Wisconsin’s FAMILY CARE: ADVOCACY and APPEALS Betsy Abramson, Disability Rights Wisconsin
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Transcript of Wisconsin’s FAMILY CARE: ADVOCACY and APPEALS Betsy Abramson, Disability Rights Wisconsin
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Wisconsin’s FAMILY CARE:ADVOCACY and APPEALSBetsy Abramson, Disability Rights WisconsinFamily Care Ombudsman Program Manager
www.disabilityrightswi.org 02/09
What is Family Care?
Medicaid LTC waiver program for: Wisconsin residents age 18+ Who need assistance with ADLs For:
frail elders; people with physical disabilities people with developmental disabilities
Coordinates both long term supports and health care services
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Key Elements of Family Care
Entitlement Eliminates waiting lists Emphasizes consumer-directed
service delivery Managed care program with
capitated rates
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Two Main Components
Aging & Disability Resource Centers One-stop shops for elderly and disabled
persons for I&A about community resources, including LTC
Determine eligibility for Family Care enrollment
Managed Care Organizations-MCOs Manage and deliver FC benefit
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Family Care’s 12 Outcomes
1. I decide where and with whom I live2. I decide how I spend my day3. I make my own decisions regarding
my supports and services4. I have relationships with family and
friends I care about5. I do things that are important to me6. I am involved in my community
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Outcomes, continued
7. My life is stable8. I am respected and treated fairly
9. I have time, space, and opportunity for privacy
10. I have the best possible health 11. I feel safe12. I am free from abuse and neglect
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Adequacy of the ComprehensiveAssessment
Individual Service Plan – identifies member’s:Personal outcomesStrengthsNeed for supports
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Interdisciplinary Team
Member, legal representative and others member chooses
Care Manager Registered Nurse
May also include MH, OT, PT, others
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Service Plan must:
Address all LTC needs and use member’s strengths and informal supports identified in comprehensive assessment
Address member’s LTC outcomes Assist member to be self-reliant and
autonomous as possible and desired Be cost-effective Be agreed to by member
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Meaning of “Cost-Effective”
Compared to alternative services or supports that could meet same needs and achieve similar outcomes
To analyze, MCOs use Resource Allocation Decision (RAD) method
Does not mean ≠ least expensive
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Functional Eligibility – 1 of 3
Nursing Home level of Care Long-term or irreversible condition Inability to safely perform:
≥ 3 ADLs ≥ 2 ADLs and 1+ IADLs ≥ 5 IADLs ≥ 1 ADLs and ≥ 3 IADLs and cognitive
impairment ≥ 4 IADLs and cognitive impairment Complicating condition limiting ability to
independently meet needs and
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Functional Eligibility – 2 of 3
Requires frequent medical or social intervention to safely maintain acceptable health or developmental status or
Requires frequent changes in service or Requires range of medical or social
interventions due to multiplicity of conditions
ANDo Has DD requiring specialized services or
impaired condition or impaired decision-making ability
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Functional Eligibility – 3 of 3
Non Nursing Home Level of Care Qualifies for reduced Family Care
Benefit At risk of losing independence or
functional capacity: Inability to do 1 or more ADL or Inability to do 1 or more critical IADLs:
med mgt, meal prep or money mgt.
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Financial Eligibility
Asset limits generally $2,000 or less. Same exempt assets as other MA
Income limits: 3 levels Group A – no cost-share, like Medicaid Group B – cost-share, Categorically
needy, below $2,022, many deductions Group C – cost share, Medically Needy –
spenddown for income above $2,022
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Advocacy / Appeal Options
MCO grievanceState fair hearing and/orDHS complaint (handled by MetaStar)
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Rights
Receive written notice of any adverse action, including termination, suspension or reduction of eligibility or covered services.
File a grievance and/or request a fair hearing
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Notice of Adverse Action – must be in writing and must contain:
Intended action of county agency, ADRC or CMO
Effect action will have on services member is currently receiving
Any law that supports action Member’s right to file grievance,
appeal, request dept review or fair hearing
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Contents of Notice of Adverse Action, cont’d
Info on how to file grievance or appeal or request fair hearing
Member’s right to appear in person before ADRC, agency or MCO
Info regarding agencies that can assist with grievance, review, hearing.
