To be functionally eligible for Community Waivers long-term care programs, a person must fall into one of the target groups (frail elder, physical disability, or developmental disability) in addition to needing a nursing home level of care. In this case, the petitioner’s protective placement physician’s report identified the sole condition as “serious and persistent mental illness, with a supporting diagnosis listed of schizophrenia.” ALJ Jason Grace concluded the functional screen correctly denied eligibility on the basis of not being in an eligible target group, even though the petitioner did need significant help with activities of daily living.
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 January 9, 2024, under Wis. Admin. Code § DHS 10.55, to review a decision by the ADRC of La Crosse County regarding Medical Assistance (MA), a hearing was held on February 21, 2024, by telephone.
The issue for determination is whether agency erred in its determination that petitioner is not eligible for long-term care waiver services due to not falling within a “target group.”
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: Shelly Bolstad
ADRC of La Crosse County
300 4th St. N
La Crosse, WI 54601
ADMINISTRATIVE LAW JUDGE:
Jason M. Grace
Division of Hearings and Appeals
Findings of Fact
- Petitioner (CARES # —) is a 64 year-old resident of Wisconsin.
- The petitioner was placed under a Ch. 55 protective placement in La Crosse County Case No —. The examining physician’s report in that case directed the medical consultant to select all conditions related to the petitioner’s incapacity, with options provided of developmental disability, degenerative brain disorder, serious and persistent mental illness, and other like incapacities. The sole condition selected was serious and persistent mental illness, with a supporting diagnosis listed of schizophrenia.
- Petitioner sought long-term care waiver services.
- On or about December 19, 2023, the ADRC of La Crosse County completed a long-term care functional screen of the petitioner to determine functional eligibility for long-term care waiver services. She was found to be in need of assistance with 3 Activities of Daily Living (bathing, dressing, and eating) and 5 Instrumental Activities of Daily Living (meal preparation, medication administration/management, money management, laundry/chores, and transportation). She was found functionally ineligible for long-term care waiver services because she did not fall within an eligible target group. Specifically, she was found to belong to the target group of severe and persistent mental illness.
- Petitioner, by her representative, appealed.
Discussion
The long-term waiver programs, which are administered by the Department of Health Services, is designed to provide appropriate long-term care services for individuals who fall within the following “target groups”: 1. Frail elders; 2. individuals aged 18 and older who have physical disabilities, as defined in Wis. Stats. § 15.197(4)(a)2; and 3. individuals aged 18 and older who have developmental disabilities. See, e.g. Wis. Stats. §46.286. To be eligible for enrollment in a long-term care waiver program, an individual must fall within one of these target groups AND need a “nursing home” (referred to as comprehensive) or “non-nursing home” (referred to as intermediate) level of care. See, Wis. Stats. §46.286(1)(a).
The ADRC completed a long-term care functional screen (LTCFS) of the petitioner. Following that screen, the petitioner was determined not to meet one of the target groups for the long-term care waiver program. According to the examining physician’s report submitted in the record from the Ch. 55 case, the petitioner’s needs relate to a severe and persistent mental illness. See, Finding of Fact 2. That report did not attribute those needs to a developmental disability or other like incapacity. Id. That evidence was not rebutted at hearing by compelling and competent evidence. The target group of severe and persistent mental illness is not one of the eligible long-term care program target groups. While I understand that the petitioner has significant need for assistance, she is ineligible for the long-term care program because she is not a member of one of the required target groups for the program.
Based on the record before me, I am not able to find that the agency erred in its determination that petitioner is functionally ineligible for the long-term care program.
Conclusions of Law
The agency did not err in its determination that the petitioner is ineligible for long-term care program as she does not meet an eligible “target group.”
THEREFORE, it is
Ordered
That the petitioner’s appeal is dismissed.
[Request for a rehearing and appeal to court instructions omitted.]
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