A participant in Family Care cannot be disenrolled without proper advance notice. In this case, the petitioner apparently missed a yearly renewal due in August and had difficulty navigating the re-enrollment process with the ADRC (“sometime in December … Petitioner’s representative called the ADRC to request an appointment and was told that they were backed up and that he should call back sometime after January 21”). Because no representative from MilES showed up to the hearing and there was insufficient evidence of proper notice, ALJ Teresa Perez ordered the petitoner’s Family Care enrollment restored.
This decision was published with support from the Wisconsin chapter of the National Academy of Elder Law Attorneys and Krause Financial.
Preliminary Recitals
Pursuant to a petition filed on December 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 initiated on January 23, 2025. At that time, a representative from Petitioner’s MCO was present but no representative from MilES appeared. The hearing was adjourned until February 26, 2025. A copy of the hearing notice regarding the February 26, 2025 hearing date was forwarded to MilES but no representative from that agency appeared.
The issue for determination is whether Petitioner was properly disenrolled from Family Care as of September 1, 2024.
There appeared at that time the following persons:
PARTIES IN INTEREST:
Petitioner:
—
Petitioner’s Representative:
—
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:
Teresa A. Perez
Division of Hearings and Appeals
Findings of Fact
- Petitioner is a resident of Milwaukee County who was disenrolled from Family Care effective September 1, 2024.
- Petitioner was authorized to receive residential services at an adult family home prior to her disenrollment. She has continued to reside at the same adult family home.
- The reason for disenrollment was a failure to complete a Medicaid renewal prior to September 1, 2024.
- Petitioner filed a Medicaid renewal via ACCESS on September 16, 2024.
- On September 26, 2024, Milwaukee Enrollment Services (MilES) reopened Petitioner’s Medicaid Community Waivers case and backdated it to September 1, 2024.
- On September 27, 2024, MilES sent a notice to Petitioner’s representative which stated the renewal was completed and that Petitioner was enrolled in Community Waivers as of September 2024.
- On December 9, 2024, MilES sent a notice to Petitioner’s representative which stated Petitioner was enrolled in Community Waivers as of January 1, 2025.
- Despite the notices issued by MilES, Petitioner remained disenrolled from Family Care because the MCO had not received a referral from the ADRC.
- Sometime in December 2024, at the recommendation of the MCO, Petitioner’s representative called the ADRC to request an appointment and was told that they were backed up and that he should call back sometime after January 21, 2025 which he did.
- Petitioner was re-enrolled in Family Care on January 28, 2025.
- Petitioner’s managed care organization prior to her disenrollment was, and upon her re-enrollment continues to be, MyChoice Wisconsin.
- Petitioner filed a request for fair hearing on December 11, 2024 to request that Petitioner be re-enrolled in Family Care with no gap in coverage.
Discussion
Medicaid recipients are entitled to adequate and timely notice of an adverse action. See Medicaid Eligibility Handbook §23.1, et. seq.
At hearing, Mary Swab, an Eligibility Analyst from MyChoice, appeared and testified as to her understanding of what led to Petitioner’s disenrollment from Family Care; namely, that Petitioner failed to complete an annual eligibility review for Medicaid and, as a result, had her Medicaid eligibility terminated. She also testified that MilES re-opening of her Community Waivers case back to September 1, 2024 was done in error.
Petitioner’s guardian, —, appeared at the hearing and credibly testified that he had consulted with many people across different agencies after he found out that Petitioner was disenrolled from Family Care and that he endeavored to follow the instructions that he was given. No representative from MilES appeared at the hearing and thus no documentation was offered to show either that Petitioner was adequately advised that she had a Medicaid annual eligibility review due by a particular date or that she was adequately advised of her impending Medicaid termination. Nor was documentation offered to show that Petitioner received an advance notice regarding her Family Care disenrollment.
Because there was insufficient evidence in the hearing record to show that Petitioner was given proper notice of termination / disenrollment, I find that the Department of Health Services, by its various contracted agents, did not properly terminate Petitioner’s Medicaid and that the resulting disenrollment from Family Care was likewise not proper.
Conclusions of Law
Petitioner’s eligibility for Medicaid was terminated in error effective September 1, 2024 which caused her to be improperly disenrolled from Family Care from September 1, 2024 through January 27, 2025.
THEREFORE, it is
Ordered
That the matter is remanded to the Department of Health Services, Milwaukee Enrollment Services, the Milwaukee County ADRC, and MyChoice to coordinate and take the administrative steps necessary to re-enroll Petitioner in Family Care as of September 1, 2024. The agencies shall comply with this order within ten days of the date of this decision.
[Request for a rehearing and appeal to court instructions omitted.]
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