FCP 220772 (03/20/2026)
Community Support Program services ended when mental health needs could be met by outpatient care

Preliminary Recitals

A petition was filed on November 7, 2025, under Wis. Admin. Code § DHS 10.55, to review a decision by Inclusa Inc. regarding Medical Assistance (MA). The case was initially scheduled for a hearing on December 18, 2025, January 7, 2026, and February 3, 2026; however, the hearing was rescheduled at the petitioner’s guardian’s request. A hearing was then held on February 11, 2026, by telephone.

The issue for determination is whether the FamilyCare agency correctly terminated the petitioner’s Community Support Program services.

There appeared at that time the following persons:

PARTIES IN INTEREST:

Petitioner:
—

Respondent:
Department of Health Services
201 E. Washington Ave.
Madison, WI 53703
By: Karlie Stadler, Sarah Mullenberg
Inclusa Inc.
3349 Church St Suite 1
Stevens Point, WI 54481

ADMINISTRATIVE LAW JUDGE:
Kate J. Schilling
Division of Hearings and Appeals

Findings of Fact

1. Petitioner is a 66 year old resident of La Crosse County. Her mother is her guardian. The petitioner is enrolled in the FamilyCare program with Inclusa as her Managed Care Organization (MCO).
2. The petitioner’s medical history includes schizophrenia. She uses a wheelchair for mobility. The petitioner has had stays in psychiatric hospitals for stabilization; however, she has not required any hospitalizations over the past year.
3. The petitioner has supportive home care hours through a community supportive living agency. Staff come into the petitioner’s home multiple times per day seven days per week to assist the petitioner with activities of daily living and instrumental activities of daily living.
4. On September 3, 2025, the FamilyCare agency issued a Notice of Adverse Benefit Determination which stated that the petitioner’s services under the Community Support Program would be terminated as of September 20, 2025.
5. On September 17, 2025, the Community Support Program sent a notice to the petitioner that it was terminating her from the program as it determined that she no longer required the services.
6. On September 17, 2025, the petitioner’s guardian requested an appeal with the FamilyCare agency.
7. On October 7, 2025, the FamilyCare agency issued a final decision upholding its initial decision to terminate the petitioner’s Community Support Program (CSP) services.

Discussion

The Family Care Program is a Medical Assistance home and community based waiver program designed to provide long-term care services for individuals with physical and developmental disabilities and elderly individuals through a managed care service delivery model. See Wis. Stat. §46.286, Wis. Admin. Code ch. DHS 10, Family Care 1915(b) Waiver, and Family Care 1915(c) Home and Community-Based Services Waiver. The Department of Health Services (“the Department”) contracts with managed care organizations (MCOs) throughout the state to provide services to Family Care members. See the Family Care / Partnership 2026 Contract (available online at https://www.dhs.wisconsin.gov/familycare/mcos/contract.htm).

The case management responsibilities of MCOs include the identification and authorization of allowable and appropriate long term care services and supports for individual FC recipients. Wis. Admin. Code, §DHS 10.44(2)(f). The Department requires MCOs to utilize a “member-centered planning process” which entails applying the “Resource Allocation Decision” (RAD) method when determining appropriate long-term care services for a member. See FC / P Contract, Article V., Sec. K.; and Family Care / Partnership / PACE Technical Assistance Series: DHS and MCO Resource Allocation Decision (RAD) and Notice of Adverse Benefit Determination Guidelines, Issued 06/2013, Revised 02/2024. MCOs may develop service authorization guidelines for use with the RAD but such guidelines must be approved by the department. FCP Contract, Article V., Sec. K.1.a. When evaluating authorization requests, MCOs may 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.

The FamilyCare contract lists the Community Support Program as a covered service under the FamilyCare benefit package. FC Contract, Article VI, Benefit Package Service Definitions, page 472. The services provided under the CSP are listed in the administrative code.

(6) COMMUNITY SUPPORT PROGRAM (CSP) SERVICES.

(a) Covered services. Community support program services shall be covered services when prescribed by a medical prescribing provider and provided by a provider certified under s. DHS 105.255 for recipients who can benefit from the services. These non-institutional services make medical treatment and related care and rehabilitative services available to enable a recipient to better manage the symptoms of his or her illness, to increase the likelihood of the recipient’s independent, effective functioning in the community and to reduce the incidence and duration of institutional treatment otherwise brought about by mental illness. Services covered are as follows:

