When a Family Care member has a significant change in circumstances, the MCO must reassess the member’s care needs. In this case, the petitioner had multiple emergency room visits and was ultimately hospitalized, resulting in a reassessment and increase in his Supportive Home Care (SHC) hours. He argued the increased hours should be backdated months, to the start of his increased care needs. ALJ Brian Schneider concluded the increase could not be backdated, noting in the contract that increased benefits do not begin until the new care plan is completed and signed by the MCO, member, and provider.
This decision was published with support from the Elder Law & Special Needs Section of the State Bar of Wisconsin, the Wisconsin chapter of the National Academy of Elder Law Attorneys, and Krause Financial.
Preliminary Recitals
Pursuant to a petition filed March 25, 2025, under Wis. Admin. Code, §DHS 10.55, to review a decision by Inclusa regarding the Family Care Program (FCP), a hearing was held on April 30, 2025, by telephone. The issue for determination is whether the agency correctly refused to backdate increased supportive home care hours.
PARTIES IN INTEREST:
Petitioner:
—
Respondent:
Department of Health Services
1 West Wilson Street, Room 651
Madison, WI 53703
By: Brook Jaeger
Inclusa
3349 Church St Suite 1
Stevens Point, WI 54481
ADMINISTRATIVE LAW JUDGE:
Brian C. Schneider
Division of Hearings and Appeals
Findings of Fact
- Petitioner is a 41-year-old resident of Rock County.
- Petitioner is eligible for the FCP with Inclusa as his managed care organization (MCO). He lives with his wife and children, and his wife is his primary caregiver.
- Petitioner has diabetes, heart disease, chronic pain, digestive disorders, and anxiety, among other issues. He was first enrolled in the FCP in April, 2023, and he was allowed 25.25 weekly SHC hours as part of his plan.
- In the spring, 2024, petitioner was seen in the emergency room multiple times. At that point it appeared that his condition was worsening, but no action regarding SHC was taken.
- In August, 2024, Inclusa documented a request for increased SHC hours. A meeting was held on September 6 to document needs and a task assessment, and the result was a determination by the agency that petitioner actually needed less SHC hours. The plan was to reduce SHC to 17.25 weekly hours.
- Before the reduction in hours occurred, petitioner was hospitalized in September, 2024. After his release meetings with Inclusa staff and the family led to a reassessment of petitioner’s needs. The new service plan was finalized and as of November 8, 2024, SHC was increased to 48 hours weekly.
- Petitioner then appealed the start date of the increased SHC, seeking to have the increase backdated to April, 2024. The request was denied, and on January 30, 2025, a grievance panel affirmed that the backdated increase was denied.
Discussion
The Family Care program, 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 MCO must develop an Individual Service Plan (ISP) in partnership with the client. Wis. Admin. Code, §DHS 10.44(2)(f). The ISP must reasonably and effectively address all of the client’s long-term needs and outcomes to assist the client to be as self-reliant and autonomous as possible, but nevertheless must be cost effective. While the client has input, the MCO does not have to provide all services the client desires if there are less expensive alternatives to achieve the same results. Wis. Admin. Code, §DHS 10.44(1)(f); DHS booklet, Being a Full Partner in Family Care, page 9. ISPs must be reviewed periodically. Admin. Code, §DHS 10.44(j)(5).
Wis. Admin. Code, §DHS 10.55(1) provides that a person may request a fair hearing to contest the denial of eligibility for the program, a cost share and financial eligibility, or the “entitlement” to the FCP. functional eligibility. In addition, the participant must file a grievance with the MCO over any decision, omission, or action of the MCO. The grievance committee shall review and attempt to resolve the dispute. If the dispute is not resolved to the participant’s satisfaction, he may then request a hearing with the Division of Hearings and Appeals. Wis. Admin. Code, §DHS 10.55(2).
FCP policies are found primarily in the Department’s standard contract with the FCP MCOs. The contract is found on-line at https://www.dhs.wisconsin.gov/familycare/mcos/fc-fcp-2025-contract.pdf. Supportive home care is an allowable service.
The issue here is not whether petitioner requires 48 hours per week SHC, but when the change should be effective. First, the request to go back to April, 2024 is denied. The only assessments of petitioner’s needs prior to his September, 2024 hospitalization were done by Inclusa, and the one done prior to the September hospitalization determined that he needed only 17.25 hours SHC per week. Petitioner and his wife testified that they believed he required more hours before then, but they have not offered any medical or professional assessment supporting their belief. Thus the hours that were covered until the case was reassessed in October, 2024 must be upheld, and no backdate can be ordered. The remaining question is the start date of the increased services.
Here SHC was increased because of a determination that petitioner had a significant change in circumstances. If there is a significant change, the MCO must do a reassessment as set forth in the FCP contact, Article V.C.1.b and c. See Contract, Article V.F.2.d. Article V.C.1 discusses the need for an assessment and documentation for a new member. In other words, if there is a significant change in circumstances, the MCO must review the change as if it is a new case. Under those procedures, services begin when the plan is completed and signed by the MCO, the member, and the provider. See Contract, Article V.C.d – g. There are provisions for immediate authorizations if necessary to ensure health and safety, but there is no suggestion that petitioner was under such an emergency situation. The Inclusa service authorization policy and procedure, found at exhibit 11 of the agency’s exhibits, echoes those timelines. See section 4.0 of the document, beginning at page 63 of the exhibit package.
I conclude that the MCO correctly started the increased SHC hours when the service plan was finalized. The request for backdating services must be denied.
Conclusions of Law
The MCO correctly began a new service plan with increased SHC services effective November 8, 2024 following a reassessment after a determination of a significant change in condition. There is no medical or other professional evidence of a change in condition prior to petitioner’s September, 2024 hospitalization, and thus increased services cannot be approved for the period before that event.
THEREFORE, it is
Ordered
That the petition for review is hereby dismissed.
[Request for a rehearing and appeal to court instructions omitted.]
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