A person enrolled in Family Care is required to pay a cost share, though the Department may waive or reduce the requirement if undue financial hardship would result. In this case, the petitioner enrolled in Family Care March 2, discussed services with Inclusa staff, and then decided to disenroll March 21. ALJ Brian Schneider concluded he had no legal basis to order the cost share waived, noting the availability of requesting an undue hardship waiver instead.
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 April 19, 2025, under, Wis. Admin. Code, §DHS 10.55, to review a decision by the Dunn County Dept. of Human Services regarding the Family Care Program (FCP), a hearing was held on June 4, 2025, by telephone.
The issue for determination is whether a monthly FCP cost share can be waived after petitioner opted out of the program.
PARTIES IN INTEREST:
Petitioner:
—
Respondent:
Department of Health Services
1 West Wilson Street, Room 651
Madison, WI 53703
By: April Koch
Dunn County Dept. of Human Services
PO Box 470
Menomonie, WI 54751
ADMINISTRATIVE LAW JUDGE:
Brian C. Schneider
Division of Hearings and Appeals
Findings of Fact
- Petitioner (CARES # —) is a resident of Burnett County.
- Petitioner’s sister, who is power of attorney, first applied for Medicaid Waivers on petitioner’s behalf in December, 2024. Eventually she was found eligible. She enrolled in the FCP on March 2, 2025, with Inclusa as the managed care organization (MCO).
- By a notice dated February 26, 2025, the income maintenance agency informed petitioner that she was eligible for Community Waivers with a monthly cost share of $966.17.
- After enrolling, petitioner’s sister discussed services with Inclusa staff. She determined that the types of services available under the FCP were not what she was seeking for petitioner. She thus disenrolled from the FCP as of March 21, 2025. At that point the only service provided by Inclusa was case management because no other services were arranged.
- Petitioner filed this appeal to determine if the cost share for March, 2025, which was assessed on March 4 after enrollment, can be waived.
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 under Wisconsin Statute, §46.286, and is described comprehensively in the Wisconsin Administrative Code, Chapter DHS 10. See also Medicaid Handbook at §28.1, etc.
Petitioner was eligible for the FCP. An eligible person’s income is reviewed to determine if the recipient has enough income to be responsible for payment of a monthly “cost share.” Handbook, §28.6. There is no dispute that petitioner’s cost share was determined correctly.
The administrative code contains a provision regarding waiver of current cost share amounts:
(4) PAYMENT OF COST SHARE REQUIRED.
(a) Except as provided in par. (b), a person who is required to contribute to the cost of his or her care but who fails to make the required contributions is ineligible for the family care benefit.
(b) If the department or its designee determines that the person or his or her family would incur an undue financial hardship as a result of making the payment, the department may waive or reduce the requirement. Any reduction or waiver of cost share shall be subject to review at least every 12 months. A reduction or waiver under this paragraph shall meet all of the following conditions:
- The hardship is documented by financial information beyond that normally collected for eligibility and cost-sharing determination purposes and is based on total financial resources and total obligations.
- Sufficient relief cannot be provided through an extended or deferred payment plan.
- The person is notified in writing of approval or denial within 30 days of providing necessary information to the department or its designee.
Wis. Admin. Code, §DHS 10.34(4)(a) and (b). See also the FCP contract, §III.D.2, found at www.dhs.wisconsin.gov/familycare/mcos/fc-fcp-2025-contract.pdf. The code says that the department “may” waive/reduce the cost share requirement—it is not required to do so. To request a waiver, the person is directed to complete form DHS F-01827. It is available on-line, or can be requested from the county agency or Inclusa.
I cannot find a legal basis for the Division of Hearings and Appeals to order that the cost share be waived because petitioner chose to not pursue FCP services. When she enrolled, she became liable for the cost share. The only way to have the cost share waived is to request a waiver by filing Form F-01827. There was no mention in the hearing of such a request being made prior to filing this appeal. That said, the only penalty that I can see for failure to pay the cost share is ineligibility for the FCP. Petitioner already has chosen to disenroll from the program.
Conclusions of Law
There is nothing in the FCP law or state contract that allows the Division of Hearings and Appeals to waive a monthly FCP cost share directly upon appeal; a waiver must be requested through the Department’s Bureau of Programs and Policy.
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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