CWA 216153 (03/26/2025)
Family Care backdated when renewal missed due to agency technical issues

Preliminary Recitals

Pursuant to a petition filed on December 4, 2024, under Wis. Admin. Code § HA 3.03, to review a decision by the Milwaukee Enrollment Services regarding Medical Assistance (MA), a hearing was held on February 19, 2025, by telephone.

The issue for determination is whether petitioner’s Family care enrollment must be continued after 7/31/24 without lapse after it was discontinued due to agency error.

There appeared at that time the following persons:

PARTIES IN INTEREST:

Petitioner:
—

Petitioner’s Representative:
Attorney John Zabkowicz
Pruitt Zabkowicz S.c.
731 S. Main St.
Racine, WI 53403

Respondent:
Department of Health Services
1 West Wilson Street, Room 651
Madison, WI 53703
By: L. Griffin
Milwaukee Enrollment Services
1220 W Vliet St
Milwaukee, WI 53205

ADMINISTRATIVE LAW JUDGE:
John Tedesco
Division of Hearings and Appeals

Findings of Fact

1. Petitioner is a resident of Milwaukee County.
2. The facts in this case are not in dispute.
3. Petitioner was enrolled in Medicaid and FCP.
4. Petitioner attempted to complete a Medicaid renewal.
5. Due to agency error in the form of various technical problems making the completion of a timely renewal a challenge for petitioner, the Medicaid renewal failed and Medicaid was terminated.
6. The agency terminated petitioner’s FCP enrollment effective 7/31/24 due to petitioner not being enrolled in Medicaid.
7. Renewal was completed on 8/6/24. Medicaid eligibility was continued with no gap in enrollment.
8. A fair hearing found that the late renewal was due to agency error from technical problems.
9. Petitioner was required by the ADRC to re-apply for Family Care in order to have eligibility. That new enrollment process took until re-enrollment in Family care on 12/4/24.
10. FCP was reinstated as of 12/4/24.

Discussion

The Family Care program (FCP) is a MA waiver program that provides appropriate long-term care services for elderly or disabled adults. Wis. Stat. §46.286; see also Wis. Admin. Code, Chapter DHS 10. To be eligible, a person must meet the program’s financial and non-financial criteria, including functional criteria. Wis. Admin. Code, §§DHS 10.32(1)(d) and (e). Wis. Admin. Code, §DHS 10.33(2) provides that an FCP applicant must have a functional capacity level of comprehensive or intermediate (also called nursing home and non-nursing home). The process contemplated for an applicant is to test for functional eligibility, then for financial eligibility, and if the applicant meets both standards, to certify him/her as eligible.

The agency explained at hearing that petitioner’s Medicaid enrollment lapsed due to no renewal being processed. It was not disputed that petitioner made numerous attempt to complete a timely renewal which was not completed due to agency technical issues.

The petitioner did everything petitioner was required to do to complete the Medicaid renewal but the agency was unable to process the renewal timely. The IM agency has reversed the Medicaid termination and petitioner’s Medicaid enrollment is now continuous and without a lapse. The ADRC took excessive time to re-enroll petitioner. It is undisputed that petitioner always remained financially and functionally eligible for FCP.

The FCP agency explained at hearing that it has no process by which it can reverse the termination or and allow continuation of enrollment even when, as here, the petitioner’s Medicaid termination was agency error.

Conclusions of Law

The petitioner’s FCP enrollment lapse was caused by agency error and, thus, was itself error.

THEREFORE, it is

Ordered

That the matter is remanded to the agency with direction to reverse the termination of FCP and to retroactively continue FCP enrollment without lapse from 7/31/24 onward. This action must be completed within 10 days of this Decision.

[Request for a rehearing and appeal to court instructions omitted.]