Section DHS 10.56 - Continuation of services(1) REQUEST FOR CONTINUATION OF SERVICES PENDING OUTCOME OF CMO APPEAL. Prior to reducing, suspending or terminating services under the family care benefit, a CMO shall provide to the enrollee prior notification of its intent to reduce, suspend or terminate the services in accordance with s. DHS 10.52 (3). If an enrollee who has received a notice that services will be reduced, suspend or terminated files an appeal with the CMO under s. DHS 10.53 (2) before the effective date of the reduction, suspension or termination, the enrollee may request that the CMO continue to provide the services pending the outcome of the appeal.(1m) REQUEST FOR CONTINUATION OF SERVICES PENDING OUTCOME OF DHA FAIR HEARING. An enrollee is entitled to continuation of services pending the outcome of a fair hearing if all of the following apply:(a) The CMO's decision on appeal under s. DHS 10.53 (2) is to proceed with reducing, suspending, or terminating the enrollee's service.(b) The enrollee's services were continued pending the outcome of the CMO appeal decision.(c) The enrollee requests a fair hearing on the CMO's appeal decision before the effective date of the CMO's appeal decision.(d) The enrollee requests continuation of services before the effective date of the CMO's appeal decision.(2) REQUIREMENT FOR CONTINUATION. Except as provided in sub. (2m), a CMO may not reduce, suspend or terminate services under dispute pending the outcome of the enrollee's appeal under s. DHS 10.53 (2) or fair hearing under s. DHS 10.55 if a request for continued benefits was made under sub. (1) or (1m).(2m) EXEMPTION FROM RIGHT TO CONTINUATION. If the sole issue is a federal or state law requiring an automatic change adversely affecting some or all enrollees and the enrollee does not dispute that he or she falls within the category of enrollees to be affected by the change, the enrollee does not have the right to continuation of services pending the outcome of the enrollee's appeal under s. DHS 10.53 (2) or fair hearing under s. DHS 10.55. A CMO will not receive a monthly capitated payment for such an individual and is not required to continue services in such circumstances.(3) LIABILITY FOR CONTINUATION OF SERVICES. The enrollee shall be liable for the cost of services provided during the period in which services have been continued under this section if the outcome of the appeal or fair hearing is unfavorable to the enrollee. The CMO shall notify in writing an enrollee who requests continuation of services under this section of the potential for liability under this subsection and the time period during which the enrollee will be liable. If the department or its designee determines that the person would incur a significant and substantial financial hardship as a result of repaying the cost of the services provided, the department may waive or reduce the enrollee's liability under this subsection.Wis. Admin. Code Department of Health Services DHS 10.56
Cr. Register, October, 2000, No. 538, eff. 11-1-00; CR 09-003: am. (2), cr. (2m) Register November 2009 No. 647, eff. 12-1-09.Amended by, CR 22-026: am. (1), cr. (1m), am. (2) to (3) Register May 2023 No. 809, eff. 6/1/2023