DLTC INFO MEMO 2010-07
STATE OF WISCONSIN
Department of Health Services
Division of Long Term Care
DLTC Information Memo Series 2010-07
Date: December 21, 2010
Index Title: Cooperation with Ombudsman Programs
Supersedes DLTC Info Memo 2008-13
To: Listserv
For: Managed Care Organizations
Aging and Disability Resource Centers
From: Susan Crowley, Administrator
Division of Long Term Care
Subject: Cooperation with Ombudsman Programs
Document Summary
This memo details the Department's expectations for the working
relationship between MCOs, ADRCs, and ombudsman services provided through
the Board on Aging and Long Term Care Ombudsman Program and Disability
Rights Wisconsin's (DRW) Family Care and IRIS Ombudsman Program. This memo
is intended to further interpret and implement the language of
Wis.Adm.Code § DFS 10.57.
Background
As of October 1, 2008 the Department of Health Services has contracted
with Disability Rights Wisconsin (DRW) for Ombudsman services to current
or potential enrollees of the Family Care and Family Care Partnership
programs, or to their families or guardians, as required by Wis. Stats. §
46.281(1n)(e) (2007-8). Through 2009 Act 406, Wis. Stats. § 46.281 (1n)
(e) was amended to include ombudsman services for IRIS participants ages
18-59.
The Family Care and IRIS Ombudsman program at DRW is in addition to the
existing Ombudsman Program through the Wisconsin Board on Aging and Long
Term Care (BOALTC). Both of these Ombudsman programs are available to the
current or potential enrollees of the Family Care and Family Care
Partnership programs or to their families or guardians. The DRW Family
Care and IRIS Ombudsman program serves current or potential enrollees who
are age 18-59 and the BOALTC Ombudsman program serves current or potential
enrollees who are age 60 and older.
Regional Ombudsmen are available to respond to current or potential
enrollees' concerns in a timely fashion. Both Ombudsmen programs will
assist current or potential enrollees in navigating the programs and
resolving issues using informal negotiations, whenever possible. Some of
the ombudsman services include:
- Assistance with ensuring quantity and quality of services
- Complaint investigation
- Mediation and resolution of conflicts
- Provision of information and education on current and potential
enrollees' rights and benefits
- Assistance with preparation for and representation at appeals,
grievances and fair hearings
Cooperation with Ombudsman
It is the Department's expectation that each ADRC and MCO informs current
and potential enrollees of their rights to ombudsman services, and shall
cooperate with any Ombudsman under this program selected by an enrollee or
potential enrollee. As provided in the rule, below, cooperation does not
allow the unauthorized release of enrollee information or abridge the
enrollee's right to confidentiality.
- HFS 10.57 Cooperation with advocates.
(1) DEFINITIONS.
In this section:
(a) "Advocate" means an individual or organization whom a client
has chosen to assist him or her in articulating the client's preferences,
needs and decisions.
(b) "Cooperate" means:
1. To provide any information related to the client's eligibility,
entitlement, cost sharing, care planning, care management, services or
service providers to the extent that the information is pertinent to
matters in which the client has requested the advocate's assistance.
2. To assure that a client who requests assistance from an advocate is not
subject to any form of retribution for doing so.
(2) COOPERATION WITH ADVOCATES. The department and each resource
center and CMO shall cooperate with any advocate selected by a client.
Nothing in this section allows the unauthorized release of client
information or abridges a client's right to confidentiality.
Information related to services or service providers includes contract
language between the managed care organization and service providers. The
contract language between the Department and a managed care organization
is available online for the Ombudsman.
If an Ombudsman under the contract with DRW is requesting information
that falls within the definition of protected health information (PHI)
under HIPAA, the ADRC and/or the MCO should explain their local policies
and procedures related to release of protected member information.
Board on Aging and Long Term Care Statutory Authority
The BOALTC Ombudsman program has, by statute, authority to obtain access
to all residents and tenants of Wisconsin nursing homes, Community Based
Residential Facilities (CBRFs), Residential Care Apartment Complexes (RCACs),
and persons served by the Community Options Program and Family
Care/Partnership programs. The BOALTC ombudsman program is not under
contract with DHS because the program was mandated by Congress through the
Older Americans Act and operating in Wisconsin since 1972.
The BOALTC has authority through Wis. Stat. § 16.009 (4)(1)(e) to have
access to person specific information without consent in limited
circumstances:
- If the resident's guardian refuses to consent;
- If the ombudsman or designated representative has reason to believe
that the guardian is not acting in the best interested of the
resident; and
- For investigations only by a designated representative, if the
designated representative obtains the approval of the ombudsman.
It is the general practice of the BOALTC to use a standard release that
they have an individual sign to authorize access to records.
The Department is pleased to have Ombudsman programs available for all
current and potential enrollees. The Ombudsman programs along with the
MCOs' Member Rights Specialists are integral to protecting the enrollees'
rights and ensuring quality.
Ombudsman Programs Contact Information
Per the Department contract with the Managed Care Organizations, the
Ombudsman Programs contact information should appear in each Managed Care
Organization's member handbook and notice of action form.
- Disability Rights Wisconsin (DRW) Ombudsmen from this agency
provide advocacy to Family Care and Partnership members age 18-59.
131 W. Wilson St., Suite 700
Madison, WI 53703
608-267-0214
TTY: 888-758-6049
Fax: 608-267-0368
Madison Toll-free: 800-928-8778
Milwaukee Toll-free: 800-708-3034
Rice Lake Toll-free: 877-338-3724
http://www.disabilityrightswi.org
(Exit DHS)
(includes contact information for other locations)
- Wisconsin Board on Aging and Long Term Care Ombudsmen from this
agency provide advocacy to Family Care and Partnership members 60 and
older.
Board on Aging and Long Term Care
1402 Pankratz Street, Suite 111
Madison, WI 53704-4001
Toll-free: 800-815-0015
Fax: 608-246-7001
http://longtermcare.wi.gov/
(Exit DHS)
DHS CENTRAL OFFICE CONTACT:
Office of Family Care Expansion
1 W. Wilson, Rm. 518
Madison, WI 53703
DHS OFCE@dhs.wisconsin.gov
MEMO WEB SITE: http://www.dhs.wisconsin.gov/dsl_info/
cc: All DLTC Councils and Committees
Disability Rights Wisconsin
Board on Aging and Long Term Care
Wisconsin Council of Independent Living Centers
Independent Living Council of Wisconsin
Grass Roots Empowerment Program
People First
ARC Wisconsin
Wisconsin Homes and Services for the Aging
Area Administrators / Human Services Area Coordinators
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Last Revised:
May 06, 2013 |
