Transcript WISCONSIN’S FAMILY CARE - Disability Rights Wisconsin

Wisconsin’s FAMILY CARE:
ADVOCACY and APPEALS
Betsy Abramson, Disability Rights Wisconsin
Family Care Ombudsman Program Manager
608-267-0214
[email protected]
www.disabilityrightswi.org
02/09
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What is Family Care?
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Medicaid LTC waiver program for:
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Wisconsin residents age 18+
Who need assistance with ADLs
For:
frail elders;
 people with physical disabilities
 people with developmental disabilities
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Coordinates both long term
supports and health care services
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Key Elements of Family Care
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Entitlement
Eliminates waiting lists
Emphasizes consumer-directed
service delivery
Managed care program with
capitated rates
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Two Main Components
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Aging & Disability Resource Centers
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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
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Manage and deliver FC benefit
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Family Care’s 12 Outcomes
1. I decide where and with whom I live
2. I decide how I spend my day
3. I make my own decisions regarding
my supports and services
4. I have relationships with family and
friends I care about
5. I do things that are important to me
6. I am involved in my community
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Outcomes, continued
7. My life is stable
8. 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 safe
12. I am free from abuse and neglect
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Adequacy of the Comprehensive
Assessment
 Individual
Service Plan –
identifies member’s:
 Personal outcomes
 Strengths
 Need for supports
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Interdisciplinary Team
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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:
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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”
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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
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Nursing Home level of Care
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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
AND
o Has DD requiring specialized services or
impaired condition or impaired decisionmaking ability
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Functional Eligibility – 3 of 3
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Non Nursing Home Level of Care
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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
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Asset limits generally $2,000 or
less. Same exempt assets as other
MA
Income limits: 3 levels
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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
grievance
State fair hearing
and/or
DHS 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:
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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
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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
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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
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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
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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:
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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
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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
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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
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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
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Development of service plan unacceptable
to member because:
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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
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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
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For individuals age 18-59,
Disability Rights Wisconsin
800-928-8778
www.disabilityrightswi.org
For individuals 60+, Board on Aging
and Long Term Care
1-800-815-0015
www.longtermcare.state.wi.us
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DRW’s Family Care Ombudsman
Program – Types of Assistance
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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
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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
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Insufficient member/guardian
participation in ISP development
Arbitrary terminations by MCOs of longstanding 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
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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
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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
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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
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For individuals age 18-59,
Disability Rights Wisconsin
800-928-8778
www.disabilityrightswi.org
For individuals 60+, Board on Aging
and Long Term Care
1-800-815-0015
www.longtermcare.state.wi.us
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DRW Family Care
Ombudsman Program
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FCOP Manager:
Betsy Abramson
608-267-0214
[email protected]
Ombudsmen and part-time attorney
www.disabilityrightswi.org
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