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1 Wisconsin’s FAMILY CARE: ADVOCACY and APPEALS Betsy Abramson, Disability Rights Wisconsin Family Care Ombudsman Program Manager 608-267-0214

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Presentation on theme: "1 Wisconsin’s FAMILY CARE: ADVOCACY and APPEALS Betsy Abramson, Disability Rights Wisconsin Family Care Ombudsman Program Manager 608-267-0214"— Presentation transcript:

1 1 Wisconsin’s FAMILY CARE: ADVOCACY and APPEALS Betsy Abramson, Disability Rights Wisconsin Family Care Ombudsman Program Manager /09

2 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 2

3 Key Elements of Family Care  Entitlement  Eliminates waiting lists  Emphasizes consumer-directed service delivery  Managed care program with capitated rates 3

4 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 4

5 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 5

6 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 6

7 Adequacy of the Comprehensive Assessment  Individual Service Plan – identifies member’s: Personal outcomes Strengths Need for supports 7

8 Interdisciplinary Team  Member, legal representative and others member chooses  Care Manager  Registered Nurse May also include MH, OT, PT, others 8

9 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 9

10 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 10

11 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 11

12 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 decision- making ability 12

13 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. 13

14 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 14

15 Advocacy / Appeal Options  MCO grievance  State fair hearing and/or  DHS complaint (handled by MetaStar) 15

16 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 16

17 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 17

18 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 18

19 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. 19

20 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 20

21 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 21

22 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 22

23 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 23

24 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 24

25 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) 25

26 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 26

27 Family Care Ombudsman  For individuals age 18-59, Disability Rights Wisconsin  For individuals 60+, Board on Aging and Long Term Care

28 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

29 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 29

30 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 30

31 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 31

32 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 32

33 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 33

34 Family Care Ombudsman  For individuals age 18-59, Disability Rights Wisconsin  For individuals 60+, Board on Aging and Long Term Care

35 DRW Family Care Ombudsman Program  FCOP Manager: Betsy Abramson  Ombudsmen and part-time attorney 35


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