Grievances and Appeals2018-07-31T08:24:31+00:00

Appeals and Grievances

My Choice Family Care is committed to providing you with the highest quality long-term care support and customer service. We are always looking for ways to improve, and your suggestions and concerns are always welcomed.

Your Care Team or a MCO member liaison is usually the best place to start with any concern. Many concerns can be resolved by speaking with your Care Team or the MCO member liaison.

You will not get in trouble or be treated any differently if you disagree with your Care Team, the MCO, or providers. Making a complaint, or requesting an appeal or grievance will not affect the way the MCO, your team, or your providers treat you.

The difference between an appeal and a grievance:

  • When you request an appeal, it is because you have received a decision in writing that you do not agree with. You may receive notifications from several places about many different decisions—you may receive a notice from your team about a specific service such as in-home care or a piece of equipment, from My Choice about your cost share or functional eligibility, or from Income Maintenance about your Medicaid eligibility. When you request an appeal, you are requesting that the decision you do not agree with be reviewed again by a neutral committee or a judge. The result of an appeal is that a neutral party will either agree that the original decision was correct (uphold), or find that the original decision was incorrect (overturn).
  • When you request a grievance, it is because you have a concern or complaint that you would like to formalize and document. Unlike an appeal, the neutral party will not make any decision. The neutral party (a Metastar reviewer or the grievance committee) will review your concern and make recommendations on how the concern can be resolved. Grievances also help My Choice identify areas we can improve so that our members have the best care management possible.
If you are unhappy with your team, any service, or a provider, please do not hesitate to contact us at any time. As a member of Family Care, you have the right to make a complaint, and/or request an appeal or grievance at any time. Each has different rules and timelines, which can be confusing. There are many people who can help you. Information on who can help you with your complaint, appeal or grievance, what the difference between an appeal and grievance is, and how you can request an appeal or grievance is listed below. Information about your appeal and grievance options is also available in your Member Handbook.

Your Team

You can always tell your Care Team about any concern you have, and your team will try to answer your questions or resolve your concerns. Talking with your team is usually the easiest and fastest way to address your concern.

Family, Friends, Neighbors, Providers, Attorneys

With your permission, your family, friends, or other people you know and trust can help you talk to somebody about your concern, or help with an appeal or grievance if you want.

Managed Care Organization (MCO) Contacts

If you do not want to address your questions or concerns to your team, there are people at the MCO who can help:

  • Reception Staff can connect you to the best person to help:
  • MCO Member Liaison
    • By phone, call 414-287-7621 or toll-free at 877-489-3814
    • The member liaison will help you understand your rights as a Family Care member and will work with you to try to answer your questions or resolve your concerns. The MCO member liaison can help you decide exactly how you would like to proceed to have your complaint or concern addressed.
  • MCO Member Rights Specialists

Advocate/Ombudsman Agencies

Ombudsman and advocacy agencies are independent and not affiliated with My Choice Family Care. They offer assistance, free-of-charge, with your Family Care concern, grievance, or appeal:

  • For people under age 60:
    • Disability Rights Wisconsin
      131 West Wilson Street
      Suite 700
      Madison, WI 53703
      800-928-8778
    • Legal Aid Society
      414-765-0600
  • For people 60 years old and older:
    • Board on Aging and Long-Term Care
      1402 Pankratz Street
      Suite 111
      Madison, WI 53704-4001
      800-815-0015
    • Senior Law
      414-278-1222
A grievance can be filed when you are not satisfied with My Choice Family Care, your team, one of our providers, or have concerns about the quality of your care or services. These are not the only reasons you may submit a grievance—you can request a grievance at any time.

You can request a grievance from My Choice Family Care MCO, or through the State of Wisconsin Department of Health Services (DHS) review process, which is completed by an agency called Metastar.

My Choice Family Care MCO Grievances

The MCO member rights specialist will try to help informally address your concerns, and may work with you and your team to negotiate a solution. If we are unable to come up with a solution, or if you do not want to work to informally address your concerns, the member rights specialist will schedule a grievance meeting. The MCO Grievance and Appeal Committee will meet with you and your Care Team, and will offer recommendations on how your issue may be resolved.

How to Request a My Choice Family Care MCO Grievance: (*not a comprehensive list)

  • You can ask your team for the MCO grievance request forms.
  • You can call one of the member rights specialists at 414-287-7616 or 414-287-7654.
  • You can also write about your grievance request, and mail or fax it to:
    • My Choice Family Care
      Member Rights Specialists
      10201 W. Innovation Drive
      Suite 100
      Wauwatosa, WI 53213
      Fax: 414-755-1893

DHS (Metastar) Reviews

The State of Wisconsin Department of Health Services works with an agency called Metastar to review Family Care member concerns. A Metastar investigator will review your case and will talk to you, your Care Team, and MCO staff for information on the concern. The Metastar investigator will try to resolve your concerns.

