DHA Case No. FCP 206782 (Wis. Div. of Hearings and Appeals January 11, 2023) (DHS) ↓ Download PDF 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 needed help with one […] Read more

DHA Case No. FCP 206604 (Wis. Div. of Hearings and Appeals January 5, 2023) (DHS) ↓ Download PDF Family Care members in Group A (due to eligibility for MAPP, for example) do not have a cost share. In this complex case, the petitioner lost MAPP eligibility when her child turned 18 and her fiscal test […] Read more

DHA Case No. FCP 203910 (Wis. Div. of Hearings and Appeals March 23, 2023) (DHS) ↓ Download PDF If payments to a relative for services exceed 10% of the maximum CSAS, the MEH requires a notarized agreement. In this case, the petitioner had an agreement to pay her daughters $500 per month, but it was […] Read more

DHA Case No. FCP 189482 (Wis. Div. of Hearings and Appeals February 27, 2019) (DHS) ↓ Download PDF To be covered under Family Care, a service must be cost-effective. In this case, the MCO denied the petitioner’s request to install an ADA-height elongated toilet in his rented apartment, saying there were less costly alternatives. ALJ […] Read more

DHA Case No. FCP 189820 (Wis. Div. of Hearings and Appeals February 6, 2019) (DHS) ↓ Download PDF To be covered under Family Care, a service must be medically necessary. In this case, the petitioner’s request for acupuncture therapy was denied because it had been tried and proved ineffective for her in the past. ALJ […] Read more

DHA Case No. FCP 189985 (Wis. Div. of Hearings and Appeals January 14, 2019) (DHS) ↓ Download PDF MCOs must consider an MA recipient’s income when determining benefits. In this case, the petitioner’s MCO reduced his out-of-benefit food budget when he started working, reasoning he could contribute that towards the cost of his food. ALJ […] Read more

DHA Case No. FCP 189984 (Wis. Div. of Hearings and Appeals January 14, 2019) (DHS) ↓ Download PDF MCOs must consider an MA recipient’s income when determining benefits. In this case, the petitioner’s MCO reduced his out-of-benefit food budget when he started receiving the state supplemental SSI payment, reasoning he could contribute that towards the […] Read more

DHA Case No. FCP 189662 (Wis. Div. of Hearings and Appeals January 14, 2019) (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 was enrolled in Family Care and receiving […] Read more

DHA Case No. FCP 207851 (Wis. Div. of Hearings and Appeals August 31, 2023) (DHS) ↓ Download PDF An MCO must determine whether a requested service is medically necessary and cost-effective. But in this case, the petitioner’s mother and guardian refused to cooperate with the MCO’s attempts to get the information it needed to make […] Read more

DHA Case No. FCP 208522 (Wis. Div. of Hearings and Appeals June 28, 2023) (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 her functionally ineligible because […] Read more

DHA Case No. FCP 207586 (Wis. Div. of Hearings and Appeals July 20, 2023) (DHS) ↓ Download PDF MCOs in the Family Care program may authorize residential services—such as placement in an Adult Family Home (AFH)—only if they are the most cost-effective option, if they are needed to support the member’s long-term care outcomes, or […] Read more

DHA Case No. FCP 208218 (Wis. Div. of Hearings and Appeals June 12, 2023) (DHS) ↓ Download PDF Cost share reductions are effective the month of the change report, even if the actual change in income or expense was earlier. In this case, the petitioner enrolled in Family Care with a cost share effective November […] Read more

DHA Case No. FCP 208068 (Wis. Div. of Hearings and Appeals August 9, 2023) (DHS) ↓ Download PDF 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’s primary diagnosis was schizophrenia […] Read more

DHA Case No. FCP 173457 (Wis. Div. of Hearings and Appeals September 15, 2016) (DHS) ↓ Download PDF The Medicaid Eligibility Handbook used to direct that the snapshot date for a spousal asset assessment was the “date of the first request for Community Waivers.” In this case, the petitioner was determined functionally eligible on August […] Read more