FCP 218749 (10/14/2025)
Four-month ADRC delay was agency error

The attached proposed decision of the Administrative Law Judge dated August 12, 2025 is hereby adopted as the final order of the Department.

[Request for a rehearing and appeal to court instructions omitted.]

Preliminary Recitals

Pursuant to a petition filed on June 16, 2025, 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 29, 2025, by telephone.

This decision is being issued proposed because the provisions in the Medicaid Eligibility Handbook regarding the begin date/start date/enrollment date are internally inconsistent and are inconsistent with state statute.

NOTE: Post-hearing the parties were contacted and asked to submit additional documentation. ADRC’s e-mail has been marked as Respondent’s Exhibit 3; the enrollment letter from My Choice has been marked as Respondent’s Exhibit 4; Milwaukee Enrollment Services submitted five additional documents, that were not previously provided—an April 2025 budget, a request for verification dated March 13, 2025, a request for verification dated March 31, 2025, a notice denying February benefits dated April 8, 2025, and Forward Health screens. These have been marked as Respondent’s Exhibits 5-9, respectively.

The issue for determination is whether MY Choice Family Care (MY Choice) correctly enrolled the Petitioner in Family Care effective May 1, 2025.

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, Enrollment Analyst
MY Choice Family Care
10201 Innovation Dr, Suite 100
Wauwatosa, WI 53226

ADMINISTRATIVE LAW JUDGE:
Mayumi M. Ishii
Division of Hearings and Appeals

Findings of Fact

1. Petitioner is a resident of Milwaukee County.
2. On August 12, 2024, Milwaukee Enrollment Services (MILES) sent the Petitioner a notice indicating that he needed to complete a renewal by September 17, 2024, or his Medicaid benefits could end on September 20, 2024. (Respondent Exhibit 1, pg.11)
3. On September 18, 2024, MILES sent the Petitioner a notice indicating that his Medicaid/Community Waivers benefits would be ending effective October 1, 2024, because he did not complete his renewal. (Respondent Exhibit 1, pg. 24-25)
4. On October 17, 2024, the Petitioner’s power of attorney (POA) contacted the nursing home to inquire about applying for Medicaid, because the Petitioner only had enough money to pay for his care through January 2025. (Petitioner Exhibit 1)
5. On October 28, 2024, Petitioner’s POA reached out to the ADRC, indicating that the Petitioner previously disenrolled from Family Care because he sold his house, but would like to reapply because he was going to run out of funding to privately pay for his care. The ADRC informed the POA that an Options counselor was being assigned, but it could take eight weeks. (Petitioner Exhibit 2)
6. Due to a backlog of cases, the ADRC was unable to comply with their internal timelines. (Testimony of Catherine Moe)
7. The Petitioner was referred to the ADRC on October 28, 2024. (Petitioner Exhibit 3; Respondent Exhibit 3)
8. The ADRC did not assign an Options counselor until February 27, 2025. (Petitioner Exhibit 3)
9. A long-term care functional screen was completed on March 4, 2025. (Petitioner Exhibit 9)
10. On March 7, 2025, the Petitioner filed an ACCESS application for healthcare benefits beginning February 2025. (Petitioner Exhibit 5, pg. 2)
11. On March 13, 2025, MILES sent the Petitioner a request for verification of his assets due April 7, 2025. (Respondent Exhibit 6)
12. Petitioner’s POA contacted the Options counselor on March 19, 2025, indicating that the requested verifications were submitted the week prior and inquiring whether the financial documents he submitted had been received. (Petitioner Exhibit 6)
13. By March 27, 2025, Petitioner’s POA reached out to others at ADRC because he had not heard back from the Options counselor. (Id.)
14. On March 31, 2025, MILES sent the Petitioner another request for verification of assets that was due April 7, 2025. (Respondent Exhibit 7)
15. On April 8, 2025, MILES sent the Petitioner notice advising him that his application for Medicaid was denied as of February 1, 2025, because he was over the income limit, and because he did not provide the requested verification. The agency counted Petitioner’s pension of $1,189.51 per month and Social Security Income of $2,030.00 per month. (Respondent’s Exhibit 8)
16. On April 16, 2025, the Petitioner’s authorized representative called MILES to verify receipt of the requested verification. MILES indicated that they were received, but not until April 11, 2025. (Respondent Exhibit 1, pg. 6)
17. On April 17, 2025, MILES sent the Petitioner a notice indicating that he was enrolled in community waivers beginning March 1, 2025, and that he had a cost share of $1,503.76 per month from March 1, 2025 to April 30, 2025, and $1,513.51 beginning May 1, 2025. The agency counted the same pension of $1,189.51 per month and Social Security Income of $2,030.00 per month. (Respondent Exhibit 1, pg. 30)
18. A referral was made to MY Choice for enrollment on April 28, 2025. (Testimony of Ms. Moe)
19. On May 4, 2025, the Department of Health Services sent the Petitioner a notice indicating that his Family Care enrollment began May 1, 2025. (Respondent Exhibit 4)
20. The Petitioner filed a request for hearing that was received on June 15, 2025. (Petitioner’s Exhibit 10)

