FCP 219488 (11/04/2025)
Petitioner needing 24/7 care did not have to move to residential setting

Preliminary Recitals

Pursuant to a petition filed on August 6, 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 September 24, 2025, by telephone.

The issue for determination is whether the respondent correctly denied the petitioner’s request for additional supportive home care hours.

There appeared at that time the following persons:

PARTIES IN INTEREST:

Petitioner:
—

Petitioner’s Representative:
—

Respondent:
Department of Health Services
201 E. Washington Ave.
Madison, WI 53703
By: Elizabeth Griffin
MY Choice Family Care
10201 Innovation Dr, Suite 100
Wauwatosa, WI 53226

ADMINISTRATIVE LAW JUDGE:
Peter McCombs
Division of Hearings and Appeals

Findings of Fact

1. Petitioner is a resident of Dane County.
2. Petitioner has been diagnosed with Huntington’s Disease, irritable bowel syndrome (IBS), and Type 2 Diabetes Mellitus. These progressive and chronic conditions significantly impair his ability to perform Activities of Daily Living (ADLs) and Instrumental Activities of Daily Living (IADLs).
3. Since his enrollment on November 1, 2024, his functional status has been declining, resulting in three increases in Supportive Home Care (SHC) hours, now totaling 101.25 hours per week. Despite these increases, the member continues to experience incontinence, mobility challenges, and frequent falls.
4. Petitioner resides in a single-story condominium with his wife, who is unable to assist with care due to her own health limitations and frequent absence. Petitioner’s main natural support is his daughter, —. — assists with supervision and personal care/homemaking after SHC caregivers leave for the day.
5. A risk reduction agreement was signed in August 2025 due to the member’s remaining at home against IDT recommendations and declining safety interventions.
6. SHC homemaking and personal care hours totaling 101 hours weekly provided by — include:
   • SHC homemaking (bathroom/bedroom/kitchen cleaning, meal preparation, laundry, grocery shopping, cleaning adaptive equipment and supervision) totaling 44 hours weekly
   • SHC personal care grooming, dressing, bathing, toileting, ambulation/transfers, smoking breaks) totaling 57 hours weekly.
7. On June 23, 2025, Petitioner’s daughter requested 24/7 in-home caregivers/SHC hours.
8. The request for 24-hour in-home Supportive Home Care (SHC) was denied following an assessment process and RAD determination, which included multiple team meetings, functional evaluations, and ongoing communication with the member’s daughter, —. Since the member’s enrollment on November 1, 2024, his care needs have been closely monitored, resulting in three documented increases in SHC hours, culminating in a total of 101 hours per week.
9. Petitioner’s care team determined that relying solely on a home care agency to provide 24/7 in-home care poses significant concerns for the member’s health and safety, especially in the absence of additional support typically required for 24/7 care.
10. The request for increased SHC hours was denied by the respondent on June 26, 2025.
11. The initial denial was upheld by the respondent’s Member Rights Committee on July 29, 2025.
12. Petitioner timely requested a Fair Hearing on August 6, 2025.

Discussion

The FCP provides appropriate long-term care services for elderly or disabled adults. It is supervised by the Department of Health Services (Department), authorized by Wis. Stat. § 46.286, and comprehensively described in Chapter DHS 10 of the Wisconsin Administrative Code. The Department contracts with managed care organizations (MCOs) throughout the state to provide case management services to members. Case management services include the development of individual service plans (ISPs) and the authorization of allowable and appropriate long term care services. Wis. Admin. Code §DHS 10.44(f). The ISP must reasonably and effectively address all of the FCP recipient’s long-term needs and outcomes, assist the recipient to be as self-reliant and autonomous as possible, and be cost effective when compared to alternative services or supports that could meet the same needs and achieve similar outcomes. Id

The contracts between the Department and the individual MCOs require MCOs to determine appropriate long term care services by engaging in a “member-centered planning process” and, more specifically, by applying the “Resource Allocation Decision” (RAD) method. See Wisconsin Department of Health Services, Division of Medicaid Services Family Care Contract (“FCP Contract”), Article V, Sec. K (issued January 1, 2024, with October and November amendments) (available online at: https://www.dhs.wisconsin.gov/familycare/mcos/fc-fcp-2024-contract-nov-amend.pdf); see also OFCE Memo, Issued 6/26/2013 (Revised 02/2024) available on-line at https://www.dhs.wisconsin.gov/ familycare/mcos/communication/ta13-02.pdf.

