MGE 214557 (01/15/2025)
Family Care benefits restored after mixup between IM and MCO

The attached proposed decision of the Administrative Law Judge dated October 19, 2024, is hereby adopted as the final order of the Department.

Preliminary Recitals

Pursuant to a petition filed on August 13, 2024, under Wis. Stat.§ 49.45(5), and Wis. Admin. Code § HA 3.03(1), to review a decision by the Milwaukee Enrollment Services regarding Medical Assistance (MA), a hearing was held on September 24, 2024, by telephone.

The issue for determination is whether the Department, by its agents, correctly disenrolled the petitioner from Family Care effective March 31, 2024, because she did not timely complete her healthcare renewal with the income maintenance agency.

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: —
Milwaukee Enrollment Services
1220 W Vliet St
Milwaukee, W1 53205

ADMINISTRATIVE LAW JUDGE:
Kenneth D. Duren
Division of Hearings and Appeals

Findings of Fact

1. Petitioner (—) is a widowed resident of Milwaukee County. She is — of age. She lives in an assisted living facility in Milwaukee. She was receiving managed care via the Family Care MA Waivers program in at least January, 2024, under an ongoing certification. See, Exhibit #1, at pp. 1, 4 & 10.
2. On January 15, 2024, the Department issued a renewal application form to the petitioner via mail stating that the member should act to file it with the agency by February 16, 2024, (i.e., “cutoff”) to avoid case closure on February 29, 2024, if she did not do so. See, Exhibit #1, at p. 34.
3. On February 19, 2024, the IM agency issued an About Your Benefits Notice to the petitioner informing her that her Community Waivers benefits would end, effective March 1, 2024, because her renewal had not been completed. See, Exhibit #1, at pp. 16-17.
4. On February 23, 2024, the Department’s Milwaukee County income maintenance (“IM”) unit received the petitioner’s renewal application. See, Exhibit #1, at p. 1.
5. On February 27, 2024, the IM unit processed the petitioner’s renewal application and pended her case because assets required verification. See, Exhibit #1, at p. 4.
6. On February 28, 2024, the IM unit issued a verification request letter stating that the agency needed proof of a checking account — balance at —. This verification was due by March 18, 2024. See, Exhibit #1, at p. attached verification request letter dated February 28, 2024.
7. On March 18, 2024, the IM agency acted to extend the due date for the verification to March 28, 2024. See, Exhibit #1, at p. 4, attached Case Comments for March 18, 2024.
8. On March 28, 2024, the petitioner’s authorized representative called the agency twice to see if all needed information was in hand at the agency. She did not reach an agency worker. The agency tried to call back that day, but did not reach her. Instead, the IM agency extended the due date for the then pending asset verification to April 3, 2024, and issued another verification letter stated April 3, 2024, was the due date. See, Exhibit #1, at p. 4 (Case Comment for 3/28/24) and at pp. 30-32.
9. On or about March 31, 2024, Family Care provider My Choice of Wisconsin, by —, filed DHS form F-02404 with the Department’s Division of Public Health requesting disenrollment of the petitioner from Family Care because she had failed to complete a financial eligibility requirement, i.e., she had “failed to complete Medicaid recertification…”. See, Exhibit #1, at p. 11.
10. There is no written negative notice in this record that was issued to the petitioner informing her of the March 31, 2024 disenrollment from My Choice/Family Care; of her right to appeal that disenrollment or how and where to do so. Nor did any representative from the Family Care agency appear at the hearing.
11. The petitioner verified the bank checking account asset on April 2, 2024; that was the only asset sought to be verified by the agency. See, Exhibit #1, at p. 4 (Case Comment on 4/2/24); and see, at p. 31.
12. On April 2, 2024, the IM agency updated the petitioner’s financial eligibility case to add the asset verification it sought; and processed the My Choice/Family Care disenrollment information from the contract agency on the same date because the petitioner had not completed her financial eligibility by the re-enrollment date of March 31, 2024. See, Exhibit #1, at p. 4 (Case Comment of 4/2/2024).
13. On April 3, 2024, the IM agency issued a Notice to the petitioner informing her that her health care renewal had been completed; it did not mention Community Waivers eligibility, but instead told her that she could be eligible for MA if she met a six-month spenddown deductible of — and that she was not eligible for any Medicare Savings Plan because her income was in excess of program limits. See, Exhibit #1, at pp. 21-28.
14. Subsequently on April 3, 2024, the agency issued a follow up Notice informing the petitioner that her six-month spenddown deductible had been reduced to — for the period of April – September, 2024, due submitted bills and or Medicare premiums being counted as allowable expenses. See, Exhibit #1, at pp. 6-8.

