COMPLAINTS, GRIEVANCES, AND APPEALS PROCESS

The Managed Care Organization (MCO) of My Choice Family Care is committed to providing you with the highest quality services and customer service. We are always looking for ways to improve. Your comments, suggestions, and concerns are always welcomed.

If you are unhappy with any service or provider, please do not hesitate to contact us at any time.

You can voice your concerns and opinions to your Team and your Team will try to answer your questions or resolve your concerns. If you do not want to address your questions or concerns to your Team, you can contact the My Choice Family Care Member Liaison at 414-287-7621 or Toll Free at 1-877-489-3814. The Member Liaison will help you understand your rights as a Family Care Member and will work with you to try and resolve any questions and concerns you may have.

As a Member of Family Care, you have the right to file a Complaint, Grievance, or Appeal at any time. Your Team or the Member Liaison can help you decide exactly how you would like to proceed to have your complaint or concern addressed.

A complete description of the process for Complaints, Grievances, and Appeals is listed below.

COMPLAINTS

You may make a Complaint when you are not satisfied with a service or provider.

You can complain in person or in writing to the provider or to your Team. You can also contact the My Choice Family Care’s Member Liaison who will help you put your Complaint in writing.

The My Choice Family Care’s Member Liaison can be reached at 414-287-7621 or Toll Free at 1-877-489-3814.

Making a complaint will not affect the way the MCO or your providers treat you.

GRIEVANCES

If your Complaint is not resolved to your satisfaction, you may file a Grievance. You may also file a Grievance if you would like to bypass the Complaint process.

You should let your Team know that you would like to file a Grievance. You can file a Grievance in writing or in person with the My Choice Family Care.

The MCO Grievance and Appeal Committee will review your Grievance. The MCO Grievance and Appeal Committee will review and resolve grievances brought before them. The Member and/or Member’s representative or provider has the option of presenting information and appearing before the Committee.

The MCO will respond to your request, schedule a Grievance review and the MCO Grievance and Appeal Committee will make a decision no later than 20 business days from the date we first received your request for a Grievance.

You can file a Grievance at any time.

If you disagree with the decision of the MCO Grievance and Appeal Committee, you or others acting on your behalf can request that the Department of Health Services review your grievance. You could also talk to the Member Liaison or an advocate for advice on other options.

Filing a Grievance will not affect the way the MCO or your providers treat you.

To file a Grievance at the local level, send your Grievance to:

My Choice Family Care

Member Rights Specialists

901 North 9th Street, Suite 307A

Milwaukee, WI 53233

Or call one of the Member Rights Specialists at 414-287-7616 or 414-287-7654.

If you do not want to file a Grievance at the local level, you can file a Grievance with the State of Wisconsin Department of Health Services (DHS). To do this, please contact:

DHS Family Care Grievances

c/o MetaStar

2909 Landmark Place

Madison, WI 53713

Toll Free: 1-888-203-8338

Fax: 608-274-8340

TTY: 608-264-9853

Email: dhsfamcare@wisconsin.gov

If you are not happy with the result of the DHS review, you can file a Grievance with My Choice Family Care, if you have not already done so. You could also talk to our Member Liaison or an advocate for advice on other options.

Filing a Grievance will not affect the way the MCO or your providers treat you.

APPEALS

If you disagree with a decision made by the MCO, you may file an Appeal.

Appeals are filed on a form or in a letter. The Member Rights Specialists or your Team can help you file an Appeal. You can file an Appeal in writing or in person with the MCO, the State of Wisconsin Department of Health Services, or the Division of Hearing and Appeals (DHA). You can file an Appeal to the MCO, the Department of Health Services, and DHA in any order, or you can file Appeals to two or all three at the same time. If an Appeal to DHA is not decided in your favor, then you cannot go back and Appeal to the MCO. If the MCO Appeal decision is not in your favor, you may still file to DHA.

To file an Appeal with the MCO, send your Appeal to:

My Choice Family Care

Attention: Member Rights Specialists

901 North 9th Street, Suite 307A

Milwaukee, WI 53233

Or call a Member Rights Specialist at 414-287-7616 or 414-287-7654.

If you file an Appeal with My Choice Family Care, we will send you a letter within 5 business days to let you know we received your request. We then will try to help informally address your concerns or come up with a solution that satisfies both My Choice Family Care and you. If we are unable to come up with a solution or if you do not want to work with the staff from My Choice Family Care to informally address your concerns, our Grievance and Appeal Committee will meet to review your Appeal.

The MCO Grievance and Appeal Committee makes a decision based on the information presented to them. The Committee bases its decision on supporting documents, such as the Resource Allocation Decision method, which balances your outcomes and cost-effectiveness; the Member Centered Plan; MCO Policies & Procedures; and relevant assessments.

After the committee hears your Appeal, the My Choice Family Care will send you a decision letter within 20 business days after we first received your Appeal. My Choice Family Care may take up to 30 business days to issue a decision if:

You ask for more time to give the Committee information, or

We need more time to gather information. If we need additional time, we will send you a written notice informing you of the reason for delay.

If you think waiting 20 business days for a decision could seriously harm your health or ability to perform your daily activities, you can ask us to speed up your Appeal. We call this an Expedited Appeal. We will let you know as soon as possible if we can expedite your Appeal. In an Expedited Appeal, you will get a decision on your Appeal within 72 hours of your request. My Choice Family Care may extend this to a total of 14 days if additional information is necessary and if the delay is in your best interest.