How to Request a DHS (Metastar) Review: (*not a comprehensive list)

  • You can call Metastar directly at:
  • You can send your request in writing to:
    • DHS Family Care Grievances
      c/o MetaStar
      2909 Landmark Place
      Madison, WI 53713
      Email: dhsfamcare@wisconsin.gov
      Fax: 608-274-8340
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: 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: 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 Law414-278-7722

Board on Aging and Long Term Care Ombudsman (for Members 60 years or older) – Toll Free 800-815-0015

Legal Aid Society of Milwaukee414-765-0600

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.

If you have received a written decision (called a Notice of Action or “NOA”) from your Care Team that you do not agree with, you can request an appeal with both My Choice Family Care MCO and the State of Wisconsin Division of Hearings and Appeals (DHA) fair hearing.

These are some examples of why you may receive this notice:

  • Your Care Team has assessed your need for supportive home care, and found you have improved and can now do more things on your own. They send you a notice that they will be reducing your supportive home care time.
  • You requested a piece of medical equipment, and your Care Team, through their assessment, does not think it is the most appropriate item to support your needs. They send you a notice that they have denied your request.

With an MCO appeal, the MCO member right specialist will try to help informally address your concerns, and may work with you and your team to negotiate a solution. If we are unable to come up with a solution or if you do not want to work to informally address your concerns, the member rights specialist will schedule an appeal meeting. The MCO Grievance and Appeal Committee will review and make a decision based on the information they receive at the meeting.

With a DHA Fair Hearing, DHA staff will schedule a date, time, and location for a hearing. An administrative law judge will listen to your concerns, talk to My Choice Family Care staff, review documents that you submit if you choose, and review documents submitted by My Choice Family Care staff. The administrative law judge will the make a decision and issue a decision in writing.

Note: If you request an MCO appeal first, and do not like the decision, you can then request a fair hearing on the same issue. If you request a fair hearing with DHA first and you do not like the decision, you cannot then request an MCO appeal. You cannot file both an MCO appeal and fair hearing at the same time.

Note: You have the right to ask My Choice Family Care, DHS, or DHA to continue your services during your appeal. You must do this within 15 days of receiving written notice of an action. You team or the member rights specialist can help you with this, but it is important to talk to them as soon as you can.

My Choice Family Care MCO Appeals

How to Request an MCO Appeal: (*not a comprehensive list)

  • You can ask your team for the MCO appeal request forms.
  • You can call one of the member rights specialists at 414-287-7616 or 414-287-7654 and verbally request an appeal.
  • There is a My Choice Family Care appeal request form at the end of your Member Handbook.
  • You can send written appeal requests to:

State of Wisconsin Division of Hearings and Appeals (DHA) – Fair Hearings

How to Request a DHA Fair Hearing (your request MUST be in writing): (*not a comprehensive list)

  • You can ask your team for a State fair hearing request form.
  • You can call one of the member rights specialists at 414-287-7616 or 414-287-7654 who can help you get the fair hearing request form to DHA.
  • There is a State fair hearing request form at the end of your Member Handbook.
  • You can contact DHA directly via telephone for information or to request a fair hearing request form: 608-266-3096 or TTY: 608-264-9853
  • You can also write a short statement that describes your issue and requests a fair hearing. You can send written appeal requests to:
    • Family Care Request for Fair Hearing
      c/o Wisconsin Division of Hearings and Appeals
      5005 University Avenue, Suite 201
      P.O. Box 7875
      Madison, WI 53707-7875
      Fax: 608-264-9885

If you receive a written notification about a change in your Family Care eligibility or your cost share, you can only appeal that type of decision through the DHA fair hearing process– you cannot request an MCO appeal.

These are some examples of this type of change:

  • Your functional screen has changed, and you will have a change to the services you had been receiving.
  • You think your cost share is not correct.
  • You are being disenrolled from My Choice Family Care.

State of Wisconsin Division of Hearings and Appeals (DHA) Fair Hearings

How to Request a DHA Fair Hearing (your request MUST be in writing): (*not a comprehensive list)

  • You can ask your team for a State fair hearing request form.
  • You can call one of the member rights specialists at 414-287-7616 or 414-287-7654 to help you get the fair hearing request form to DHA.
  • There is a State fair hearing request form at the end of your Member Handbook.
  • You can contact DHA directly via telephone for information or to request a fair hearing request form: 608-266-3096 or TTY: 608-264-9853
  • You can also write a short statement that describes your issue and requests a fair hearing. You can send written appeal requests to:
    • Family Care Request for Fair Hearing
      c/o Wisconsin Division of Hearings and Appeals
      5005 University Avenue, Suite 201
      P.O. Box 7875
      Madison, WI 53707-7875
      Fax: 608-264-9885

Note: You have the right to ask DHS or DHA to continue your services during your fair hearing. You must do this within 15 days of receiving written notice of an action. Your team or a member rights specialist can help you with this, but it is important to talk to one of them as soon as you can.