​Caring Starts with Your Rights

Understanding Grievances & Appeals

• What Is A Grievance?

  A grievance is when you are not satisfied with My Choice Wisconsin, one of our providers, or have concerns about the quality of your care or services. Unlike appeals, you can file a grievance at any time. Some examples include:

  • Your in-home personal care worker often arrives late.
  • You feel your team doesn’t listen to you.
  • If you have trouble getting appointments with a certain provider.
• What Is An Appeal?

  An appeal is a request for a review of a decision made by My Choice Wisconsin. For example, you can file an appeal if:

  • Your care team denies a service or support you requested.
  • You do not agree with a decision to reduce, end, or to deny payment for a service that is included in My Choice Wisconsin’s benefit package.

Grievances & Appeals Process

• Process for Grievances
  • First, contact your care team. They can help to quickly and informally resolve your concerns. 
  • If you don’t feel comfortable or don’t want to talk with your team, you may call a Member Rights Specialist at My Choice Wisconsin. A Member Rights Specialist will work with you to reach an agreement. 
  • If you cannot fix the issue with the Member Rights Specialist, you may request it be taken to our Grievance and Appeals Committee. 
  • If you are a member that also has Medicare and need to make a complaint or grievance regarding a Medicare service, you may use the Medicare Complaint Form to file a complaint with Medicare.

  Members may file a grievance with the MCO at any time.

  See Contact Information by Program below.
• Process For Appeals
  • First, call a My Choice Wisconsin Member Rights Specialist. The Member Rights Specialist may be able to help you reach an agreement without filing a formal appeal. 
  • If your concern is not resolved with the Member Rights Specialist, you may work with them to file an appeal with My Choice Wisconsin.

  Members may file an appeal with the MCO within 60 days of the adverse benefit determination notification.

  See Contact Information by Program below.
• Appointing a Representative

  You have the right to name another person to act for you as your “representative” to file a grievance or appeal. If you want to appoint a trusted friend, relative, or provider as your representative, you may fill out and mail the Appointment of Representative (AOR) form or call our Customer Service team (1-800-963-0035) for assistance. 

What if I Don’t Agree with My Choice Wisconsin’s Decision?

• For a Grievance – Family Care and Medicaid-Only Partnership Members

  If you are not happy with the resolution of your grievance with your Members Rights Specialist and the Grievance and Appeals Committee, you have the right to file a grievance with the Department of Health Services (DHS).

  • You must file no later than 45 days from the date of the My Choice Wisconsin grievance decision.
  • DHS contracts with MetaStar, an external quality review organization. You can call them at 888-203-8338 to request a grievance review. 
  • Your My Choice Wisconsin grievance decision letter has more information about this process. 
• For a Grievance – Medicare Dual Advantage and Medicare/Medicaid Partnership Members

  If you are not happy with the resolution of your grievance with your Members Rights Specialist and the Grievance and Appeals Committee, you may use the Medicare Complaint Form to file a complaint directly with Medicare.
• For an Appeal – Family Care and Medicaid-Only Partnership Members

  If you are not happy with the resolution of your appeal with your Members Rights Specialist and the Grievance and Appeals Committee, you have the right to file an appeal with the state’s Division of Hearings and Appeals (DHA) for a fair hearing. 

  • You must file no later than 90 days from the date of the My Choice Wisconsin appeal decision. If you appeal to DHA before the effective date, the service may continue. 
  • You may complete this form (English) and then mail or fax it back to DHA using the address on the form. If you need additional languages, please find the appropriate form here.  
  • An administrative law judge will make a decision about your appeal and issue a decision to you in writing.
  • You may need to pay for the cost of services if the hearing decision is not in your favor.

  See Contact Information by Program below.
• For an Appeal – Medicare Dual Advantage and Medicare/Medicaid Partnership Members
  • Medicare Part C “Level 2” appeals – if the My Choice Wisconsin decision is adverse to the member, we automatically forward it to be reviewed by the independent review entity, Maximus. Your My Choice Wisconsin decision letter will notify you of this and will provide additional information about this process. 
  • Medicare Part D “Level 2” appeals – if you are not happy with the My Choice Wisconsin resolution of your appeal, you have the right to file an appeal with the independent review entity, Maximus. Your My Choice Wisconsin decision letter has instructions on how you may contact Maximus and deadlines you must follow. 
  • Please reference your program’s Evidence of Coverage for more information. 

Understanding Advanced Directives

• What are Advanced Directives?

  Advance directives are important documents that protect your dignity and help avoid arguments and assumptions about your care. They tell your family and doctors the type of healthcare you would or would not want if you become unable to communicate your wishes or are incapacitated. 
• Informational Video

  Learn all about Advanced Directives by watching our informational video (English) featuring three MCW Nurse Practitioners.

  • Advanced Directives Video – Arabic captions
  • Advanced Directives Video – Chinese captions
  • Advanced Directives Video – Hmong captions
  • Advanced Directives Video – Laotian captions
  • Advanced Directives Video – Russian captions    
  • Advanced Directives Video – Serb-Croatian captions
  • Advanced Directives Video – Spanish captions

Contact Information By Program

• Family Care

  My Choice Wisconsin’s Member Rights Specialist:
  Phone: 1-800-963-0035 ext. 3448

  Fax: 608-245-3821

  Write:
  My Choice Wisconsin Health Plan
  ATTN: Member Rights Specialist
  10201 W. Innovation Drive
  Suite 100
  Wauwatosa, WI 53226
• Partnership

  My Choice Wisconsin’s Member Rights Specialist:
  Phone: 1-800-963-0035 ext. 3448

  Fax: 608-245-3821

  Write:
  My Choice Wisconsin Health Plan
  ATTN: Member Rights Specialist
  10201 W. Innovation Drive
  Suite 100
  Wauwatosa, WI 53226

  To mail a written request for a Part D drug Coverage Determination or Re-determination:
  My Choice Wisconsin by Molina Healthcare
  ATTN: Pharmacy Services
  5117 W. Terrace Drive, Suite 100
  Madison, WI 53718
• Medicare Dual Advantage

  My Choice Wisconsin’s Member Rights Specialist:
  Phone: 1-800-963-0035 ext. 3448

  Fax: 608-245-3821

  Write:
  My Choice Wisconsin Health Plan
  ATTN: Member Rights Specialist
  10201 W. Innovation Drive
  Suite 100
  Wauwatosa, WI 53226

  To file a complaint directly with Medicare, follow this link.

  To mail a written request for a Part D drug Coverage Determination or Re-determination:
  My Choice Wisconsin by Molina Healthcare
  ATTN: Pharmacy Services
  5117 W. Terrace Drive, Suite 100
  Madison, WI 53718
• Request for Aggregate Numbers

  If you wish to obtain aggregate numbers of grievances, appeals and exceptions filed with the plan, please contact the Member Rights Specialist by phone, fax, or mail.

  My Choice Wisconsin’s Member Rights Specialist:
  Phone: 1-800-963-0035 ext. 3448

  Fax: 608-245-3821

  Write:
  My Choice Wisconsin Health Plan
  ATTN: Member Rights Specialist
  10201 W. Innovation Drive
  Suite 100
  Wauwatosa, WI 53226