To request an Expedited Appeal, contact:

My Choice Family Care

Member Rights Specialists

Phone: 414-287-7616 or 414-287-7654

Toll free: 1-877-489-3814

TTY: 711

Email: DLFamCMemberRights@mychoicefamilycare.com

If you disagree with the Grievance and Appeal Committee’s decision, you can request a State Fair Hearing with DHA or ask for a review by DHS, if you have not already done so. You must do so within 45 calendar days from the date of the MCO Grievance and Appeal Committee’s decision.

To file an Appeal with the Wisconsin Department of Health Services please contact:

DHS Family Care Grievances

c/o MetaStar

2909 Landmark Place

Madison, WI 53713

Toll Free: 1-888-203-8338

Fax: 608-274-8340

TTY: 608-264-9853

Email: dhsfamcare@wisconsin.gov

DHS/MetaStar will reply in writing to let you know they received your Appeal request. They will try to resolve your concerns informally. DHS/MetaStar will complete the review and send you a letter with their findings within 20 business days of your request. If you are not happy with the result of the DHS review, you can file an Appeal with the MCO or DHA. You have up to 45 calendar days to Appeal with the MCO or DHA after receiving the letter from DHS/MetaStar.

To file an appeal with the Division of Hearings and Appeals, you must send a written request to:

Family Care Request for Fair Hearing

c/o Wisconsin Division of Hearings and Appeals

5005 University Avenue, # 201

P.O. Box 7875

Madison, WI 53707-7875

Phone: 608-266-3096

Fax: 608-264-9885

TTY: 608-264-9853

After you send in your request for a State Fair Hearing, DHA will mail you a notice with the date, time and location of your hearing. An Administrative Law Judge will run the hearing. The Administrative Law Judge must issue a decision within 90 days of the date you filed a request for hearing.

If you disagree with the Administrative Law Judge’s decision, you have two options.

1) Ask for a re-hearing within 20 days from the date of the Judge’s decision.

2) Take your case to circuit court. You must file your petition within 30 days from the date of the Judge’s decision.

You must file your Appeal no later than 45 calendar days after you receive the Notice of Action.

If you receive a notification of your Appeal rights, you should read this notice carefully. The notice may tell you the deadline for filing your Appeal. You can always call our Member Liaison for assistance.

Continuing Your Services During Your Appeal

If My Choice Family Care decides to stop or reduce a service you are currently receiving, you have the right to ask My Choice Family Care, DHS or DHA to continue your services during your Appeal. Once services stop, they cannot be continued.

If you want your services to continue, you must:

Submit (fax, mail) your appeal request on or before the date the My Choice Family Care plans to stop or reduce your services; AND

Ask that your services continue throughout the course of your Appeal.

If your services were continued during an Appeal with My Choice Family Care and you lose the appeal, you can continue your services at the next level of Appeal if you, once again, request that they continue.

If you request your services to continue and the final decision of the Appeal is not in your favor you may have to pay My Choice Family Care back for the service you received during the Appeal process.

You may contact the following agencies for assistance with your Grievance or Appeal:

Disability Rights Wisconsin (for Members 18-59 years old) – 414-773-4646

Senior Law – 414-278-7722

Board on Aging and Long Term Care Ombudsman (for Members 60 years or older) –

Toll Free 1-800-815-0015

Legal Aid Society of Milwaukee – 414-765-0600

The State Fair Hearing Process

You, or someone with legal authority to act on your behalf (as specified in ch. HS 3.05(2) WisStats), can file a request for a Fair Hearing Process for the following issues before, during, or after using the MCO appeal process:

  1. You were unable to get a service listed in your plan of care in a timely manner
  2. Your services were reduced or stopped, or you were denied a service in the Family Care benefit package
  3. Your plan of care requires you to live in a place you do not want to live
  4. You think the services in your plan of care are not the right services to meet your needs, or feel they restrict the way you want to live
  5. Your Team asked the State of Wisconsin to dis-enroll you from the program
  6. You do not agree with the My Choice MCO’s decision on an Appeal or Grievance
  7. You are not satisfied with the mediation attempts by the State on an Appeal or Grievance

To submit your request for a State Fair Hearing, you must file the Appeal or Grievance within 45 days of having a service denied, reduced or stopped or within 45 days of getting a notice from the MCO Grievance Committee or the Department of Health Services (whichever is later) to:

State Fair Hearings Division of Hearings and Appeals

5005 University Avenue, Room 201

Madison, WI 53705-5400

Phone: 608-266-3096

Fax: 608-264-9885

TTY: 608-264-9853

In order for your service to continue during an appeal process, all three of these conditions must be met:

  1. The member files a grievance by the date of the intended action, or within 14 days of receipt of the written notice from the MCO and/or DHS (whichever is later); and
  2. The current level of services was authorized by the MCO Team; and
  3. You request for the services to be continued.

If the following conditions are met, the MCO may continue the Member’s current benefits until a decision on the Appeal or Grievance is reached.

While you are waiting for a decision on the appeal, service will continue or be reinstated. Services must continue until one of the following happens:

  1. You withdraw the Appeal or Grievance
  2. You do not request a State Fair Hearing within 15 days from when the MCO mails an adverse MCO decision
  3. A State Fair Hearing decision adverse to the Member is made
  4. The authorization expires or authorization service limits are met

If your request for services and or items is upheld, the MCO shall authorize and/or provide the service as soon as possible and in accordance with the timeframe on the order rendered from the Administrative Law Judge.