DHS 10.55 (4). Department concurrent review of fair hearing requests.
DHS 10.55 (4) (b) When a client an enrollee has requested a fair hearing under sub. (1) (d) to (g) (3), the department shall concurrently conduct an informal review and investigate the facts surrounding the client’s request using the process established under s. DHS 10.54 in an attempt to resolve the problem informally 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) 3. In the case of an enrollee grievance against appealing a CMO decision, the person voluntarily disenrolls from the CMO.
SECTION 41. DHS 10.56 (1) to (3) are amended to read:
DHS 10.56 Continuation of services. (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 a grievance an appeal with the CMO under s. DHS 10.53 (2), or requests a department review under s. DHS 10.54 or a fair hearing under s. DHS 10.55 related to the reduction or termination of services and 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 grievance, department review or fair hearing appeal. (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 grievance appeal under s. DHS 10.53 (2), department review under s. DHS 10.54 or fair hearing under s. DHS 10.55 if a request for continued benefits was made under sub. subs. (1) or (1m). (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 grievance appeal under s. DHS 10.53 (2), department review under s. DHS 10.54, 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. (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 grievance, department review 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.
SECTION 42. DHS 10.56 (1m) is created to read:
DHS 10.56 (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:
(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. (b) The enrollee’s services were continued pending the outcome of the CMO appeal decision.
(c) The enrollee requests a fair hearing on the CMO’s appeal decision before the effective date of the CMO’s appeal decision.
(d) The enrollee requests continuation of services before the effective date of the CMO’s appeal decision.
SECTION 43. DHS 10.62 (1) (b) is amended to read:
DHS 10.62 (1) (b) Recovery under this section from the estate of an enrollee who was not found eligible under s. 46.286 (1) (b) 2m. a., Stats., and who did not receive services that are recoverable under s. 46.27 (7g), ss. 49.496 (3) or 49.682, Stats., shall be treated as follows: SECTION 44. DHS 10.71 is repealed.
SECTION 45. DHS 10.73 (1) and (4) (a) 1. are amended to read:
DHS 10.73 (1) Purpose. This section implements ss. 50.034 (5m) to (5p) (5n) and (8), 50.035 (4m) to (4p) (4n) and (11) and 50.04 (2g) to (2i) (2h), Stats., which establish requirements for adult family homes, residential care apartment complexes, community−based residential facilities and nursing homes to provide information to prospective residents and to refer certain prospective or newly admitted residents to a resource center and establish penalties for non−compliance. DHS 10.73 (4) (a) 1. The person is under the age of 17 years and 9 6 months.
SECTION 46. DHS 73 (Title) is amended to read:
DHS 73 Title SELECTED FISCAL MANAGEMENT PROCEDURES AND STANDARDS UNDER THE COMMUNITY OPTIONS PROGRAM AND MEDICAL ASSISTANCE HOME AND COMMUNITY−BASED SERVICES WAIVER
SECTION 47. DHS 73.01 is amended to read:
DHS 73.01 Authority and purpose. This chapter is promulgated under the authority of ss. 46.27 (2) (h) 2., (7) (cj) 3. b., (11) (c) 5n. b. and (12), 46.277 (5) (d) 1n. b. and (5r), and 227.11 (2) (a), Stats., to establish certain standards and procedures related to assessments, case plans, service agreements, participant payment of service providers and verification that services have been received for county administration of the community options program (COP) under s. 46.27, Stats., and county administration of home and community−based services waivers from medical assistance requirements that the department receives from the secretary of the U.S. department of health and human services under 42 USC 1396n (c), to establish conditions of hardship under which the department may grant exceptions in individual cases to limits on spending by counties for care provided in CBRFs and to establish criteria for county agency determination of the infeasibility of in−home services as a condition for paying for services provided to a program participant residing in a CBRF. SECTION 48. DHS 73.02 is amended to read:
DHS 73.02 Applicability. This chapter applies to county departments designated under s. 46.27 (3) (b), Stats., to administer the community options program (COP), and to county departments and private non−profit agencies with which the department contracts to provide home and community−based services through a medical assistance waiver, and to vendors providing assessments, case plans or supportive home care services funded under s. 46.27 (7), Stats., or under a medical assistance waiver. SECTION 49. DHS 73.03 (4) is repealed.
SECTION 50. DHS 73.03 (5), (8m), (11), and (14) are amended to read:
DHS 73.03 (5) “County department” means a county department designated under s. 46.27 (3) (b), Stats., a county department established under s. 46.215, 46.22, 46.23, 46.272, 51.42, or 51.437, Stats., which provides home and community−based services under a medical assistance waiver or a private non−profit agency designated by the department to provide services under a medical assistance waiver. DHS 73.03 (8m) “Initially applies for services” means applies for the first time for services in addition to an assessment or care plan under COP, the COP−waiver under s. 46.27 (11), Stats., or the community integration program under s. 46.277, Stats., and has not previously received the services. DHS 73.03 (11) “Participant” means a person receiving an assessment, case plan or supportive home care services funded under s. 46.27 (7), Stats., or under a medical assistance waiver. SECTION 51. DHS 73.04 (1) is amended to read:
DHS 73.04 (1) Assessment. Within the limits of state and federal funds, a county department shall carry out an assessment in accordance with s. 46.27 (5) (am) and (6), Stats., of any person residing in a nursing home who wants to be assessed for eligibility to receive support services within the community rather than within the nursing home, any person seeking admission to or about to be admitted to a nursing home for whom community services represent an alternative to nursing home residence or any person whom the county department judges would otherwise require nursing home care in the absence of comprehensive community services. The assessment shall include a face−to−face discussion with the person or the person’s guardian and any appropriate family members and caregivers. The assessment shall result in an outline of what would be required to enable the person to live at home or in a homelike setting integrated with the community and to meet the person’s preferences for location, type and manner of services provided. SECTION 52. DHS 73.05 is repealed.
SECTION 53. DHS 73.07 (2) is repealed.
SECTION 54. DHS 73.10 (1) and (2) are amended to read:
DHS 73.10 (1) Limitation on funding. Each county shall annually establish limits on spending for services for persons who reside in CBRFs from the allocations received under s. 46.27 (7) and (11), Stats., and s. 46.277 (5), Stats., for community long−term support services. A county department shall include those limits in the county plan for participation in COP under s. 46.27 (4) (c), Stats. (2) Limitation on eligibility. If the projected cost of the services for an individual who is residing or intending to reside in a CBRF and initially applies for services to a county department would cause the county department to exceed a limit on spending for services provided to persons who reside in CBRFs under sub. (1), the individual is not eligible for those services using funds allocated under s. 46.27 or 46.277 (5), Stats., unless the department grants a hardship exception under sub. (3) for the individual. SECTION 55. DHS 73.10 (3) is repealed.
SECTION 56. DHS 73.11 (1) is amended to read:
SECTION 57. DHS 104.01 (5) (a) 1. is amended to read:
DHS 104.01 (5) (a) 1. Applicants and recipients have the right to a fair hearing in accordance with procedures set out in this subsection when aggrieved by action or inaction of the agency or the department. This subsection does not apply to actions taken by a PRO or to adverse benefit determinations made by a care management organization or managed care organization under ss. 46.287 (2) (a) 1m. or 49.45 (5) (ag), Stats. SECTION 58. DHS 105.17 (1c) (c) is repealed.
SECTION 59. Effective date. This rule takes effect on the first day of the month following publication in the Wisconsin Administrative Register as provided in s. 227.22 (2) (intro.), Stats.
