A person who has a cost share but fails to pay it is ineligible for Family Care. In this case, the petitioner lost eligibility for MAPP and thus had a cost share imposed. At the time of the hearing she still had not paid any of her cost share. Although part of the problem was that the petitioner’s disability income happened to end at the same time and was not reported for more than a month, ALJ Brian Schneider concluded the disenrollment was correct.
This decision was published with support from the Wisconsin chapter of the National Academy of Elder Law Attorneys and Krause Financial.
Preliminary Recitals
Pursuant to a petition filed October 30, 2024, under Wis. Stat., §49.45(5), and Wis. Admin. Code, §HA 3.03(1), to review a decision by the Barron County Dept. of Human Services regarding Medical Assistance (MA) and Family Care Program (FCP) costs shares and a proposed discontinuance of the FCP, a hearing was held on January 15, 2025, by telephone. A hearing set for December 11, 2024 was rescheduled at the petitioner’s request.
The issue for determination is whether petitioner failed to pay the appropriate cost shares.
PARTIES IN INTEREST:
Petitioner:
—
Respondent:
Department of Health Services
1 West Wilson Street, Room 651
Madison, WI 53703
By: Kristen Burstad
Barron County Dept. of Human Services
335 E Monroe Ave
Barron, WI 54812
ADMINISTRATIVE LAW JUDGE:
Brian C. Schneider
Division of Hearings and Appeals
Findings of Fact
- Petitioner (CARES # —) is a resident of Polk County. Barron County DHS is a lead county for the Great Rivers IM Consortium that includes Polk County.
- Petitioner has been eligible for the Medicaid Purchase Plan (MAPP), and concurrent with that eligibility, the FCP. During the pandemic petitioner did not have to verify a work activity for MAPP eligibility. Her monthly income during that time was $1,606 social security and $1,184.56 sick/disability benefits.
- In 2024, when MAPP policy reverted to requiring a work activity, petitioner’s daughter/representative informed the economic support worker that petitioner did not do a work activity. Therefore, MAPP closed effective July 1, 2024, and petitioner’s FCP eligibility would remain in place only if she paid a monthly cost share.
- Petitioner’s last sick/disability payment was received in August, 2024. Beginning September, 2024 her only income was social security.
- After the verification process was completed, the agency reopened the FCP by a notice dated August 6, 2024, retroactive to July 1. The notice informed petitioner that she had to pay a monthly cost share of $1,667.56. Petitioner’s daughter did not pay the cost shares.
- By a notice dated October 3, 2024, the agency informed petitioner that the FCP would end November 1, 2024 because she did not pay the cost share. Petitioner filed this appeal, and benefits were ordered to be continued pending this decision.
- On October 17, 2024, petitioner’s daughter informed the worker that the sick/disability income ended in August. The worker continued FCP eligibility under the continued benefits order but reduced the cost share to $467.20 effective October 1, 2024. As of the hearing, petitioner’s daughter still had not paid any cost shares.
Discussion
The Family Care program, which is supervised by the Department of Health Services, is designed to provide appropriate long-term care services for elderly or disabled adults. It is authorized under Wisconsin Statute, §46.286, and is described comprehensively in the Wisconsin Administrative Code, Chapter DHS 10. See also MA Handbook, Chapter 28.
A person who is eligible for MA is eligible for the FCP without a cost share, which is called Group A. Handbook, Appendix 28.6.2. That was petitioner’s category until MAPP closed. Now she would be eligible under Group B or B+, which include individuals not in Group A. Individuals in Group B not only must meet income requirements but asset limits as well. Handbook, App. 28.1.2.
Group B status is available to a person who has gross income below the institutions categorically needy income limit, which currently is $2,829. Handbook, §39.4.1. If income is higher, a Group B recipient may have health insurance premiums, certain medical/remedial expenses and a Personal Maintenance Allowance (possibly including housing expenses) subtracted from her income before a cost share is computed. 42 C.F.R. §435.726; Wis. Admin. Code, §DHS 103.07(1)(d).
When MAPP ended, the agency determined FCP eligibility by taking her gross monthly income and subtracting a $1,123 personal needs allowance and $174.70 health insurance premium to come up with the $1,667.56 cost share. The cost share reduced when petitioner’s daughter reported the end of the sick/disability income.
A person who is required to contribute to the cost of her care but who fails to make the required contributions is ineligible for the FCP. Wis. Stat., §49.286(2)(c); Wis. Admin. Code, §§DHS 10.32(1)(f) & 10.34(4)(a).
Here the cost share was determined correctly. Petitioner failed to make the required payments. The agency thus correctly sought to close the FCP. At the hearing I asked if petitioner could remain eligible for the FCP if she paid the current cost share and agreed to a plan to pay the missed payments. The FCP representatives from Inclusa agreed that she could. I thus will dismiss the appeal because the agency actions were correct, and petitioner’s daughter should work with Inclusa to keep the program open. I note, finally, that there is a provision to waive or reduce cost share requirements due to undue hardship. Wis. Admin. Code, §DHS 10.34(4)(b); see also the FCP contract, §III-D. Petitioner’s daughter might also look into having the cost share reduced to make up for the back payments.
Conclusions of Law
The agency correctly sought to close petitioner’s FCP because she failed to pay the monthly cost share.
THEREFORE, it is
Ordered
That the petition for review is hereby dismissed.
[Request for a rehearing and appeal to court instructions omitted.]
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