CWA 218656 (07/30/2025)
Petitioner with mental health diagnosis resulting in physical symptoms was functionally eligible

Preliminary Recitals

Pursuant to a petition filed June 11, 2025, under Wis. Admin. Code, §HA 3.03, to review a decision by the ADRC of Eau Claire County regarding Community Waiver eligibility, a hearing was held on July 29, 2025, by telephone.

The issue for determination is whether petitioner meets the level of care requirement.

PARTIES IN INTEREST:

Petitioner:
—

Respondent:
Department of Health Services
1 West Wilson Street, Room 651
Madison, WI 53703
By: Elizabeth Nett
ADRC of Eau Claire County
721 Oxford Ave, Room 1130
Eau Claire, WI 54703

ADMINISTRATIVE LAW JUDGE:
Brian C. Schneider
Division of Hearings and Appeals

Findings of Fact

1. Petitioner is a 50-year-old resident of Eau Claire County.
2. Petitioner has a unique diagnosis of Functional Neurologic Disorder/Conversion Disorder (FND), a mental health diagnosis which results in physical symptoms, particularly weakness in his legs. All medical and social work professionals agree that he is at risk of failing to obtain nutrition, self-care, and safety without intervention.
3. Petitioner cannot stand or ambulate for any length of time. If he showers, he must use a shower chair, but he cannot reach all areas of his body when he is seated. He thus does self-sponge baths, but again, is unable to reach all areas. He is able to dress if seated but is exhausted when finished. He uses a cane for mobility, and although he is able to toilet, he uses grab bars.
4. Petitioner needs assistance with grocery shopping and laundry/chores. He takes his own medications but only if they are prepacked with assistance from the Community Support Program. He needs assistance with money management and transportation because of his mental health issues.
5. Petitioner applied for community waiver programs (either Family Care or IRIS) in May, 2025. A functional screen was completed on June 11, 2025. Because petitioner has a mental health diagnosis but displays physical symptoms, the screener was unable to choose a target group and could not enter assistance categories because they did not fit the functional screen instructions. The result was that petitioner was found to not meet an institutional level of care, and his application was denied by a notice dated June 11, 2025.

Discussion

The Family Care Program (FCP), which is supervised by the Department of Health Services, is designed to provide appropriate long-term care services for elderly or disabled adults. It is authorized in the Wisconsin Statutes, §46.286, and is described comprehensively in the Wisconsin Administrative Code, Chapter DHS 10. The IRIS program was developed pursuant to a Medical Assistance waiver obtained by the State of Wisconsin, pursuant to section 6087 of the Deficit Reduction Act of 2005 (DRA), and section 1915(c) of the Social Security Act. It is a self-directed personal care program. Both programs are under the umbrella of the Community Waivers structure.

Wis. Admin. Code, §DHS 10.33(2) provides that an FCP applicant must have a functional capacity level of comprehensive or intermediate; I note here that Wis. Stat., §46.286, uses the terms “nursing home” and “non-nursing home” levels just as the agency in this case. If the person meets the comprehensive (nursing home) level, he is eligible for full services through a managed care organization (MCO), including Medical Assistance (MA). Wis. Admin. Code, §DHS 10.36(1)(a). If the person meets the intermediate (non-nursing home) level, he is eligible for full services only if she is in need of adult protective services or she is financially eligible for MA. Wis. Admin. Code, §DHS 10.36(1)(b). A person eligible under the non-nursing home level is eligible for less FCP services. To be eligible for IRIS, a person must have a nursing home level of care. IRIS Policy Manual, §1.2B.2

Wis. Admin. Code, §DHS 10.33(2)(c) describes comprehensive functional capacity:

(c) Comprehensive functional capacity level. A person is functionally eligible at the comprehensive level if the person requires ongoing care, assistance or supervision from another person, as is evidenced by any of the following findings from application of the functional screening:

1.  The person cannot safely or appropriately perform 3 or more activities of daily living.
2. The person cannot safely or appropriately perform 2 or more ADLs and one or more instrumental activities of daily living.
3. The person cannot safely or appropriately perform 5 or more IADLs.
4. The person cannot safely or appropriately perform one or more ADL and 3 or more IADLs and has cognitive impairment.
5. The person cannot safely or appropriately perform 4 or more IADLs and has cognitive impairment.
6. [Not applicable to petitioner’s situation]

ADLs include bathing, dressing, eating, mobility, and transferring. Wis. Admin. Code, §DHS 10.13(1m). IADLs include meal preparation, medication management, money management, laundry and chores, telephone, transportation, and the ability to function at a job site. Admin. Code, §DHS 10.13(32).

The Department has developed a computerized functional assessment screening system. The system relies upon a face-to-face interview with a quality assurance screener who has at least a Bachelor of Science degree in a health or human services related field, with at least one year of experience working with the target populations (or, if not, an individual otherwise specifically approved by the Department based upon like combination of education and experience). The screener asks the applicant, or a recipient at a periodic review, questions about his or her medical conditions, needs, cares, skills, activities of daily living, and utilization of professional medical providers to meet these needs. The screener then submits the Functional Screen Report for the person to the Department’s Division of Medicaid Services. The Department enters the Long-Term Functional Screen data into a computer program to see if the person meets any of the required levels of care.

If the screener enters information into the functional screen correctly, then it is assumed that the computer will accurately determine the level of care. However, although functional screeners are trained to score an ADL as “independent” if the person is able to complete it independently with the use of adaptive equipment or durable medical equipment (DME), the Department has consistently upheld the policy that the need for adaptive equipment is the equivalent of requiring assistance. See, most recently, Final Decision no. FCP-191012, dated 2/15/19. The policy is based on a Department Functional Screen Information Access version 2019.1 (usually called the “Logic”), which states “An ADL is counted if some degree of help is needed (1 or greater), of if adaptive equipment is required.”

Petitioner’s case clearly falls within the cracks of the functional screening system. Under the instructions his diagnosis is mental health, but his symptoms are physical. Following the logic of the screen, petitioner can meet neither the mental health nor the physical disability target group. However, as an administrative judge, I am not bound by the functional screen results. I am bound by the definition of comprehensive (nursing home) functional capacity found in the Wisconsin Administrative Code.

Based on that logic and coupled with the code definition of comprehensive functional capacity, I can conclude that petitioner cannot safely perform three ADLs (bathing, toileting, and mobility). He thus meets the subdivision 1 of the definition, even without reviewing the need for IADL assistance. That said, he also needs assistance with the IADLs meal preparation (grocery shopping), medication management, money management, laundry/chores, and transportation. He thus would meet the level of care under all five of the cited bases. The matter will be remanded to the ADRC to change petitioner’s functioning to nursing home level (under either the mental health or physical disability target group, whichever can be utilized), and to continue processing his community waivers application based on that functional level.

Conclusions of Law

Petitioner meets the nursing home level of care for FCP/IRIS eligibility.

THEREFORE, it is

Ordered

That the matter be remanded to the ADRC of Eau Claire County with instructions to change petitioner’s level of care to nursing home, and to continue processing his community waivers application based upon that level of care. The agency shall take the action within 10 days of this decision.

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