Member’s right to review free copies of record for appeal and how to request copies
Right to continue services, pending appeal
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Continuing Benefits Pending Appeal
Members must receive notice of right to continue current services pending grievance/review/hearing
MCOs may not deny a request to continue services
However, member may be responsible for cost of continued services if loses appeal and no hardship granted.
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1. MCO Grievances
Member may file grievance w/ MCO Member may seek internal MCO
assistance in doing so MCO’s “Member Advocate” to help
member pursue rights, but does not represent member
MCO’s Grievance Committee will hear grievance
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2. Grievances to DHS - 1 of 2
Can be filed locally with MCO or at state level with DHS
DHs process for review, investigation, analysis of client grievances and appeals for informal resolution if: Client files grievance/appeal w/ DHS Client requests DHS review of county
agency, ADRC or CMO
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Grievances to DHS – 2 of 2
DHS required to complete review w/in 20 days of client request, unless client and DHS agree to extension
Concurrent review process whenever DHS informed that FC applicant / member has requested fair hearing
Grievances or appeals from MCOs, filed with DHS, handled by MetaStar
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3. Fair Hearing
May request without first filing for grievance
Must request within 45 days after receipt of notice of a decision in contested matter
Receipt presumed 5 days after notice date
Conducted by DHA’s ALJs
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Grounds for Fair Hearing – 1 of 2
Denial of eligibility or reduction of FC benefit amount
Cost-sharing determination Denial of entitlement Failure to provide timely services
and support items in care plan Reduction of service/support items
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Grounds for Fair Hearing – 2 of 2
Development of service plan unacceptable to member because: Unacceptable place to live Care, treatment or support items insufficient to
meet member’s needs Care, treatment or support items are
unnecessarily restrictive or unwanted Termination of FC benefit Recovery of FC benefit payments (All others: must first seek request by DHS)
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Hearing-related Rights
May choose representative - FCOP May inspect records relevant to
grievance/review/fair hearing Receive copies of documents free Decision within 90 days of receipt of
request for fair hearing
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Family Care Ombudsman
For individuals age 18-59,Disability Rights Wisconsin800-928-8778www.disabilityrightswi.org
For individuals 60+, Board on Aging and Long Term Care1-800-815-0015www.longtermcare.state.wi.us
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DRW’s Family Care Ombudsman Program – Types of Assistance
Provide info and education on rights Inform applicants and members of
services and supports in benefit package
Investigate complaints Resolve and mediate issues Work with enforcement agencies Represent consumers in grievances
and hearings
Family Care challenges – 1 of 5
Lack of comprehensive options counseling
Inadequate funding for economic support specialists in some counties – delays in eligibility determinations and enrollment
Transitioning from old waiver programs – services cut/ineligible
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Family Care Challenges – 2 of 5
Insufficient member/guardian participation in ISP development
Arbitrary terminations by MCOs of long-standing consumer-provided relationships
Inadequate recovery-based mental health services, including CSPs
Failure to inform members of right to choose family members as paid caregivers
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Family Care challenges – 3 of 5
Lack of, or limited choices due to inadequate provider networks
Denial, termination or reduction of services w/o justification or inadequate notice
Failure to inform members of SDS option and inadequate training for care managers regarding option
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Family Care challenges – 4 of 5
Care managers filing for guardianship and protective placements
Bypassing family members as guardians
Ignoring powers of attorney Inappropriate placement in nursing
homes or other large facilities
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Family Care Challenges – 5 of 5
Cost-share calculation errors Improper denials for assistance
technology devices that enable members to be active outside home
Overuse of sheltered workshops to meet needs of members who want to work
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Family Care Ombudsman
For individuals age 18-59,Disability Rights Wisconsin800-928-8778www.disabilityrightswi.org
For individuals 60+, Board on Aging and Long Term Care1-800-815-0015www.longtermcare.state.wi.us
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DRW Family Care Ombudsman Program
FCOP Manager:Betsy [email protected]
Ombudsmen and part-time attorney
www.disabilityrightswi.org
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