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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
DHS 10.13 Definitions
DHS 10.21 Contracting
DHS 10.23 Standards for performance by resource centers
DHS 10.31 Application and eligibility determination
DHS 10.42 Certification and contracting
DHS 10.52 Required notifications
DHS 10.53 Grievances
DHS 10.54 Department reviews
DHS 10.55 Fair hearing
DHS 10.56 Continuation of services
DHS 73.01 Authority and purpose
DHS 73.02 Applicability
DHS 73.03 Definitions
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 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
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Links to Admin. Code and Statutes in this Register are to current versions, which may not be the version that was referred to in the original published document.