Section 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 care management organization 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) .

d. Failure to provide timely services and support items that are included in the plan of care.

e. Reduction of services or support items under the family care benefit.

f. Development of a plan of care that is unacceptable because the plan of care requires the enrollee to live in a place that is unacceptable to the enrollee or the plan of care provides care, treatment or support items that are insufficient to meet the enrollee's needs, are unnecessarily restrictive or are unwanted by the enrollee.

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.

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) , or may contest the choice of service provider. In these instances, the enrollee shall first send a written request for review by the unit of the department that monitors care management organization contracts. This unit shall review and attempt to resolve the dispute. If the dispute is not resolved to the satisfaction of the enrollee, he or she may request a hearing under the procedures specified in par. (a) 1. (intro.) .

(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.

1999 a. 9 ; 2003 a. 33 ; 2013 a. 20 .