8. Appealing a Denial

#8 in our series on the Children’s Long-Term Support Waiver

What is the Children’s Long–Term Support (CLTS) Waiver Program?

The CLTS Waiver Program provides funding and support for families who have children with disabilities, who are Medicaid eligible, so they can care for their children at home and participate in their communities. This fact sheet will help families who have a denial for a requested service, or who have been denied eligibility for the CLTS Program.

A Service We Requested Was Denied or Reduced—What Can We Do?

The CLTS Program will cover the cost of allowable services or items if they are included in your child’s Individual Service Plan (ISP). The ISP must be approved by your county, but sometimes the county reduces or denies an item or service in a child’s plan.

Never hesitate to question a decision. You have a right to be fully informed and to understand the reasons for all decisions. If you disagree with a decision about your child’s waiver services or eligibility, you have a legal right to appeal the decision. The information below explains the steps you can take if you want to appeal a decision.

Steps to Appealing Denial of Services

Step 1: You may choose to start by setting up a meeting with your child’s service coordinator and asking to review what was denied. Understanding the reason for the denial is helpful in overturning the decision.

Step 2: Review the outcomes that were developed to justify the purchase of the item or a service. Remember, all services must be justified by outcome statements.

Step 3: If the requested service or item is the best way for your child can meet the stated outcomes, you can complete your county’s grievance process. Each county has its own process, but in most cases it is informal – no attorney is needed.

Consider the following before completing the process: • Ask your child’s doctor to send a letter to address why the service is needed. • Ask school or community therapists to write a letter and explain why it is needed.

Step 4: If the appeal to the county does not resolve the problem, families can seek an appeal from the state. There may be situations when families prefer to go directly to the state appeals process and skip filing a grievance with a county.

You can request a hearing by completing the Division of Hearings and Appeals (DHA) Request for Fair Hearing Form at doa.wi.gov/Pages/LicensesHearings/DHAWFSRequestingaHearing.aspx

You can also write on a piece of paper or on a copy of the Notice of Action of Denial that you would like to appeal through a fair hearing process and mail this request with your name, address and phone number to: Division of Hearings and Appeals, PO Box 7875, Madison, Wisconsin 53707.

It’s important to keep timelines in mind for requesting a fair hearing. You have 45 days from the date of the decision to file a request for a fair hearing. You can ask your support and service coordinator to help you file for an appeal. Call 608.266.7709 if you have questions about this process.

Fair hearings are informal meetings, almost always held over the phone, before an Administrative Law Judge. You will be asked to state “your side of the story” so it’s best to have it written down. See Advocates Guide to a Fair Hearing on the Family Voices website for more tips on how to prepare.

My Child Was Denied Eligibility for the CLTS Program—What Can We Do?

If your family has completed the application and eligibility process for one of the CLTS Programs, and your child has been determined not eligible, there are steps you can take to appeal the denial.

Step 1: You may start by requesting a meeting with the screener and reviewing the answers to the questions. Keep in mind that how the functional screen was completed, and the answers you provided to the screener, are key in determining whether your child will be deemed eligible.

Consider how you answered the questions related to your child’s care needs and challenges. This is where many families get hung up! Realize this is a time to be realistic about your child’s limitations and how he or she is delayed compared to peers. (See Family Voices of Wisconsin CLTS Fact Sheet #3 for more ideas.)

Your screener can update or re-submit answers to the functional screen that may move your child from being ineligible to eligible for the CLTS Program.

Step 2: If a meeting with the screener does not resolve the problem, and your child is still denied eligibility, families can submit a county grievance or go directly to the State of Wisconsin’s Division of Hearings and Appeals (DHA) — see page 1 for contact information and forms needed to complete a DHA request for a fair hearing.

Both appeals processes are informal and can be completed over the phone. Other family members, advocates or witnesses can participate to can help address the denial and provide evidence related to why the denial should be overturned.

To prepare for an appeal consider the following:

• Collect medical records that will provide more details about your child’s condition. • Request letters from your child’s doctors, therapists or community providers.

Tip for Families

Use a smartphone to take videos of your child during difficult times to show the screener a more realistic view of your child and increase the screener’s understanding of these challenges or limitations.

Who Can Help?

The following organizations can assist families with an appeal: • Disability Rights Wisconsin, drwi.org or 800.928.8778. • ABC for Health, safetyweb.org or 800.585.4222

If you have questions, contact your Regional Center for Children and Youth with Special Health Care Needs. To find your Center, go to dhs.wisconsin.gov/cyshcn/regionalcenters.htm or call 800.642.7837.