When a member disagrees with a Medicaid HMO’s decision, the member must first appeal to the HMO. The Division of Hearings and Appeals does not have jurisdiction until there is a final determination by the HMO’s internal grievance and appeals committee. In this case, the petitioner did not appeal to iCare’s internal grievance committee first, so ALJ Debra Bursinger dismissed the appeal.
Preliminary Recitals
Pursuant to a petition filed on June 27, 2023, under Wis. Stat. § 49.45(5)(a), and Wis. Admin. Code § HA 3.03, to review a decision by the iCare regarding Medical Assistance (MA), a hearing was held on July 27, 2023, by telephone.
The issue for determination is whether DHA has jurisdiction over this matter.
There appeared at that time the following persons:
PARTIES IN INTEREST:
Petitioner:
—
Respondent:
Department of Health Services
1 West Wilson Street, Room 651
Madison, WI 53703
By: Attorney Emory Harlan
iCare
1555 N. Rivercenter Drive
Suite 206
Milwaukee, WI 53212
ADMINISTRATIVE LAW JUDGE:
Debra Bursinger
Division of Hearings and Appeals
Findings of Fact
- Petitioner (CARES # ) is a resident of Milwaukee County.
Discussion
As a Medicaid HMO, iCare is required to provide or arrange for the provision of medically necessary and appropriate medical services for its enrollees as required under Wis. Stats. §49.46(2), and Wis. Admin. Code §DHS 107.01(1). Medicaid HMOs may develop PA guidelines that differ from fee-for-service guidelines. However, the application of such guidelines may not result in less coverage than fee-for-service.
When a member disagrees with a determination by a Medicaid HMO, the member can appeal that determination. Per Wis. Stat. §49.45(5)(ag) and the HMO and PIHP Member Grievances and Appeals Guide, a member must first appeal to the HMO before a hearing can occur with the Division of Hearings and Appeals. The Division of Hearings and Appeals does not have jurisdiction over a matter until there is a final determination by the HMO’s internal grievance and appeals committee.
The Guide can be found online at https://www.forwardhealth.wi.gov/WIPortal/content/Managed%20Care%20Organization/Contracts/Home.htm.spage.
In this case, the Petitioner did not appeal to iCare’s internal grievance committee before filing an appeal with the Division of Hearings and Appeals. According to the Petitioner’s statements at the time of the hearing, she may have filed an appeal with the grievance committee since filing the DHA appeal but she does not have a final determination at this time.
Once the Petitioner receives a final determination from the iCare grievance committee, she can file a new appeal with the Division of Hearings and Appeals if she disagrees with the grievance committee’s decision.
Conclusions of Law
DHA does not have jurisdiction over this matter.
THEREFORE, it is
Ordered
That the Petitioner’s appeal is dismissed.
[Request for a rehearing and appeal to court instructions omitted.]