A participant in Family Care can be involuntarily disenrolled if they are determined ineligible for MA. In this case, the petitioner submitted his renewal timely and was eligible, but his MCO disenrolled him in error and could not reenroll him without an order. ALJ Nicole Bjork issued the order, noting that this case was about correcting an erroneous disenrollment, not backdating enrollment.
This decision was published with support from the Wisconsin chapter of the National Academy of Elder Law Attorneys.
Preliminary Recitals
Pursuant to a petition filed on June 11, 2024, under Wis. Admin. Code § DHS 10.55, to review a decision by the MY Choice Family Care regarding Medical Assistance (MA), a hearing was held on July 23, 2024, by telephone.
The issue for determination is whether the agency correctly disenrolled Petitioner from the family care program (FCP) and reenrolled him effective June 1, 2024.
There appeared at that time the following persons:
PARTIES IN INTEREST:
Petitioner:
—
Respondent:
Department of Health Services
1 West Wilson Street, Room 651
Madison, WI 53703
By: Mary Swab
MY Choice Family Care
10201 Innovation Dr, Suite 100
Wauwatosa, WI 53226
ADMINISTRATIVE LAW JUDGE:
Nicole Bjork
Division of Hearings and Appeals
Findings of Fact
- Petitioner is a resident of Milwaukee County and is enrolled in MA as well as the FCP, which his ICA being My Choice.
- On April 24, 2024, Petitioner submitted an MA renewal. The case was pended for verification of assets with a due date of May 20, 2024. Petitioner timely submitted his verification on May 1, 2024. Petitioner’s case was confirmed and his MA remained open with no gap in coverage.
- In May 2024, My Choice disenrolled Petitioner in error. Once the error was discovered, Petitioner was reenrolled with an effective date of June 1, 2024, leaving a gap in coverage for May 2024.
- A My Choice representative testified during the hearing that this was an agency error and they should not have disenrolled Petitioner. However, once they accidentally disenrolled him, the system would not allow him to be reenrolled for May 2024 without a court order.
- Petitioner filed an appeal seeking coverage for May 2024.
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). Once a person meets all the program’s eligibility criteria, she is “entitled to enroll in a care management organization and to receive the family care benefit.” Wis. Admin. Code §DHS 10.36(1).
A FCP participant can be involuntarily disenrolled from the FCP if they lose or are determined ineligible for MA. See Contract Between the Department of Health Services and MCOs, Article IV, Enrollment and Disenrollment, pg. 45, found online at: https://www.dhs.wisconsin.gov/familycare/mcos/fc-fcp-2024-contract.pdf
In this case, Petitioner was already enrolled in the FCP. He was disenrolled from the FCP as a result of the processing of his health care renewal. IM acknowledged that Petitioner was incorrectly disenrolled from the FCP due to agency error in processing his May 2024 health care renewal. But for that error, it was indicated that Petitioner would have been found to continue to be eligible for FCP and the disenrollment would not have occurred. It was indicated that Petitioner continued to be financially and functionally eligible for the FCP at the time of his health care renewal. Petitioner’s representative, the IM representative, and MCO representative at hearing all agreed Petitioner’s FCP benefits should be reinstated as of May 1, 2024.
I would note that this case does not deal with backdating FCP following a delayed processing of a new application but the incorrect disenrollment from the FCP due to agency error. Thus, it is issued as a final decision.
Conclusions of Law
Due to agency error, the petitioner was incorrectly disenrolled from the Family Care program.
THEREFORE, it is
Ordered
That this matter be remanded to the IM/MCO with the following instructions: within 10 days of the date of this Decision, take all necessary administrative steps to restore petitioner’s FCP enrollment and authorizations retroactive to May 1, 2024.
[Request for a rehearing and appeal to court instructions omitted.]
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