DHA Case No. FCP 213736 (Wis. Div. Hearings and Appeals Aug. 28, 2024) (DHS) ↓ Download PDF A participant in Family Care can be involuntarily disenrolled if they are determined ineligible for MA. In this case, the petitioner submitted his renewal timely and was eligible, but his MCO disenrolled him in error and could not […] Read more

DHA Case No. FCP 213572 (Wis. Div. Hearings and Appeals Sep. 24, 2024) (DHS) ↓ Download PDF A service that is “duplicative with respect to other services being provided” is not medically necessary. In this case, the petitioner attended after-hours recreational activities in the community while living with her mother for many years. But when […] Read more

DHA Case No. FCP 213852 (Wis. Div. Hearings and Appeals Sep. 12, 2024) (DHS) ↓ Download PDF Family Care enrollment may only be backdated when the agency has caused a delay after the application date. In this case, the petitioner mistakenly applied for Institutional MA in March and was found eligible before discovering that she […] Read more

DHA Case No. MRA 213308 (Wis. Div. Hearings and Appeals Jul. 31, 2024) (DHS) ↓ Download PDF A Community Waivers member in Group B or B Plus may use spousal improverishment rules to give income to his or her spouse as an “institutionalized person,” but Group A members are excluded from that definition. In this […] Read more

DHA Case No. CWA 212224 (Wis. Div. of Hearings and Appeals July 3, 2024) (DHS) ↓ Download PDF Family Care enrollment may be backdated if agency error causes a delay in enrollment. In this case, the ADRC completed the functional screen on October 31 but did not notify IM of the referral until January 10. […] Read more

DHA Case No. MGE 212813 (Wis. Div. of Hearings and Appeals June 28, 2024) (DHS) ↓ Download PDF Family Care enrollment may be backdated if agency error causes a delay in enrollment. In this case, the agency requested verification of a new funeral trust—which the petitioner had created but not reported during the pandemic—during a […] Read more

DHA Case No. CWA 213069 (Wis. Div. of Hearings and Appeals June 28, 2024) (DHS) ↓ Download PDF Family Care enrollment may be backdated if agency error causes a delay in enrollment, but only back to the first date the person was determined functionally eligible, was determined MA eligible, and had signed the enrollment form. […] Read more

DHA Case No. FCP 213209 (Wis. Div. of Hearings and Appeals June 27, 2024) (DHS) ↓ Download PDF A Family Care member can be involuntarily disenrolled if they lose or are determined ineligible for MA. In this case, the petitioner was disenrolled when the agency failed to test her for Community Waivers eligibility while processing […] Read more

DHA Case No. MGE 213356 (Wis. Div. of Hearings and Appeals June 20, 2024) (DHS) ↓ Download PDF In this very brief—but slightly horrifying—case, Milwaukee Enrollment Services notified the petitioner that she was no longer eligible for Community Waivers because “you have asked us to stop giving you this benefit.” This was an undisputed error. […] Read more

DHA Case No. CWA 212568 (Wis. Div. of Hearings and Appeals June 6, 2024) (DHS) ↓ Download PDF Family Care enrollment can be backdated if agency error by the ADRC or IM causes unreasonable delay. In this case, the petitioner was determined functionally and financially eligible as of December 14, but Income Maintenance simply failed […] Read more

DHA Case No. FCP 212098 (Wis. Div. of Hearings and Appeals April 26, 2024) (DHS) ↓ Download PDF Family Care enrollment can be backdated if agency error by the ADRC or IM causes unreasonable delay. In this case, the petitioner claimed to have sent verification of assets being below $2,000 in December—via ACCESS and, a […] Read more

DHA Case No. FCP 211909 (Wis. Div. of Hearings and Appeals April 23, 2024) (DHS) ↓ Download PDF An individual is functionally eligible for Family Care if he or she needs a “nursing home” level of care, as determined by the functional screen. In this case, the petitioner’s functional screen found the petitioner functionally ineligible […] Read more

DHA Case No. MGE 211532 (Wis. Div. of Hearings and Appeals April 19, 2024) (DHS) ↓ Download PDF Family Care enrollment can be backdated if agency error by the ADRC or IM causes unreasonable delay. In this case, the petitioner applied August 8 and Income Maintenance did nothing until September 19, well beyond the 30-day […] Read more

DHA Case No. FCP 211741 (Wis. Div. of Hearings and Appeals April 17, 2024) (DHS) ↓ Download PDF Beginning on the date of enrollment, an MCO must pay for needed services, including the continuation of current services “necessary to ensure health and safety and continuity of care,” until the full assessment and member-centered plan are […] Read more