As stated in the recent DMS Ops Memo 25-07, the state must maintain Medicaid coverage while completing regularly scheduled renewals as long as the renewal is received before the end of the month the renewal is due. In this case, the petitioner completed his renewal May 28, before the end of his renewal month, but MilES was unable to reopen his Medicaid case until June 9 due to a computer system error. He was then disenrolled from Famil Care because a state database indicated he hadn’t completed his renewal. ALJ Teresa Perez concluded the petitioner was entitled to Family Care enrollment effective June 1, noting: “That a computer system says something does not necessarily make it so.”
See CWA 218281 for a similar case on the same issue.
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 June 11, 2025, under Wis. Admin. Code § DHS 10.55, to review a decision by the Department of Health Services and its contracted agent, MY Choice Family Care, to disenroll Petitioner from Family Care, a hearing was held on July 23, 2025, by telephone. This appeal was held with a companion appeal (Case No. MGE-218665) regarding a closure of Petitioner’s Medicaid case. A separate decision has been issued under that case number.
The issue for determination is whether Petitioner was properly disenrolled from Family Care from June 1, 2025 through June 15, 2025.
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: Andrea Williams, MyChoice
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 receives Family Care benefits.
- Petitioner’s managed care organization is MyChoice.
- Petitioner’s Medicaid renewal was due in May 2025.
- Petitioner contacted Milwaukee Enrollment Services (MilES) to initiate his Medicaid renewal on May 12, 2025. MilES made a number of errors while processing Petitioner’s renewal but was able to correct all of them by May 28, 2025. On that date, the agency confirmed that Petitioner remained eligible for full-benefit Medicaid.
- On May 28, 2025, after confirming Petitioner’s ongoing Medicaid eligibility, MilES attempted to reopen his Medicaid case but was unable to do so due to a computer system error. On June 9, 2025, MilES completed a manual certification to accomplish the reopening of Petitioner’s Medicaid back to June 1, 2025.
- Despite timely completing his Medicaid renewal and continuously meeting all program eligibility requirements, Petitioner was disenrolled from Family Care effective June 1, 2025 because the State’s MMIS database indicated to MyChoice that he was no longer eligible for Medicaid as of that date.
- Petitioner was re-enrolled in Family Care as of June 16, 2025.
- During the time period that he was disenrolled, Petitioner continued receiving services that had been previously authorized by Family Care and paid for some or all of those services out of pocket.
- Petitioner filed a request for a fair hearing seeking Family Care enrollment from June 1, 2025 through June 15, 2025.
Discussion
To participate in Family Care, an individual must meet the financial and non-financial eligibility criteria for one of the following: a “full benefit category of [Elderly, Blind, Disabled] Medicaid,” BadgerCare Plus, Wisconsin Well Woman Medicaid, or Adoption Assistance. Medicaid Eligibility Handbook (MEH) §§1.1.2 and 28.1.2 Therefore, if a person becomes ineligible for any of the above-listed categories of Medicaid, they become ineligible for Family Care and must be disenrolled.
In this case, Petitioner was automatically disenrolled from MyChoice on June 1, 2025 based on an entry in a centralized state database indicating that he had become ineligible for Medicaid. In fact, Petitioner continued to meet Medicaid eligibility requirements continuously and completed his Medicaid renewal by May 28, 2025. These facts are not in dispute.
As stated in a recently issued publication from the Department of Health Services, “federal rules require states to maintain coverage while completing regularly scheduled renewals as long as the renewal is received before the end of the month the renewal is due.” DMS Operations Memo 25-07. That publication goes on to state, “The member’s existing health care coverage must be maintained while their renewal is being processed by the IM agency. This requirement applies to all renewals received during the renewal month, including renewals received after adverse action but on or before the last business day of the renewal month.” Although the policy announced in that publication is new, the federal rules upon which it is based are not. Moreover, Petitioner, as stated above, did not become ineligible for Medicaid or fail to complete his Medicaid renewal. That a computer system says something does not necessarily make it so. He thus should not have been disenrolled from Family Care on June 1, 2025.
I am remanding this matter to order that Petitioner be re-enrolled in Family Care from June 1, 2025 through June 15, 2025.
Conclusions of Law
Petitioner is entitled to Family Care enrollment from June 1, 2025 through June 15, 2025 because he was eligible for full benefit Medicaid throughout that time period and because he completed his renewal in the month that it was due.
THEREFORE, it is
Ordered
That this matter is remanded to the agency with instructions to: (1) reinstate the petitioner’s Family Care benefits from June 1, 2025 through June 15, 2025, (2) send written confirmation to Petitioner that it has done so, and (3) instruct Petitioner and/or his providers in writing regarding how to submit claims and/or request reimbursement for previously authorized services that Petitioner continued to receive from June 1, 2025 through June 15, 2025. These actions shall be completed within 10 days of the date of this order.
[Request for a rehearing and appeal to court instructions omitted.]
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