Discussion

An appeal contesting a negative action like the discontinuance or disenrollment of Medical Assistance or MA Waivers, must be filed within 45 days of the effective date of the discontinuance or disenrollment. Likewise, disenrollment from Family Care, an MA Waivers sub-program, due to a termination of previously authorized services, must be appealed within 90 days of the effective date of that action. See, Wis. Stat., §49.45(5).

Here, I conclude the petitioner’s appeal is timely because the agency has not demonstrated that she was issued a negative notice advising her of her disenrollment from My Choice/Family Care due to the financial verification request that was pending. The time limit for appeal was tolled, i.e., did not begin to run due to the lack of a clear notice of this negative action.

As to the merits of the dispute, the agency extended the petitioner’s verification deadline twice out as far as April 3, 2024 as the final stated deadline. The petitioner, a very elderly woman, with the assistance of her adult daughter, verified the sought bank information with the county’s income maintenance (“IM”) Unit, which had requested it, on April 2, 2024. Medicaid Eligibility Handbook, § 20.1.4.

The Family Care agency independeptly and separately acted to disenroll her from the My Choice/Family Care program effective March 31, 2024, because it had not received the very financial information that its governmental partner, the IM agency, had extended the deadline to receive to April 3, 2024. The Family Care entity did not provide any worker to explain why the petitioner was disenrolled even though the IM Unit had extended the verification deadline.

This is the proverbial “Catch 22” of modern bureaucracy. In doing what one was required to do by the date it was required, the requested benefit was lost because the doing of the thing required was too late even though it was done before the deadline. See, Medicaid Eligibility Handbook, at §20.8.1.

The verification was timely completed under the extension. I can only conclude that the disenrollment was performed under a faulty logic and because of inter-agency miscommunication, and it needs to be rescinded and the IM Unit and the My Choice/Family Care agency are to redetermine her re-enrollment and eligibility for My Choice/Family Care retroactive to March 31, 2024, as if her asset verification of April 2, 2024, had been received on March 31, 2024.

The parties are reminded that this is a Proposed Decision and the ORDER below will only te effectuated if the Secretary of the Department of Health Services adopts this Proposed Decision in a Final Decision.

Conclusions of Law

That the Department and its agents incorrectly disenrolled the petitioner from My Choice/Family Care effective March 31, 2024, because she had not verified her financial information by that date; the county IM Unit had extended the deadline for submission of the verification items sought to April 3, 2024, and the petitioner verified this information on April 2, 2024.

THEREFORE, it is

Ordered

That the matter is remanded to the Department and its agents at MilES and My Choice/Family Care with instructions to: rescind the disenrollment of the petitioner from My Choice/Family Care program retroactive to March 31, 2024; process her verification made on April 2, 2024, as if it were filed with both Department agents on March 31, 2024; review and redetermine the petitioner’s eligibility for My Choice/Family Care benefits retroactive to March 31, 2024, as if she had timely verified by March 31, 2024, and certify her for all My Choice/Family Care benefits to which she was otherwise entitled retroactive to that date, if any, with written notice to the petitioner. These actions shall be completed within 10 days of the date of the final decision, if and only if, this proposed decision is adopted by the Secretary of the Department of Health Services in a final decision.