Community Waivers members in Group A have no cost share. In this case, the petitioner moved from Group A to Group B when she lost her eligibility for the Widow/Widower Group (a special status class of full-benefit Medicaid) due to receiving Medicare Part A. ALJ Jason Grace concluded the petitioner did owe a cost share and that the cost share was correctly determined by the agency.
This decision was published with support from the Elder Law & Special Needs Section of the State Bar of Wisconsin, the Wisconsin chapter of the National Academy of Elder Law Attorneys, and Krause Financial.
Preliminary Recitals
Pursuant to a petition filed on January 8, 2026, 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 January 28, 2026, by telephone.
The issue for determination is whether the agency correctly determined petitioner’s cost share.
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: Kyra Oberg, Income Maintenance, and Mary Jo Noyes
MY Choice Family Care
10201 Innovation Dr, Suite 100
Wauwatosa, WI 53226
ADMINISTRATIVE LAW JUDGE:
Jason M. Grace
Division of Hearings and Appeals
Findings of Fact
- Petitioner is a resident of —. She is enrolled in the Family Care program with My Choice Wisconsin, her managed care organization.
- On or about —, 2025, the Petitioner became eligible for Medicare Part A and B.
- Petitioner was required to complete her health care renewal by November 31, 2025. She completed that renewal on November 10, 2025.
- By notice dated November 11, 2025, the petitioner was informed that she was enrolled in Community Waivers as of December 1, 2025. The notice also indicated that she had a monthly cost share of $728.27, as of December 1, 2025. This was based on gross income of $2,373.00 from social security. She was provided deductions consisting of a personal maintenance allowance of $1,459.72; health insurance premiums of $185.00; and medical remedial expenses of $0.01.
- By notice dated December 8, 2025, the petitioner was informed that her monthly cost share increased to $750.27 starting January 1, 2026. This was based on gross income of $2,439.90 from social security. She was provided deductions consisting of a personal maintenance allowance of $1,486.72; health insurance premiums of $202.90; and medical remedial expenses of $0.01.
- On January 8, 2026, the petitioner filed an appeal seeking to contest her cost share as of December 2025.
Discussion
The Family Care (FC) Program 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. Wis. Admin. Code §DHS 10.44(f).
Petitioner had been enrolled in the Family Care with no cost share as she was a Group A Medicaid member under the Widow/Widower Group. Medicaid Eligibility Handbook (MEH), §§ 25.3 (503 Group), 25.4 (Widow/Widower Group), and 28.6 (Group A, Group B, and cost share). She became ineligible for Widow/Widower Group in April 2025 when she started to receive Medicare Part A. Id. She remained eligible for Family Care but her status changed to a Group B Medicaid member. Id. As such, she was required to pay a cost share amount toward the cost of her waiver services. Id and Wis. Admin. Code, §DHS 10.34. The cost share amount is calculated in agency’s computer system by applying the cost share deductions to members’ gross income. Id. The possible deductions include the personal maintenance allowance, family maintenance allowance, health insurance, special exempt income, and MREs. MEH, §§ 28.6.3 Admin. Code, §DHS 10.34.
In determining the December cost share, the agency found petitioner had total gross monthly income of $2,373.00. The agency found petitioner had total permitted deductions of $1,644.73, consisting of a personal maintenance allowance of $1,459.72; health insurance premiums of $185.00; and medical remedial expenses of $0.01. It found she had a monthly cost share of $728.27 ($2,373.00 – $1,644.73). The petitioner did not contest these calculations.
The petitioner had a change in income, resulting in an increase in her cost share starting January 1, 2026. The agency found petitioner’s total gross monthly income increased to $2,439.90. The agency found petitioner had total permitted deductions of $1,689.63, consisting of a $1,486.72 personal maintenance allowance, $202.90 health insurance premiums, and medical/remedial expenses of $.01. It found she had a monthly cost share of $750.27 ($2,439.90 – $1,689.63). The petitioner did not contest these calculations. Based on the record before me, I find that the agency correctly determined the cost share.
Conclusions of Law
The agency correctly determined petitioner’s cost share.
THEREFORE, it is
Ordered
That petitioner’s appeal is dismissed.
[Request for a rehearing and appeal to court instructions omitted.]
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