46.287(2)(a)1m.a.a. Denial of functional eligibility under s. 46.286 (1) 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.

46.287(2)(a)1m.b.b. Failure to provide timely services and support items that are included in the plan of care.

46.287(2)(a)1m.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.

46.287(2)(a)1m.d.d. Reduction, suspension, or termination of a previously authorized service, unless the service was only authorized for a limited amount or duration and that amount or duration has been completed.

46.287(2)(a)1m.f.f. The failure of a care management organization to act within the time frames provided in 42 CFR 438.408 (b) (1) and (2) regarding the standard resolution of grievances and appeals.

46.287(2)(a)1m.g.g. Denial of an enrollee’s request to dispute financial liability, including copayments, premiums, deductibles, coinsurance, other cost sharing, and other member financial liabilities.

46.287(2)(a)1m.h.h. Denial of an enrollee, who is a resident of a rural area with only one care management organization, to obtain services outside the care management organization’s network of contracted providers.

46.287(2)(a)1m.i.i. Development of a plan of care that is unacceptable to the enrollee because the plan of care requires the enrollee to live in a place that is unacceptable to the enrollee; the plan of care does not provide sufficient care, treatment, or support to meet the enrollee’s needs and support the enrollee’s identified outcomes; or the plan of care requires the enrollee to accept care, treatment, or support that is unnecessarily restrictive or unwanted by the enrollee.

46.287(2)(a)2.2. 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.

46.287(2)(b)(b) An enrollee may contest a decision, omission or action of a care management organization other than those specified in par. (a) 1m. by filing a grievance with the care management organization. If the grievance is not resolved to the satisfaction of the enrollee, he or she may request that the department review the decision of the care management organization.

46.287(2)(c)(c) Information regarding the availability of advocacy services and notice of adverse actions taken and appeal rights shall be provided to a client by the resource center or care management organization in a form and manner that is prescribed by the department by rule.

46.288(1)(1) Standards for performance by resource centers and for certification of care management organizations, including requirements for maintaining quality assurance and quality improvement.

46.288(2)(2) Criteria and procedures for determining functional eligibility under s. 46.286 (1) (a), financial eligibility under s. 46.286 (1) (b), and cost sharing under s. 46.286 (2) (a).

46.288(3)(3) Procedures and standards for procedures for s. 46.287 (2), including time frames for action by a resource center or a care management organization on a contested matter.

46.2895(1)(a)(a) A county, a tribe or band, or any combination of counties or tribes or bands, may create a special purpose district that is termed a “long-term care district”, that is a local unit of government, that is separate and distinct from, and independent of, the state and the county or tribe or band that created it, and that has the powers and duties specified in this section, if each county or tribe or band that participates in creating the district does all of the following:

46.2895(1)(a)1.b.b. Specifies the long-term care district’s primary purpose, which shall be to operate, under contract with the department, a resource center under s. 46.283, a care management organization under s. 46.284, or a program described under s. 46.2805 (1) (a) or (b).

46.2895(1)(a)1.c.c. Specifies the number of individuals who shall be appointed as members of the long-term care district board, the length of their terms, and, if the long-term care district is created by more than one county or tribe or band, how many members shall be appointed by each county or tribe or band.

46.2895(1)(a)2.2. Files copies of the enabling resolution with the secretary of administration, the secretary of health services and the secretary of revenue.

46.2895(1)(c)(c) A long-term care district may not operate a care management organization under s. 46.284 or a program described under s. 46.2805 (1) (a) or (b) if the district operates a resource center under s. 46.283.