To be functionally eligible for Family Care, a person must fall into one of the program’s target groups in addition to needing a nursing home level of care. In this case, the petitioner was diagnosed with schizophrenia and a substance use issue. Although the petitioner met the definition of “severe and persistent mental illness,” ALJ Kelly Cochrane concluded he was not in any of the long-term care target groups (frail elder, physical disability, or developmental disability) and was not functionally eligible.
This result accords with FCP 208068. But note FCP 206000, in which ALJ Jason Grace concluded a petitioner with Major Neurocognitive Disorder was included in the Developmental Disability target group.
This decision was published with support from the Wisconsin chapter of the National Academy of Elder Law Attorneys.
Preliminary Recitals
Pursuant to a petition filed on October 26, 2023, under Wis. Admin. Code § DHS 10.55, to review a decision by the ADRC of Milwaukee County regarding Medical Assistance (MA), a hearing was held on December 14, 2023, by telephone.
The issue for determination is whether petitioner is functionally eligible for the Family Care Program (FCP).
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: Catherine Moe, QI Coordinator, ADRC
ADRC of Milwaukee County
Aging Resource Ctr-Suite 300
1220 W Vliet St
Milwaukee, WI 53205
ADMINISTRATIVE LAW JUDGE:
Kelly Cochrane
Division of Hearings and Appeals
Findings of Fact
- Petitioner is a resident of Milwaukee County. He is diagnosed with schizophrenia and a substance use issue.
- On August 17, 2023 petitioner was referred for eligibility screening for the FCP.
- On August 25, 2023 a Long-Term Care Functional Screen (LTCFS) was performed for the petitioner.
- On September 6, 2023 the agency issued a notice to petitioner advising him that he was not functionally eligible for any long-term care programs like the FCP.
Discussion
The FCP, which is supervised by the Department of Health Services (DHS), is designed to provide appropriate long-term care services for elderly or disabled adults. It is authorized in the Wisconsin Statutes, § 46.286, and is described comprehensively in the Wisconsin Administrative Code, Chapter DHS 10. The FCP is intended to meet the long-term care and health care needs of the following “target groups”: frail elders, an adult with a physical disability as defined under Wis. Stat. § 15.197(4)(a)2., or an adult with developmental disability as defined in Wis. Stat. § 51.01(5)(a). See Wis. Stat. § 46.286(1); see also Wis. Adm. Code DHS § 10.32(1)(c).
Under the laws referenced above, “physical disability” means a “physical condition, including an anatomical loss or musculoskeletal, neurological, respiratory or cardiovascular impairment, which results from injury, disease or congenital disorder and which significantly interferes with or significantly limits at least one major life activity of a person.” Wis. Stat. § 15.197(4)(a)2. “Developmental disability” means:
a disability attributable to brain injury, cerebral palsy, epilepsy, autism, Prader-Willi syndrome, intellectual disability, or another neurological condition closely related to an intellectual disability or requiring treatment similar to that required for individuals with an intellectual disability, which has continued or can be expected to continue indefinitely and constitutes a substantial handicap to the afflicted individual. “Developmental disability” does not include dementia that is primarily caused by degenerative brain disorder.
Wis. Stat. § 51.01(5)(a).
As part of determining whether someone is functionally eligible for the FCP, the agency uses a uniform functional screening process—the LTCFS. See Wis. Adm. Code DHS § 10.33(2)(a). The agency performed that function for the petitioner. Petitioner is not diagnosed with either a physical or developmental disability and is not a frail elder. He was determined to meet the definition of “severe and persistent mental illness”, however, that is not an eligible target group for the FCP. See Wis. Stat. § 46.286(1), Wis. Adm. Code DHS § 10.32(1)(c) and Wis. Stat. § 51.01(14t). He therefore does not meet the target group eligibility under the law for the FCP. I must find the agency correctly determined that he was not functionally eligible for the FCP.
Conclusions of Law
The petitioner is not functionally eligible for the FCP.
THEREFORE, it is
Ordered
The petition for review herein is dismissed.
[Request for a rehearing and appeal to court instructions omitted.]
If you found this decision useful, sign up for my email newsletter. You’ll get summaries of newly published decisions and a PDF of useful information on estate recovery.