CWK 211595 (03/22/2024)
CLTS Waiver agency and DHS had opposite functional eligibility determinations

Preliminary Recitals

Pursuant to a petition filed on January 3, 2024, under Wis. Admin. Code § HA 3.03(1), to review a decision by the La Crosse County Department of Human Services regarding Medical Assistance (MA), a hearing was held on February 14, 2024, by telephone. The administrative law judge requested that, following the hearing, the agency submit the following to the Division of Hearings and Appeals (and to provide a copy to Petitioner of that submission): the functional screen report completed prior to the functional screen in dispute, an explanation of why Petitioner is eligible for on-going Katie Beckett Medical Assistance but not benefits through the Children’s Long Term Support Program, and a copy of a policy regarding continuous coverage for children that the agency’s representative referenced at hearing. The agency submitted all requested documents and they are incorporated into the hearing record.

The issue for determination is whether the agency properly found that Petitioner is no longer functionally eligible for the Children’s Long Term Support Program.

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: Angela Welch, CLTS Waiver Supervisor
La Crosse County Department of Human Services
300 N. 4th Street
PO Box 4002
La Crosse, WI 54601

ADMINISTRATIVE LAW JUDGE:
Teresa A. Perez
Division of Hearings and Appeals

Findings of Fact

1. Petitioner (CARES # —) is a five-year old resident of La Crosse County who receives services from the Children’s Long Term Support Waiver Program (hereafter, CLTS). She also receives Katie Beckett Program benefits.
2. In November 2022, Petitioner was found to be functionally eligible for CLTS and to meet the criteria for inclusion in the mental health target group / psychiatric level of care.
3. As part of Petitioner’s annual re-certification for CLTS in 2023, a CLTS Support and Service Coordinator from the agency completed a long term care functional screen (LTCFS) using information that she gathered from Petitioner and her mother, staff at Petitioner’s school, an unpaid caregiver, Petitioner’s grandmother, and medical and behavioral health records from the prior year. The LTCFS returned a result of not functionally eligible.
4. By notice dated December 22, 2023, the agency advised Petitioner that, effective January 5, 2024, she would be disenrolled from the CLTS Program because she was no longer functionally eligible for the program.
5. By notice dated January 2, 2024, the Department of Health Services (hereafter, the Department) informed Petitioner that she had been approved to continue receiving Katie Beckett benefits based on the information the Department has on file. On February 13, 2024, the Department notified Petitioner that her eligibility for Katie Beckett Medicaid was approved for April 1, 2024 through April 1, 2025.
6. On January 3, 3024, Petitioner filed an appeal of the notice of disenrollment from CLTS.

Discussion

To be eligible for both the CLTS Program and the Katie Beckett Program, a child must be found functionally eligible which requires the child to have a qualifying level of care and to be a member of a qualifying target group. It is undisputed that the standards for determining functional eligibility for the two programs are the same. Here, Petitioner has been determined by one unit of government to be eligible for the Katie Beckett Program and by another to be ineligible for the CLTS Program.

Petitioner’s mother expressed understandable confusion about her daughter’s ongoing eligibility for Katie Beckett and simultaneous disenrollment from CLTS based on a finding that she is not functionally eligible. At hearing, the agency’s CLTS Waiver Supervisor Angela Welch agreed to investigate the circumstances resulting in this seemingly incongruous result and to report back to the undersigned administrative law judge and to Petitioner. Supervisor Welch hypothesized that Petitioner may have qualified for continuous Katie Beckett eligibility under a new policy that guarantees 12 months of continuous coverage to children enrolled in certain Medicaid programs even if they stop meeting eligibility criteria prior to the end of that 12-month period. However, following the hearing, Supervisor Welch discovered that Petitioner’s ongoing eligibility for Katie Beckett is not based on that policy. Rather, Petitioner’s Katie Beckett eligibility was continued following completion of an administrative review by the Department of Health Services. Thus, the Department of Health Services effectively determined that Petitioner continues to meet all eligibility criteria for the Katie Beckett Program.

I understand that the method for reviewing Petitioner’s ongoing eligibility for the Katie Beckett Program that was employed by the Department was quite different than the method employed by the CLTS Waiver agency (i.e., completion of a long term care functional screen) and do not find any fault with the actions of the CLTS Waiver agency. However, I cannot find that Petitioner is functionally ineligible for the CLTS Program when the Department has found her to be functionally eligible for the Katie Beckett Program until April 2025 given that the legal standard for determining functional eligibility for the two programs is identical.

Conclusions of Law

Petitioner remains functionally eligible for the CLTS Program.

THEREFORE, it is

Ordered

That the matter is remanded to the agency to rescind the prior notice of disenrollment and to continue Petitioner’s CLTS Waiver eligibility until her next review, if she meets all other eligibility criteria. The agency shall comply with this order within ten calendar days of the date of this decision.

[Request for a rehearing and appeal to court instructions omitted.]