1. Initial assessment. At the time of admission, the recipient, upon a psychiatrist’s order, shall receive an initial assessment conducted by a psychiatrist and appropriate professional personnel to determine the need for CSP care;
2. In-depth assessment. Within one month following the recipient’s admission to a CSP, a psychiatrist and a treatment team shall perform an in-depth assessment to include all of the following areas:
   1. Evaluation of psychiatric symptomology and mental status;
   2. Use of drugs and alcohol;
   3. Evaluation of vocational, educational and social functioning;
   4. Ability to live independently;
   5. Evaluation of physical health, including dental health;
   6. Assessment of family relationships; and
   7. Identification of other specific problems or needs;
3. Treatment plan. A comprehensive written treatment plan shall be developed for each recipient and approved by a psychiatrist. The plan shall be developed by the treatment team with the participation of the recipient or recipient’s guardian and, as appropriate, the recipient’s family. Based on the initial and in-depth assessments, the treatment plan shall specify short-term and longterm treatment and restorative goals, the services required to meet these goals and the CSP staff or other agencies providing treatment and psychosocial rehabilitation services. The treatment plan shall be reviewed by the psychiatrist and the treatment team at least every 30 days to monitor the recipient’s progress and status;
4. Treatment services, as follows:
   1. Family, individual and group psychotherapy;
   2. Symptom management or supportive psychotherapy;
   3. Medication prescription, administration and monitoring;
   4. Crisis intervention on a 24-hour basis, including short-term emergency care at home or elsewhere in the community; and
   5. Psychiatric and psychological evaluations;
5. Psychological rehabilitation services as follows;
   1. Employment-related services. These services consist of counseling the recipient to identify behaviors which interfere with seeking and maintaining employment; development of interventions to alleviate problem behaviors; and supportive services to assist the recipient with grooming, personal hygiene, acquiring appropriate work clothing, daily preparation for work, on-the-job support and crisis assistance;
   2. Social and recreational skill training. This training consists of group or individual counseling and other activities to facilitate appropriate behaviors, and assistance given the recipient to modify behaviors which interfere with family relationships and making friends;
   3. Assistance with and supervision of activities of daily living. These services consist of aiding the recipient in solving everyday problems; assisting the recipient in performing household tasks such as cleaning, cooking, grocery shopping and laundry; assisting the recipient to develop and improve money management skills; and assisting the recipient in using available transportation;
   4. Other support services. These services consist of helping the recipient obtain necessary medical, dental, legal and financial services and living accommodations; providing direct assistance to ensure that the recipient obtains necessary government entitlements and services, and counseling the recipient in appropriately relating to neighbors, landlords, medical personnel and other personal contacts; and
6. Case management in the form of ongoing monitoring and service coordination activities described in s. DHS 107.32 (1) (d).

Wis. Admin Code § DHS 107.13 (6)

According to the petitioner’s CSP Crisis Plan dated 6/2/2025, the petitioner was receiving weekly home visits from a CSP case manager, monthly in-home appointments with a CSP psychiatrist, medication delivery and oversight, encouragement and assistance going to the —, and the availability of CSP staff, if needed, for crisis response and stabilization. (Petitioner’s Exhibit 3.) The petitioner’s guardian also testified that CSP staff had been helping the petitioner obtain quarters to do her laundry.

The FamilyCare agency contends that the Community Support Program (CSP) is no longer necessary to meet the petitioner’s mental health support needs. The agency argued that the mental health services that the petitioner receives from the CSP program can be obtained on an outpatient basis. The petitioner is able to see the same psychiatrist at the outpatient clinic as she was seeing in her home, and transportation to the appointment will be provided by the FamilyCare agency. The agency also stated that the petitioner has supportive home care staff who have been picking up her medications and can assist her with getting quarters for laundry. Additionally, the FamilyCare agency staff testified that the petitioner had not gone to the — since December, but they had confirmed that staff at the — could assist the petitioner with learning to use the equipment if she wanted to return. Finally, the agency argued that the delivery of — on Mondays by the CSP case manager was not essential to her mental health support.

On September 17, 2025, the Community Support Program itself sent a notice to the petitioner that it was discontinuing her enrollment in the program. Although this notice was not part of the hearing record, the agency representative summarized it as stating that the CSP agency had determined that the petitioner no longer had a need for CSP support and services, and that her mental health needs could be met without the CSP program. (Testimony of Sarah Mullenberg.)

At the hearing, the petitioner’s guardian testified that changes in routine are difficult for the petitioner. She asserted that it is more difficult for the petitioner to have her monthly therapy appointment on an outpatient basis as it requires her to take transportation to get to the clinic. At times, the petitioner may change her mind and refuse to go to appointments due to her disability. This requires the guardian to coordinate last minute ride changes with the transportation company. The petitioner’s standby guardian, —, also testified at the hearing that the petitioner does not like going to the building where the outpatient counseling services are offered as she is not familiar with it.

The petitioner’s guardian also testified that a CSP staff person had been helping encourage the petitioner to go to the — and show her how to use the equipment there. She confirmed that the petitioner had not been to the — since December 2025, but stated that she was aware that the petitioner would like to return to the — again. Furthermore, the petitioner’s guardian stated that the petitioner looks forward to receiving — on Mondays at lunchtime when she had the weekly visit with her CSP case manager. Since the discontinuation of the CSP, the — meal has been ordered through a food delivery service online which charges an additional $6 for delivery and the food does not always arrive hot.

It is undisputed that the Community Support Program itself sent the petitioner a notice of disenrollment from the program on September 17, 2025. As an administrative law judge, I have no authority to order the CSP to continue providing services to the petitioner after it has disenrolled her. My only authority is to review whether the FamilyCare agency correctly terminated the CSP as a service under the petitioner’s plan.

Although there was testimony at the hearing from the petitioner’s guardian that there have been some minor hiccups and timing issues related to medication delivery, scheduling transportation, and ensuring that staff help the petitioner obtain quarters for laundry, these tasks are clearly within the scope of the supportive home care staff and are likely to be resolved once the new routine becomes more established. The FamilyCare agency testified that the petitioner has supportive home care staff in her home several times per day to assist with activities of daily living and instrumental activities of daily living. The agency also testified that the community supportive living agency has a 24 hour assistance line available to call in cases of emergencies overnight or when staff are not present.

The fact that the Community Support Program itself already disenrolled the petitioner is a strong indication that the program is no longer necessary for the petitioner’s mental health support. I agree with the agency that meal delivery is not a service covered by the Community Support Program. The other services the petitioner received under the program can be provided on an outpatient basis or provided by supportive home care staff.

Conclusions of Law

The FamilyCare agency correctly terminated the petitioner’s Community Support Program services.

THEREFORE, it is

Ordered

The petitioner’s appeal is hereby dismissed.

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