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

DHA Case No. FCP 211586 (Wis. Div. of Hearings and Appeals March 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 ADRC told the petitioner not to apply for MA until after the functional screen was completed, […] Read more

DHA Case No. FCP 211142 (Wis. Div. of Hearings and Appeals March 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 filed an application October 10, but the agency never told his authorized representative of the […] Read more

DHA Case No. FCP 211940 (Wis. Div. of Hearings and Appeals March 19, 2024) (DHS) ↓ Download PDF In general, all Family Care services must be authorized before they are provided. In this case, the petitioner’s assisted living facility closed and he had to move to a new one. My Choice staff met with him […] Read more

DHA Case No. FCP 211190 (Wis. Div. of Hearings and Appeals February 12, 2024) (DHS) ↓ Download PDF 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 […] Read more

DHA Case No. FCP 211094 (Wis. Div. of Hearings and Appeals February 12, 2024) (DHS) ↓ Download PDF An MCO must develop an individual service plan that reasonably and effectively addresses the enrollee’s long-term care needs and outcomes, including needs for socialization and activities. In this case, the petitioner’s MCO stopped paying for adult day […] Read more

DHA Case No. CWA 211081 (Wis. Div. of Hearings and Appeals February 8, 2024) (DHS) ↓ Download PDF Tribal General Welfare Assistance (GWA) is exempt income only if it is based on the individual’s demonstration of need. In this case, the petitioner received GWA that was admittedly not based on need. ALJ Peter McCombs concluded […] Read more

DHA Case No. FCP 210296 (Wis. Div. of Hearings and Appeals March 5, 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 agency denied the application in August after erroneously counting a burial asset. In October, after the […] Read more

DHA Case No. FCP 211106 (Wis. Div. of Hearings and Appeals January 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—but occasionally the screening program is wrong. In this case, the petitioner used […] Read more

DHA Case No. FCP 210267 (Wis. Div. of Hearings and Appeals January 25, 2024) (DHS) ↓ Download PDF Supportive Home Care (SHC) can be a benefit provided through Family Care when the member needs assistance with chores. In this case, Inclusa sought to end the petitioner’s SHC, claiming vaguely that “petitioner may be able to […] Read more

DHA Case No. FCP 210269 (Wis. Div. of Hearings and Appeals January 26, 2024) (DHS) ↓ Download PDF Non-medical transportation can be a benefit provided through Family Care when the member needs assistance with transportation. In this case, Inclusa sought to end the petitioner’s non-medical transportation, claiming vaguely that “petitioner may be able to walk […] Read more

DHA Case No. FCP 211038 (Wis. Div. of Hearings and Appeals January 31, 2024) (DHS) ↓ Download PDF When an MCO seeks to reduce a member’s supportive home care budget, it has the burden of proof. In this case, the petitioner’s MCO sought to reduce his budget because his son reported some minor improvements. ALJ […] Read more