Discussion

Family Care is a medical assistance waiver program that provides long-term care services, through a managed care system, to frail elderly individuals, adults who have physical disabilities, and adults who have intellectual disabilities. See Wis. Stat.§ 46.286; see also Wis. Admin. Code, Chapter DHS 10.

The Petitioner’s POA filed an appeal to contest the Petitioner’s date of enrollment in Family Care. Petitioner’s POA would like enrollment to begin February 1, 2025. MY Choice enrolled the Petitioner in Family Care effective May 1, 2025.

In order to be eligible for Family Care an individual must meet both functional eligibility criteria and financial eligibility criteria. Wis. Stat. § 46.286(1)(a) and (b). However, eligibility for Family Care, does not equate to an entitlement to Family Care benefits. Id.

A person is “entitled to and may receive the family care benefit through enrollment in a care management organization, if all of the following apply”:

1. The person is at least 18 years of age.
2. The person has a physical disability, as defined in s. 15.197 (4) (a) 2., a developmental disability, as defined in s. 51.01 (5) (a), or is a frail elder.
3. The person is functionally eligible.
4. The person is financially eligible and fulfills any applicable cost-sharing requirements.

Wis. Stat. § 46.286(3)(a)(1m)-(4m); see also Wis. Admin. Code §10.36.

Petitioner was 83 years old and therefore, at least 18 years of age, as of February 1, 2025. (See Petitioner’s Exhibit 5, pg. 3.) Because the Petitioner is over age 65, he is considered a frail elder. See Wis. Stats. §46.2805. It is undisputed that the Petitioner meets functional eligibility criteria, meaning he is at a nursing home level of care, or at a non-nursing home level and at risk of losing his independence or functional capacity, unless he receives assistance from others. See Wis. Stat. § 46.286(1)(a).

The remaining question, then, is whether the Petitioner was financially eligible for Family Care as of February 1, 2025.

MILES sent the Petitioner a notice indicating that verification of assets was due by April 7, 2025. The Petitioner’s POA timely submitted the requested verification, but for reasons not made clear in the record, MILES did not note receipt of it until April 11, 2025. Consequently, the notice sent to the Petitioner on April 8, 2025, indicated that the Petitioner was not eligible for benefits as of February 1, 2025, because he did not provide requested proof by April 7, 2025, and because he was over the income limit.

If an application is denied because the required verification is not received by the due date, but verification is later received within 30 days of the application denial date, the IM agency must consider this as the person re-requesting health care, and no new application for benefits is needed. MEH §2.9.2. So, upon processing the verification on April 16, 2025, MILES found the Petitioner eligible for waiver benefits beginning March 1, 2025, with a cost share. It is unclear why the agency did not redetermine his eligibility for benefits beginning February 1, 2025, since that is what the Petitioner requested in his original application. In addition, I can find no reason in this record why the Petitioner would not be financially eligible beginning February 1, 2025, since the financial details examined in March 2025 were the same as they were in February 2025, at least according to the notices issued by MILES.

