) (dm) made under s.
13.92 (4) (b) 1., Stats., and correction in (2) (f) made under s.
13.92 (4) (b) 7., Stats.,
Register May 2023 No. 809.
DHS 10.54(1)
(1)
Department review process for grievances filed with a resource center. The department shall review, investigate, and analyze the facts surrounding client grievances in an attempt to resolve concerns and problems informally, whenever either of the following occurs:
DHS 10.54(1)(b)
(b) A client requests department review of a decision arrived at through a county agency or resource center grievance process.
DHS 10.54(2)
(2)
Timeliness of review. 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(2e)
(2e)
Department review process for grievances filed with a CMO. The department shall review and resolve enrollee grievances whenever either of the following occurs:
DHS 10.54(2e)(a)
(a) An enrollee requests department review of a decision arrived at through a care management organization grievance process under s.
DHS 10.53 (2).
DHS 10.54(2e)(b)
(b) An enrollee requests department review of a grievance request that the CMO has failed to act on within the timeframe specified under s.
DHS 10.53 (2) (d).
DHS 10.54(2j)
(2j)
Timeframe for requesting department review. An enrollee must file the request for grievance review within 45 days of the receipt of the CMO's written decision regarding the enrollee's grievance or, if the CMO fails to issue a written grievance decision to the enrollee within the timeframe specified under s.
DHS 10.53 (2) (d), within 45 days of the date that timeframe expires.
DHS 10.54(2o)
(2o)
Timeliness of review. The department shall complete its review under sub.
(2e) within 30 days of receiving a request for review from an enrollee, unless the enrollee and the department agree to an extension for a specified period of time.
DHS 10.54(2v)
(2v)
Timeliness of decision. The department shall mail or hand deliver to the enrollee and the CMO a written decision resolving the grievance within 7 days of the completion of the grievance review. This decision is final and binding on both the enrollee and CMO. Department review is the final process in resolving enrollee grievances.
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(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(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)(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)(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(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.
DHS 10.55(2)
(2)
Grievances. An enrollee may contest any decision, omission or action of a CMO other than those specified under sub.
(1g) by filing a grievance with the CMO under s.
DHS 10.53 (2). If the enrollee is not satisfied with the CMO's grievance decision, or if the CMO fails to issue a grievance decision within the timeframes specified under s.
DHS 10.53 (2) (d), the enrollee may request a department review under s.
DHS 10.54.
DHS 10.55(3)
(3)
Requesting a fair hearing. Receipt of notice is presumed within 5 days of the date the notice was mailed. A client shall file their request for a fair hearing in writing within the timeframes specified under subs.
(1) and
(1g) 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 4822 Madison Yards Way, 5
th Floor North, Madison, WI 53705-5400, faxed to the Division at (608) 264-9885, or emailed to the Division at
DHAMail@wisconsin.gov. The Division's telephone number is (608) 266-3096.
DHS 10.55(4)
(4)
Department 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 an enrollee has requested a fair hearing under sub.
(3), the department shall conduct an informal review to identify, and, as appropriate, intervene in, fair hearing requests related to member health and safety, contract non-compliance and complex situations, if it appears to the department that informal resolution of the matter may be appropriate.
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)3.
3. In the case of an enrollee appealing a CMO decision, 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)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;
CR 22-026: am. (1), renum. (1) (d) to (1g) (b), r. (1) (e), renum. (1) (f) to (1g) (i), renum. (1) (g) to (1g) (j) and am., renum. (1) (h) to (k) to (1g) (k) to (n), cr. (1g) (intro.) (a), (c), (d) to (h), am. (1m) to (3), (4) (title), (b), (5) (a) 3.
Register May 2023 No. 809, eff. 6-1-23; correction in (1g) (title) made under s.
13.92 (4) (b) 2., Stats.,
Register May 2023 No. 809.
DHS 10.56
DHS 10.56
Continuation of services. DHS 10.56(1)(1)
Request for continuation of services pending outcome of cmo appeal. Prior to reducing, suspending or terminating services under the family care benefit, a CMO shall provide to the enrollee prior notification of its intent to reduce, suspend 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, suspend or terminated files an appeal with the CMO under s.
DHS 10.53 (2) before the effective date of the reduction, suspension or termination, the enrollee may request that the CMO continue to provide the services pending the outcome of the appeal.
DHS 10.56(1m)
(1m)
Request for continuation of services pending outcome of dha fair hearing. An enrollee is entitled to continuation of services pending the outcome of a fair hearing if all of the following apply:
DHS 10.56(1m)(a)
(a) The CMO's decision on appeal under s.
DHS 10.53 (2) is to proceed with reducing, suspending, or terminating the enrollee's service.
DHS 10.56(1m)(b)
(b) The enrollee's services were continued pending the outcome of the CMO appeal decision.
DHS 10.56(1m)(c)
(c) The enrollee requests a fair hearing on the CMO's appeal decision before the effective date of the CMO's appeal decision.
DHS 10.56(1m)(d)
(d) The enrollee requests continuation of services before the effective date of the CMO's appeal decision.
DHS 10.56(2)
(2)
Requirement for continuation. Except as provided in sub.
(2m), a CMO may not reduce, suspend or terminate services under dispute pending the outcome of the enrollee's appeal under s.
DHS 10.53 (2) or fair hearing under s.
DHS 10.55 if a request for continued benefits was made under sub.
(1) or
(1m).
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 appeal under s.
DHS 10.53 (2) 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 appeal 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;
CR 22-026: am. (1), cr. (1m), am. (2) to (3)
Register May 2023 No. 809, eff. 6-1-23.
DHS 10.57
DHS 10.57
Cooperation with advocates. 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.
