SS 062-20

STATEMENT OF SCOPE

WISCONSIN DEPARTMENT OF HEALTH SERVICES

CHAPTER: DHS 10, 73, 90, 104, and 105

RELATING TO: Long-Term Care Services and Medical Assistance Fair Hearing Process

RULE TYPE: Permanent

SCOPE TYPE: Original

FINDINGS OF EMERGENCY: Not Applicable

SUMMARY

1.

Description of rule objective/s

In 2019 Wisconsin Act 9, the Wisconsin Legislature alters the availability and timing of the fair hearing process for certain community-based Medical Assistance programs and services; modifies the definition of certain managed care organization adverse benefit determinations; defines the process through which a member must contest an managed care organization decision, omission, or action that is not an adverse benefit determination; eliminates the Community Options Program as a Medical Assistance program; eliminates regional long-term care advisory committees; requires 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 removes the requirement that the secretary certify aging and disability resource centers to counties, hospitals, nursing homes, community−based residential facilities, adult family homes, and residential care apartment complexes.

2.

Existing policies relevant to the rule



DHS 10.11 Authority and purpose

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DHS 10.13 Definitions

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DHS 10.21 Contracting

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DHS 10.23 Standards for performance by resource centers

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DHS 10.31 Application and eligibility determination

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DHS 10.42 Certification and contracting

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DHS 10.52 Required notifications

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DHS 10.53 Grievances

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DHS 10.54 Department reviews

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DHS 10.55 Fair hearing

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DHS 10.56 Continuation of services

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DHS 73.01 Authority and purpose

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DHS 73.02 Applicability

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DHS 73.03 Definitions

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DHS 73.05 Reimbursement for community options program case plans

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DHS 73.10 Individual hardship exceptions to limits on funding for CBRF care

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DHS 90.06 County administrative agency designation and responsibilities

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DHS 104.01 Recipient rights

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DHS 105.17 Personal care rights

3.

Policies proposed to be included in the rule

2019 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 alternative

There 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 rule