In other words, rather than requiring MCOs to develop and apply clear coverage criteria for services, DHS requires MCOs to use a particular process in considering whether to authorize services. MCOs may, however, develop service authorization guidelines for use with the RAD. Such guidelines must be approved by the Department. FCP Contract, Article V., Sec. K.1.a. Regardless of the particular service authorization policy utilized, the MCO is responsible for covering services as part of the FC benefit package that cost-effectively addresses a member’s diagnoses, achieves appropriate growth and development, maintains and regains functional capacity, affords access to the benefits of the community, and achieves person-centered goals. FCP Contract, Article VII. The MCO shall not deny a service that is reasonable and necessary, and in an amount, scope, and duration needed to cost-effectively support the member’s long-term care outcomes. FCP Contract, Article V, Sec.K 2. 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).

The issue here is whether the MCO appropriately denied the petitioner’s request for 24/7 SHC care. Given that the petitioner is seeking to change the current status of affairs, he has the burden to demonstrate by a preponderance of the evidence that the denial of his request was incorrect.

The MCO has implemented a Department-approved Supplementary RAD guideline for Residential Services. MCO Exhibit, pg. 45-46. It requires the MCO to consider such factors as whether the member has ADL/IADL needs that surpass what a SHC/SV provider, day service provider, informal support, or a combination of the foregoing can provide; the health and safety issues of the current living situation; mental health needs and behavioral health issues of the member; the options and supports considered or attempted to maintain the member in the current living situation; the member’s preference; and whether the member requires overnight care and supervision that cannot be remedied with a Personal Emergency Support System. Id. The Supplemental RAD also provides:

A members’ living environment is critical to overall health and well-being. My Choice Wisconsin strives to ensure that members reside in the least restrictive and most effective and cost-effective setting, while addressing the member’s individual needs and outcomes. Exploring an Adult Family Home (AFH), Community Based Residential Facility (CBRF), or Residential Care Apartment Complex (RCAC) is a decision that requires extensive thought.

This is a significant change for anyone who is moving outside of their natural setting, often requiring that they give up a certain degree of autonomy, independence, and ability to go about their day freely. This is a big decision and not one to be made lightly. This guideline also helps the IDT staff in identifying the least restrictive, most cost-effective setting that will support the member’s medical, social, and functional needs as well as their personal outcomes, when natural supports and other Family Care/Partnership funded services are no longer available, sufficient, or fully exhausted to maintain the member safely in the community.
…

Id (emphasis added).

The MCO employed the RAD process and found that the petitioner’s significant needs and safety concerns could not be met in his home, and that he would be best served by relocating to a residential care facility that could provide 24/7 staffing.

The petitioner’s preference is to remain in his current residential placement. While his preference is to be considered, the FCP is a publicly funded program. Thus, the program is permitted to implement less expensive, more cost-effective options when it achieves a similar result. Petitioner’s representatives argued at hearing that increasing his SHC hours will allow him to remain in his home safely and that his current care provider, —, is sufficiently staffed and is willing to provide the overnight SHC being requested. I note that the RAD decision notes include the conclusion that, “[i]ndividuals who require 24/7 care and supervision, especially overnight care such as incontinence needs, are the safest and served best in residential settings.” Exhibit R-1, p.16.

Petitioner’s representatives argued that his diagnoses would be exacerbated by a lack of stability in his living situation. Specifically, petitioner’s daughter commented that changes in his routine can accelerate progression of his Huntington’s Disease. A representative of — also noted that residential placement would not necessarily equate to 1:1 care, as opposed to —’s ability and willingness to provide such care in petitioner’s home.

Petitioner’s Long Term Care Functional Sereen dated December 24, 2024, notes that petitioner’s current needs require 24/7 care, but the RAD completed on June 23, 2025, determined that home care is not a safe option at this time, due to petitioner’s deteriorating health. The record before me indicates that there are two appropriate options to address petitioner’s living situation: (1) the current residential placement with support services proposed by the MCO and (2) placement in a facility. The record indicates that both would be effective at meeting his current long-term care needs and outcomes.

That being the case, the record demonstrates that petitioner has established that he prefers to remain in his home, that he has natural supports to assist with the SHC being provided, that his SHC provider is capable and willing to provide 24/7 care, that moving petitioner could exacerbate the progression of his Huntington’s Disease, and that increasing his SHC to allow for 24/7 cares will allow him to remain in his home safely. While the RAD analysis notes, at Step 41, that a residential facility would be a more cost-effective option, the record does not include any further evidence that this is the case, such as an analysis comparing the cost of the current residential placement with the projected cost of the facility admission. Thus, I am remanding this matter to the MCO to rescind its June 26, 2025, notice of action denying the additional SHC hours being sought by petitioner.

Conclusions of Law

The petitioner has established that he requires 24/7 SHC, and that the provision of this care will allow him to remain in his current home safely.

THEREFORE, it is

Ordered

That this matter is remanded to My Choice Wisconsin with instructions to rescind the June 26, 2025, notice of action denying petitioner’s request for 24/7 SHC services, and approve the request. My Choice Wisconsin shall comply with these instructions within ten days of the date of this decision.

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