FCP 189984 (01/14/2019)
Food budget reduced when petitioner started receiving SSI-E

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 cost of his food. ALJ Peter McCombs concluded the MCO properly modified the food benefit.

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Preliminary Recitals

Pursuant to a petition filed on September 19, 2018, under Wis. Admin. Code § DHS 10.55, to review a decision by the Inclusa Inc/Community Link regarding Medical Assistance (MA), a hearing was held on December 4, 2018, by telephone.

The issue for determination is whether the respondent correctly reduced petitioner’s out-of-benefit food budget.

There appeared at that time the following persons:



Department of Health Services
1 West Wilson Street, Room 651
Madison, WI 53703
By: —
Inclusa Inc/Community Link
3349 Church St Suite 1
Stevens Point, WI 54481

Peter McCombs
Division of Hearings and Appeals

Findings of Fact

  1. Petitioner (CARES # —) is a 26-year-old resident of Portage County. Petitioner is presently enrolled in Family Care.
  2. Petitioner has diagnoses of autism spectrum disorder, celiac disease, intestinal disaccharidase deficiency, Type 1 diabetes, hypothyroidism, insomnia, intestinal malabsorption, autoimmune disease, hypertrophic condition of skin, dental caries, and hypoglycemia.
  3. Petitioner’s benefits through the Family Care program have included an out-of-benefit food budget to assist petitioner with purchasing food for his specialized diet.
  4. Effective August 1, 2018, Petitioner began receiving 95.99 monthly payments of SSI-E. Petitioner also receives monthly Social Security and state supplemental benefits.
  5. On August 7, 2018, the agency conducted a Resource Allocation Decision (RAD) regarding the Petitioner’s request for his continued out-of-benefit food budget. The agency noted the Petitioner has significant and multiple food allergies, in addition to uncontrolled diabetes and digestive issues.
  6. On August 8, 2018, the agency notified Petitioner that it had modified his request, reducing the food budget by $95.99, based on its conclusion that the Petitioner has informal support available and that the food budget is not authorized.
  7. On September 19, 2018, the Petitioner filed an appeal with the Division of Hearings and Appeals.


The Family Care program (FC) which is supervised by the Department of Health Services, is designed to provide appropriate long-term care services for elderly or disabled adults. Whenever the local Family Care program decides that a person is ineligible for the program, or when the CMO denies a requested service, the client is allowed to file a local grievance.

The state code language on the scope of permissible services for the FC reads as follows:

DHS 10.41 Family care services.…

(2) SERVICES. Services provided under the family care benefit shall be determined through individual assessment of enrollee needs and values and detailed in an individual service plan unique to each enrollee. As appropriate to its target population and as specified in the department’s contract, each CMO shall have available at least the services and support items covered under the home and community-based waivers under 42 USC 1396n(c) and ss. 46.275, 46.277 and 46.278, Stat., the long-term support services and support items under the state’s plan for medical assistance. In addition, a CMO may provide other services that substitute for or augment the specified services if these services are cost-effective and meet the needs of enrollees as identified through the individual assessment and service plan.

Note: The services that typically will be required to be available include adaptive aids; …home modification; … personal care services; …durable medical equipment…and community support program services.

Wis. Admin. Code §HFS 10.41(2).

The general legal guidance that pertains to determining the type and quantity of care services that must be placed in an individualized service plan (ISP) is as follows:

DHS 10.44 Standards for performance by CMOs.

(2) CASE MANAGEMENT STANDARDS. The CMO shall provide case management services that meet all of the following standards:

(f) The CMO, in partnership with the enrollee, shall develop an individual service plan for each enrollee, with the full participation of the enrollee and any family members or other representatives that the enrollee wishes to participate. … The service plan shall meet all of the following conditions:

  1. Reasonably and effectively addresses all of the long-term care needs and utilizes all enrollee strengths and informal supports identified in the comprehensive assessment under par. (e)1.
  2. Reasonably and effectively addresses all of the enrollee’s long-term care outcomes identified in the comprehensive assessment under par. (e)2 and assists the enrollee to be as self-reliant and autonomous as possible and desired by the enrollee.
  3. Is cost-effective compared to alternative services or supports that could meet the same needs and achieve similar outcomes.

Wis. Admin. Code §DHS 10.44(2)(f).

The agency testified that, through its RAD decision process, it determined that petitioner’s new SSI-E income would allow petitioner to contribute to his food budget, thereby reducing the need for assistance in this regard. In its Notice of Action terminating the food budget benefit, the agency wrote:

— is now receiving SSI-E at $95.99 per month and can contribute this amount toward his monthly food costs, gluten free food.

Exhibit R-2.

The Petitioner was represented at the hearing by his mother. She argued that the Petitioner has many medication costs, in addition to his specialized diet costs. Petitioner’s parents provide him with natural supports, including substantial medication management support and they do not collect any rent from him. Petitioner’s mother stated that the net result of Petitioner’s receipt of SSI-E benefits was provided to Inclusa, as a result of the modification to Petitioner’s food budget. She further noted that she pays for Petitioner’s pain medication herself, in the amount of approximately $180.00 per month.

The respondent’s determination here is premised upon a cost-based analysis. Specifically, the respondent maintains that, when the out-of-benefit food budget was initially approved in the amount of $418.15, Petitioner was not receiving the SSI-E income. As such, the respondent reasons that Petitioner can contribute the SSI-E earnings to his food budget thereby reducing the need for assistance with purchasing food.

MA programs, such as Family Care, operate to serve large numbers of people with a limited amount of funds. As stewards of public funding, CMO’s must consider an MA recipient’s income when determining whether or not to modify benefit requests. I find that the agency here has established that it properly considered petitioner’s request, and properly modified the request in light of petitioner’s present income. Should Petitioner’s financial, health or living situation change, he may apply for increased food budget assistance anew; at this time, however, petitioner has not established an error in the respondent’s modification of Petitioner’s out-of benefit food budget.

Conclusions of Law

The respondent has established that it properly considered petitioner’s request to continue his out-of- benefit Food budget, and properly modified the request in light of petitioner’s present income.



That petitioner’s appeal is hereby dismissed.

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

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