46.287 Hearings.
(1) Definition. In this section, “client" means a person applying for eligibility for the family care benefit, an eligible person or an enrollee.
(2) Hearing.
(a)
1. Except as provided in subd. 2., a client may contest any of the following applicable matters by filing, within 45 days of the failure of a resource center or county to act on the contested matter within the time frames specified by rule by the department or within 45 days after receipt of notice of a decision in a contested matter, a written request for a hearing under s. 227.44 to the division of hearings and appeals created under s. 15.103 (1):
a. Denial of eligibility under s. 46.286 (1).
b. Determination of cost sharing under s. 46.286 (2).
c. Denial of entitlement under s. 46.286 (3).
g. Termination of the family care benefit.
h. Imposition of ineligibility for the family care benefit under s. 46.286 (4).
i. Denial of eligibility or reduction of the amounts of the family care benefit under s. 46.286 (5).
j. Determinations similar to those specified under s. 49.455 (8) (a), made under s. 46.286 (6).
k. Recovery of family care benefit payments.
1m. Except as provided in subd. 2., a client 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 frames specified by rule by the department or within 90 days after receipt of notice of a decision upholding the adverse benefit determination, a written request for a hearing under s. 227.44 to the division of hearings and appeals created under s. 15.103 (1):
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.
b. Failure to provide timely services and support items that are included in the plan of care.
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.
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.
e. Denial, in whole or in part, of payment for a service.
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.
g. Denial of an enrollee's request to dispute financial liability, including copayments, premiums, deductibles, coinsurance, other cost sharing, and other member financial liabilities.
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.
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.
j. Involuntary disenrollment from the care management organization.
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.
(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.
(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.
History: 1999 a. 9; 2003 a. 33; 2013 a. 20; 2019 a. 9.