Free Participant Rights and Responsibilities Notification - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Long Term Care F-20985 (08/2008)

STATE OF WISCONSIN

PARTICIPANT RIGHTS AND RESPONSIBILITIES NOTIFICATION
This form meets the provisions of the Medicaid Home and Community-Based Waiver Manual, Patient Rights and Responsibilities section. Use of this form is optional.

As an applicant/participant for a Medicaid Waiver Program, you have specific rights and responsibilities. A. Applying for the Medicaid Waivers 1. You have a right to be told about the Medicaid Waiver Programs and other programs that can help you to live at home. You have a right to be told about services and other types of assistance the Medicaid Waiver Programs can provide for you. 2. You have a right to apply for the Medicaid Waiver Programs. You have a right to not participate in the Medicaid Waiver Programs. Your refusal to participate in a Medicaid Waiver Program may lead to the loss of funds from other programs such as the Community Options Program (COP). 3. You have a right to a written answer to your application for a Medicaid Waiver Program within thirty (30) days after you apply for the Program; sooner if it is an emergency. The answer must say one of three things: a. Yes, you are eligible (approval); b. No, you are not eligible (denial) and why; or c. More information is needed (approval pending) and what information is needed. 4. If your application is denied, you have the right to file a grievance and/or file a state appeal. You have the right to be told how to file a grievance or appeal and the right to get help in doing so. B. Deciding what services you receive from the Medicaid Waivers 1. If your application is approved, you have the right to have a qualified person complete an assessment of your needs. The assessment must be done within 45 days from the time you applied for the Medicaid Waiver Program (or sooner in an emergency). 2. You have the right to have your assessment include a process that invites you to share your opinions and preferences. 3. You have a right to have someone explain what your assessment includes. You have a right to a written copy of your assessment and any other reports in your case file if you ask for it. 4. You have the right to actively participate in creating the plan for services/assistance that will meet your assessed need(s). You have a right to invite friends, relatives or anyone else you choose to be a part of this process. If there are meetings held to create your plan you have a right attend these meetings. You have a right to lead these meetings and to have them occur at a time and place that is convenient for you. 5. You have a right to receive any help you need to understand and take part in planning and other meetings. This help might include interpreters, taped or Braille material, or other communication aids. 6. You have a right to design your plan for services within certain Medicaid Waiver Program rules. This plan must clearly explain what problems or needs you have and identify what will be done to solve them. The plan must pay attention to what you choose, including your preferred individual outcomes. You have a right to a written copy of your plan and to have the plan explained to you. 7. You have a right to choose from whom you will receive services. The provider you choose must be qualified. You have the right to have all conflicts-of-interest involving service provision discussed with you before you select a service provider. You have the right to have assistance in finding qualified providers. 8. You have a right to disagree with your service plan. You have a right to ask the waiver agency to change the things with which you disagree. If you disagree with any decision that is made about your services, you have a right to file a grievance. C. Receiving Medicaid Waiver Services 1. You have a right to receive services if there is funding available and you are eligible. You have a right to special equipment or other accommodations that give you equal opportunity to access Medicaid Waiver services.