Since the Petitioner should have been found financially eligible in February 2025, he was entitled to receive Family Care benefits through enrollment in February 2025, per Wis. Stat. § 46.286(3)(a). However, neither the statues nor the administrative rules clearly state when enrollment is supposed to begin. They only state that Family Care benefits are received through enrollment in a care management organization (CMO). Id. See also Wis. Admin. Code DHS §10.41.

The Medicaid Eligibility Handbook does not provide a clear explanation for when enrollment is supposed to begin. MEH §2.8.1 states that the “program start date” for waiver programs, like Family Care, is the date provided by the Managed Care Organization (MCO). However, according to MEH §28.5 the “begin date” of waiver eligibility is the program start date submitted to the IM agency by the care manager or the ADRC.

It should be noted that under Wis. Admin. Code §10.31(6)(a), the decision date for fmancial and nonfinancial eligibility determinations, including cost share determinations must be a date, “as soon as practicable, but not later than 30 days from the date the agency receives a financial and non-financial eligibility application…” In addition, the decision date for functional eligibility must be a date, “as soon as practicable, but not later than 30 days from the date the resource center receives verbal acceptance from the applicant to proceed with the functional screen…” Wis. Admin. Code §10.31(6)(am). However, “If there is a delay in securing necessary information, the agency shall notify the applicant that there is a delay in processing the application. Communications with the applicant, either orally or in writing, in the attempt to obtain the missing information shall serve as notice of the delay. If the delay is not resolved within 30 days following this notice to the applicant of the missing information, the agency shall notify the applicant in writing of the delay in completing the determination, specify the reason for the delay, and inform the applicant of their right to appeal the delay by requesting a fair hearing under s. DHS 10.55.” Wis. Admin. Code §10.31(6)(b). It should also be noted that “agency” is defined as, “any county agency, or any resource center that is not a county agency, that is responsible for all or part of determination of functional, financial, and other conditions of eligibility for the family care benefit.” Wis. Admin. Code §10.31(6)(b).

In summary, agencies must complete financial and non-financial eligibility determinations within 30 days of receiving an application, and agencies must complete functional eligibility determinations within 30 days of receiving acceptance from an applicant to do a functional screen, and if there is a delay due to a lack of information, the agency is to give written notice to the applicant that includes notice of the applicant’s right to appeal.

The Petitioner’s application for Family Care was significantly delayed due to a backlog at the Milwaukee ADRC¹. The ADRC received the referral for the Petitioner on October 28, 2024, but did not assign an Options counselor to assist the Petitioner until February 27, 2025, four months later. The LTCFS was not completed until March 4, 2025, and the application to determine financial eligibility beginning February 1, 2025, was not submitted until March 7, 2025. In addition, there appears to have been some delays in processing asset verifications that initially resulted in a denial of benefits beginning February 1, 2025. Once the verifications were processed, the Petitioner was open for Community Waivers beginning March 1, 2025. Ultimately, the ADRC did not refer the Petitioner to MYChoice until April 28, 2025, and so the Petitioner was not enrolled until May 1, 2025.

The Department issued a Final Decision that the Division of Hearings and Appeals does not have the authority to make a final decision to adjust the enrollment date; rather, only the Department may issue a final decision adjusting an enrollment date for Community Waivers. See In re —, Case No. 192893 (Nov. 5, 2019). Where agency action or inaction delays an individual’s enrollment into the Family Care Program, the Division of Hearings and Appeals recommends an enrollment date to ameliorate the agency’s errors by issuing a proposed decision for consideration by the Department Secretary, who does have the authority to adjust an individual’s enrollment date. See e.g., In re —, Case No. 167655 (March 21, 2016) and In re —, Case No. 173457 (Sept. 15, 2016).

Based on all of the above, I find that Petitioner’s Family Care Enrollment should begin February 1, 2025, when the Petitioner was eligible for and entitled to receive Family Care benefits.

Conclusions of Law

MyChoice Family Care did not correctly begin Petitioner’s enrollment on May 1, 2025.

THEREFORE, it is

Ordered

That, if this proposed decision is adopted as final by the Department of Health Services Secretary, MILES shall within ten days of the date of the final decision, take all necessary administrative steps to open Petitioner’s Community Waivers case, effective February 1, 2025 and that MYChoice shall enroll Petitioner into Family Care, effective February 1, 2025.