Wisconsin’s FAMILY CARE: ADVOCACY and APPEALS Betsy Abramson, Disability Rights Wisconsin

1. Wisconsin’s FAMILY CARE: ADVOCACY and APPEALS Betsy Abramson, Disability Rights Wisconsin Family Care Ombudsman Program Manager 608-267-0214 betsya@drwi.org www.disabilityrightswi.org 02/09

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

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

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

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

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

7. Adequacy of the ComprehensiveAssessment • Individual Service Plan – identifies member’s: • Personal outcomes • Strengths • Need for supports

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

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

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

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

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 • Has DD requiring specialized services or impaired condition or impaired decision-making ability

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.

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

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

16. Rights • Receive writtennotice of any adverse action, including termination, suspension or reduction of eligibility or covered services. • File a grievance and/or request a fair hearing

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

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 inperson 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

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.

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

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

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

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

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

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)

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

27. Family Care Ombudsman • 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

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

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

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

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

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

34. Family Care Ombudsman • 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

35. DRW Family Care Ombudsman Program • FCOP Manager: Betsy Abramson 608-267-0214 betsya@drwi.org • Ombudsmen and part-time attorney www.disabilityrightswi.org