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Wisconsin’s FAMILY CARE:ADVOCACY and APPEALSBetsy Abramson, Disability Rights WisconsinFamily Care Ombudsman Program Manager

608-267-0214betsya@drwi.org

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 Abramson608-267-0214betsya@drwi.org

Ombudsmen and part-time attorney

www.disabilityrightswi.org

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