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.
Structure Wisconsin Statutes & Annotations
Wisconsin Statutes & Annotations
46.014 - Secretary, powers and duties.
46.016 - Cooperation with federal government.
46.018 - Disbursement of funds and facsimile signatures.
46.02 - Agency powers and duties.
46.028 - Electronic benefit transfer.
46.03 - Department, powers and duties.
46.031 - County social service and mental hygiene budget and contract.
46.034 - Authority to establish services integration and coordination pilot programs.
46.035 - Department, additional powers to provide structures, facilities and permanent improvements.
46.036 - Purchase of care and services.
46.041 - Children's consultation service; establishment; purposes.
46.042 - Treatment program for emotionally disturbed children.
46.043 - Additional services of mental health institutes.
46.044 - State psychiatric institute.
46.047 - State-operated residential facilities and support services.
46.048 - Central Wisconsin Center for the Developmentally Disabled.
46.055 - Secure mental health facility for sexually violent persons.
46.056 - Wisconsin Resource Center.
46.057 - Mendota juvenile treatment center.
46.058 - Bonds of employees; police powers; investigation of complaints.
46.06 - Lands; condemnation, easements, leases, sales, purchases.
46.064 - Client wages, allowances and release payments.
46.066 - Freedom of worship; religious ministration.
46.07 - Property of patients or residents.
46.09 - Purchases, bills, audits, payments.
46.14 - Reports of state institutions.
46.15 - Institutions subject to chapter 150.
46.16 - General supervision and inspection by department.
46.17 - County buildings; establishment, approval, inspection.
46.175 - County institutions: minimum standards.
46.18 - Trustees of county institutions.
46.19 - Officers and employees of county institutions.
46.20 - Joint county institutions.
46.205 - County home in adjoining county.
46.206 - Welfare services; supervisory functions of state department.
46.208 - Relief block grants; functions of state department.
46.21 - Institutions and department of human services in populous counties.
46.215 - County department of social services in populous counties.
46.22 - County social services.
46.225 - Indigency determinations.
46.23 - County department of human services.
46.234 - Recovery residences; registration.
46.245 - Information for certain pregnant women.
46.248 - Reach Out and Read Wisconsin grants.
46.269 - Determining financial eligibility for long-term care programs.
46.271 - Long-term support pilot projects.
46.272 - Children's community options program.
46.275 - Community integration program for residents of state centers.
46.277 - Community integration program for persons relocated or meeting reimbursable levels of care.
46.2785 - Community Opportunities and Recovery Program.
46.279 - Restrictions on placements and admissions to intermediate and nursing facilities.
46.28 - Revenue bonding for residential facilities.
46.2804 - Client management of managed care long-term care benefit.
46.2805 - Definitions; long-term care.
46.281 - Powers and duties of the department, secretary, and counties; long-term care.
46.284 - Care management organizations.
46.285 - Operation of resource center and care management organization.
46.2895 - Long-term care district.
46.2896 - Counting promissory notes as assets.
46.2897 - Self-directed services option.
46.2898 - Employment of individuals with disabilities; long-term care programs.
46.2899 - Services for the developmentally disabled who receive post-secondary education.
46.29 - Council on physical disabilities.
46.293 - Specialized programs for the blind and visually impaired.
46.295 - Interpreters for the hearing-impaired.
46.297 - Telecommunication aid for the hearing impaired.
46.298 - Vehicle sticker for the hearing impaired.
46.33 - Employee counseling referral programs.
46.34 - Emission standards for hazardous air contaminants.
46.37 - Certain water and sewerage service in Winnebago County.
46.40 - Community aids funding.
46.45 - Carry-over of community aids funds.
46.47 - Grants for nonnarcotic drug treatment in county jails.
46.48 - Grants for community programs.
46.482 - Coordination of care in substance use overdose.
46.485 - Mental health services for severely emotionally disturbed children.
46.49 - Allocation of federal funds for community aids.
46.495 - Distribution of community aids funds to counties.
46.50 - State mental health authority.
46.52 - Systems change grants.
46.53 - Mental health treatment provider training.
46.535 - Crisis intervention training grants.
46.536 - Crisis program enhancement grants.
46.54 - Consumer and family self-help and peer-support programs.
46.545 - Individual placement and support.
46.55 - Grants for services to persons in treatment.
46.56 - Initiatives to provide coordinated services for children and families.
46.57 - Grants for services to persons with epilepsy.
46.65 - Treatment alternative program.
46.70 - Delivery of services to American Indians.
46.71 - American Indian drug abuse prevention, treatment and education.
46.75 - Food distribution grants.
46.77 - Food distribution administration.
46.81 - Benefit specialist program.
46.85 - Programs for older individuals.
46.856 - Alzheimer's disease; training and information grants.
46.87 - Alzheimer's family and caregiver support program.
46.90 - Elder abuse reporting system.
46.94 - Referral system for community-based services.
46.96 - Independent living center grants; independent living services.
46.972 - Primary health for homeless individuals.
46.973 - Drug dependence program.
46.975 - Grant and funding program; services related to alcohol and other drug abuse.
46.986 - Respite care program.
46.99 - Medical assistance waiver for Birth to 3 participants.
46.995 - Disabled children's long-term support program; local funding.