When applying for Family Care, Income Maintenance and the ADRC have 30 days to make their determinations of financial and functional eligibility. In this case, the petitioner was disenrolled November 1 due to excess assets, which her daughter then spent down and verified on December 28. Because the case had been closed for more than 30 days, a new referral was needed from the ADRC, which was not completed until January 25, resulting in an enrollment date of February 1. ALJ Brian Schneider concluded he could not backdate enrollment to January 1 because the determinations were made within the required 30 days—in other words, there was no delay due to agency error.
This decision was published with support from the Elder Law & Special Needs Section of the State Bar of Wisconsin and the Wisconsin chapter of the National Academy of Elder Law Attorneys.
Preliminary Recitals
Pursuant to a petition filed November 29, 2023, under Wis. Admin. Code, §HA 3.03(1), to review a decision by the Dane County Dept. of Human Services to discontinue Medical Assistance (MA) and Community Waivers, a hearing was held on February 7, 2024, by telephone. A hearing set for January 17, 2024 was rescheduled at the petitioner’s request.
Note: Following the hearing, the prefix of the case number was changed from MGE to FCP to accurately reflect the benefit program at issue in the appeal.
The issue for determination is whether eligibility can be backdated to January 1, 2024.
PARTIES IN INTEREST:
Petitioner:
—
Petitioner’s Representative:
—
Respondent:
Department of Health Services
1 West Wilson Street, Room 651
Madison, WI 53703
By: Stephanie Kuo
Dane County Dept. of Human Services
1819 Aberg Avenue
Madison, WI 53704-6343
ADMINISTRATIVE LAW JUDGE:
Brian C. Schneider
Division of Hearings and Appeals
Findings of Fact
- Petitioner (CARES # —) is a resident of Dane County.
- Petitioner was and is eligible for MA and the Family Care Program (FCP). By a notice dated September 29, 2023, the agency informed petitioner that both programs would close November 1, 2023 because of the discovery of a bank account in her name that put her over the asset limit.
- Petitioner’s daughter/authorized representative reported that the account had been frozen until October, 2023. After gaining access to it, she spent it down.
- As of the end of November, 2023, petitioner still had over $7,000 in a different bank account. On December 28, 2023, petitioner’s daughter wrote a check to the assisted living facility in the amount of $4,900 that reduced the account to under $2,000. The check cleared on December 29.
- Petitioner’s daughter reported the status to the agency on December 28. She was told that a new FCP referral would have to be filed because the case was closed for over 30 days. The new referral was signed with the Aging and Disability Resource Center (ADRC) on January 25, 2024, and the ADRC forwarded the FCP enrollment referral to the agency. Petitioner was granted MA and enrolled in the FCP effective February 1, 2024.
Discussion
The MA asset limit for an individual is $2,000. Wis. Stat., §49.47(4)(b)3g. If assets are above that limit, the person is not eligible for MA. The statute does not allow for outstanding debts to be deducted from assets, nor does it provide any exceptions for unusual situations.
The evidence shows that petitioner’s assets were over the limit in November, 2023, so the discontinuance of MA, and thus the FCP, effective November 1 was correct. The asset was reduced below the limit in late December, so petitioner should be asset-eligible for MA beginning December 1, 2023, although it appears that her income would make her ineligible for regular MA unless she met a substantial spend-down.
Petitioner’s daughter went ahead with the appeal hoping to have FCP eligibility backdated to January 1, 2024.
The FCP is a medical assistance waiver program that provides long-term care services to frail elderly individuals, individuals who have physical disabilities, and individuals who have intellectual disabilities. See Wis. Stat. § 46.286; see also Wis. Admin. Code, Chapter DHS 10. The FCP is designed to deliver benefits through a managed care system.
To be eligible for the FCP, a person must apply for benefits and meet the program’s financial, nonfinancial, and functional criteria. Wis. Stat., §46.286(1); Wis. Admin. Code, §§DHS 10.32(1)(d) and (e). However, a person who meets the program’s eligibility criteria is not entitled to receive benefits until she is enrolled in a managed care organization (MCO). See Wis. Stat., §46.286(1) (“A person is eligible for, but not necessarily entitled to, the family care benefit if … [the person] meets all eligibility criteria”). See also Wis. Admin. Code, §§DHS 10.36(1) and DHS 10.41(1). In other words, an individual cannot begin to actually receive Family Care benefits until she is enrolled in an MCO and she cannot be enrolled in an MCO until she is found eligible through the application process.
Income maintenance (“IM”) agencies determine financial and non-financial eligibility. Wis. Admin. Code §DHS 10.31(4)(a). ADRCs make functional eligibility determinations. Id. IM agencies are generally required to determine an individual’s financial and non-financial eligibility within 30 days of receipt of an application. Wis. Admin. Code §10.31(6)(a). ADRCs are generally required to determine an individual’s functional eligibility within 30 days of “receiv[ing] verbal acceptance from the applicant to proceed with the functional screen.” Wis. Admin. Code, §DHS 10.31(6)(am). The 30-day time periods for determining financial and non-financial eligibility and for determining functional eligibility may be extended if there is a delay in obtaining necessary information. Wis. Admin. Code, §10.31(6)(b).
Here petitioner’s FCP eligibility was determined within the 30-day time frame. There are instances where the Department will allow backdating of FCP eligibility where an application is delayed beyond the 30-day period through agency error or delay. However, in no instance has the Department approved backdating where the determination was made within the 30-day time frame. I thus have no authority to order petitioner’s FCP eligibility backdated to January 1, 2024 because her new application was completed within the mandated 30-day period.
Conclusions of Law
The agency correctly granted FCP eligibility effective February 1, 2024 because that is the first date of possible eligibility based upon her reapplication filed in January, 2024.
THEREFORE, it is
Ordered
That the petition for review is hereby dismissed.
[Request for a rehearing and appeal to court instructions omitted.]