News: Due Process Options for SLS and CES Waivers
Summary of Due Process Options June 2009
The following are short descriptions of how individuals and families can address concerns regarding their supports and services.
Complaints
The Complaint Process is designed for issues that do not fall within dispute resolution or appeal requirements. Examples of issues that may fall under this are when you are unhappy with how individuals are providing services or you are not satisfied with a particular aspect of service delivery.
Complaints may be addressed by contacting your Service Provider’s Director or Designee regarding your concerns. You may also contact your Resource Coordinator. When these options are not acceptable, you may contact DDRC’s Customer Relations Representative for assistance in resolving your concerns.
Procedure: Resolution Process for Consumers and Interested Parties 5-01 DDRC
SIS Complaints
This process is used when a person believes the results of the SIS interview are not accurate. This may be prompted by concern with the way the instrument was administered, that the appropriate respondents were not at the interview, or when the person’s needs have changed significantly. DDRC may arrange for a second interview if there is a concern with accuracy of the first. These results will determine the final SIS score. DDRC may request DDD involvement if unable to find resolution at the local level.
Procedure: Supports Intensity Scale Complaint Procedure 7-08 DDD
Disputing an Individual Support Level
There are times when all parties agree the SIS instrument was appropriately administered but the level determined does not appear to match the needs of the individual. DDD has established a special review panel for determining the support level of individuals in Supported Living Services that will begin July 1, 2009. The CCB submits a request to the State for redetermination when there is sufficient evidence of misplacement. It is important to review your circumstances carefully as changing support levels may have a negative impact on the amount of services you receive. This review process is for Support Level only. It does not address the impact of Service Plan Authorization Limits and Overall Authorization Caps. Changes that result in reductions of service are appealed through the 803 process.
Procedure: Process to Dispute an Individual Support Level 6-09 DDD Disputes
The Dispute Resolution Process provides individuals the right to appeal through a series of steps including a formal appeal with an Impartial Decision Maker. If you are enrolled in State-funded services, this process is employed when the services identified in your service plan have been reduced, denied or changed. Some examples include no longer funding transportation or increasing supervision support. In some cases, individuals enrolled in Medicaid-funded services may dispute decisions through this process. Examples may include decisions to move to another setting or when a person is terminated from a service agency.
When the dispute process is implemented, you will be officially notified by your Resource Coordinator or Service Provider of your right to dispute. It is helpful to inform your Resource Coordinator when you receive notice from your service provider.
Procedure: Case Management Agency Dispute Resolution Procedure 10-08 DDRC
Appeals
The Appeal Process provides appeal rights for individuals denied eligibility for developmental disability services and for those applying for or enrolled in Medicaid Waiver Services, when services and/or supports are denied, reduced or changed. You will receive official notice (LTC 803) advising you of your right to a Medicaid Fair Hearing to appeal the action. You may request a hearing through the Office of Administrative Courts by responding in writing within the timeline outlined in the notice.
SLS and CES Waiver Changes
Due to CMS directives, some services previously allowed in the SLS waiver are being modified, reduced or eliminated. Examples of changes requiring an 803 notice include elimination of a service such as the SLC, when plans are reduced to stay within the $35,000 cap, and when services are no longer available because the definition has changed. As noted above, you will receive a notice of the services and/or supports that are changing. Your request for appeal must be submitted within the timeline identified. A conference will be scheduled to set a hearing date. You may arrange for have legal representation or represent yourself in the process. It is unknown at this time whether services continue during the appeal process. Please contact your Resource Coordinator with your questions and we will do our best to support you through the process.