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2. If funding is not available, you have a right to be placed onto a waiting list for services. If you are told that you have to wait for Medicaid Waiver services, you have a right to know how the waiting list works, how many others are waiting before you and when the waiver agency estimates you will receive services. 3. You have a right to know the amount, if any, that you will have to pay for services. You have the right to be free from the expectation that you pay for or contribute to the cost of services beyond any eligibility related amount. 4. You have the right to keep money that is yours and to spend it on what you want. 5. You have a right to have help from a support/service or care manager after you receive services. You have a right to meet with this person as often as necessary. Your support/service coordinator or care manager will assure you receive the services in your plan, that they are of high quality and that the services work well together. 6. You have a right to a written notice, at least 10 days in advance, whenever your services are going to be reduced or stopped. You have the right to file a county grievance or state appeal if you disagree with the reduction or termination of services. 7. If you file a state appeal before the termination date stated in the termination notice you receive, you have a right to keep receiving the types and amounts of services until the appeal is decided. 8. If you file an appeal, you have the right to have all Medicaid overpayment and recoupment rules explained to you. 9. You have a right to pick where in the State of Wisconsin you will live, and to have Medicaid Waiver funding follow you if you choose to move to another county. D. Other rights You have a number of rights specified in Wisconsin law. These rights include but are not limited to: 1. You have a right to be treated with dignity and respect. This includes the right to free association to see whom you want, when you want, unless a court order states otherwise. 2. You have a right to control your life and the services you get as much as you are able. Within Medicaid waiver program rules, you have the right to pick where you live, if you live alone or with others, and with which other people you will live. 3. You have a right not to be hurt or threatened. You have a right to be free from all restraints. You may not be forced to take drugs you do not want to take. 4. You have the right to privacy. Your right to privacy includes having information that is said or written about you kept confidential. 5. You have a right to see your file, have it corrected, and to get copies of reports in it. E. Right to Appeal 1. You have a right to be told how to file a county grievance or state appeal. This includes being told what waiver agency action you can grieve or appeal, whom to contact, the steps and time limits for filing the appeal. 2. You may get help with a waiver agency grievance or state appeal from your support and service coordinator/care manager or from: Older adults or persons with physical disabilities may contact: The Board on Aging and Long Term Care Ombudsman Program 1402 Pankratz Street, Suite 111 Madison, Wisconsin 53704-4001 1-800-815-0015 (toll-free, voice or TDD) Or: Persons with developmental disabilities or mental illness may contact the agency below at the office nearest you:

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Disability Rights Wisconsin (formerly Wisconsin Coalition for Advocacy): www.disabilityrightswi.org Madison Office 16 N. Carroll Street, Suite 400 Madison, Wisconsin 53703 Telephone: 608-267-0214 or 1-800-928-8778 (toll-free, voice, or TDD) Fax: 608-267-0368 Rice Lake Office 801 Hammond Ave Rice Lake, WI 54868 715-736-1232 (Voice) or 1-877-338-3724 (Toll-free) Fax: 715-736-1252 TTY number for all three offices: 888-758-6049 F. Applicant/ Participant Responsibilities There are specific responsibilities you must meet when you apply for or participate in the Medicaid Waiver Program. If you do not meet these responsibilities, you may become ineligible for the Medicaid waiver programs. Reporting changes in your circumstances is very important to maintain your eligibility. Changes should be reported promptly, generally within 10 calendar days of when the change occurs. 1. You must report changes in your finances, which may affect your eligibility or the amount of benefits or services you receive. These changes might include an increase or decrease in your income or a change in the amount of assets you have. 2. You must report changes in your household circumstances, which might affect your eligibility for the amount of benefits or services that you receive. These changes might include when you or any of your children reach age 18, when someone moves in or out of your household, when you get married, divorced or separated, become pregnant or have a baby. 3. You must report any change of address when you move. 4. You must notify the county of any private health insurance that you have and you must use your private insurance to pay your medical bills before these expenses are charged to Medicaid. You must also notify the county when you are no longer covered under private insurance. 5. You must notify the county when changes occur in your medical or remedial expenses. Changes may mean that your cost-share or spend down will increase or decrease. These changes might include when your doctor no longer feels it is necessary for you to purchase medicines or when you no longer need to pay for therapy you receive because your private insurance has begun to pay for it. 6. You are responsible to pay any cost-share that you are required to contribute toward the services that you receive and to make this payment on a monthly basis. 7. You must notify the county if you give assets to another person. This may affect your eligibility for Medicaid waiver programs. My signature indicates that I have been informed of and understand my rights and responsibilities under the Medicaid waiver programs. I have received this information verbally and in writing.
SIGNATURE ­ Participant/Guardian SIGNATURE ­ Care Manager/Support and Service Coordinator Date Signed Date Signed

Milwaukee Office 6737 West Washington St. Suite 3230 Milwaukee, Wisconsin 53214 Telephone: 414-773-4646 (Voice) Fax: 414-773-4647