Section 10.56. Continuation of services.

 

(1)   Request for continuation of services. Prior to reducing or terminating services under the family care benefit, a CMO shall provide to the enrollee prior notification of its intent to reduce 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 or terminated files a grievance under s. DHS 10.53 (2) , or requests a department review under s. DHS 10.54 or a fair hearing under s. DHS 10.55 related to the reduction or termination of services and before the effective date of the reduction or termination, the enrollee may request that the CMO continue to provide the services pending the outcome of the grievance, department review or fair hearing.

(2)   Requirement for continuation. Except as provided in sub. (2m) , a CMO may not reduce or terminate services under dispute pending the outcome of the enrollee's grievance under s. DHS 10.53 (2) , department review under s. DHS 10.54 or fair hearing under s. DHS 10.55 if a request for continued benefits was made under sub. (1) .

(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 grievance under s. DHS 10.53 (2) , department review under s. DHS 10.54 , 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 grievance, department review 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.

History: 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.