MGE 218652 (07/30/2025)
Disenrollment due to agency error corrected

Preliminary Recitals

Pursuant to a petition filed on June 9, 2025, 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 July 30, 2025, by telephone.

The issue for determination is whether the respondent correctly disenrolled the Petitioner from the Family Care program.

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: Lyeshia Griffin
Milwaukee Enrollment Services
1220 W Vliet St
Milwaukee, WI 53205

ADMINISTRATIVE LAW JUDGE:
Jason M. Grace
Division of Hearings and Appeals

Findings of Fact

1. Petitioner (CARES # —) is a resident of Milwaukee County. He was enrolled in the Family Care program, with My Choice Wisconsin his managed care organization.
2. On February 10, 2025, Petitioner was provided notice that he needed to complete his annual healthcare renewal by March 18, 2025 or his benefits could end March 31, 2025.
3. On March 11, 2025, the Petitioner submitted his healthcare renewal forms.
4. On March 13, 2025, the agency issued notice requiring Petitioner to provide verification of bank accounts and VA benefits by April 1, 2025.
5. On April 2, 2025, the agency issued notice to Petitioner that his deadline to complete his MA/Community Waivers had been extended to April 11, 2025.
6. Also on April 2, 2025, the agency issued notice to Petitioner that his MA and Community Waivers would end May 1, 2025 for failure to provide verification.
7. The agency acknowledged at hearing it incorrectly closed Petitioner’s case on April 1, 2025 as it had extended the deadline to provide verification.
8. The agency received the requested VA benefits and bank statements for — and —. The agency closed the case on April 11, 2025 for lack of verification of the — account. This was agency error as the Asset Verification System indicated that Petitioner last had that account in 2023.
9. The Petitioner was financially and functionally eligible for Community Waivers and had provided all needed verification prior to April 12, 2025.
10. On May 1, 2025, the Family Care MCO notified the agency that Petitioner had been disenrolled effective April 30, 2025. The disenrollment stemmed from the incorrect finding that Petitioner had failed to timely complete his healthcare renewal and was not MA eligible.
11. On July 1, 2025, the Petitioner was re-enrolled in Community Waivers/Family Care. This left a gap in benefits May 1, 2025 – July 1, 2025.
12. The petitioner timely appealed his Community Waivers/Family Care disenrollment.

Discussion

The Family Care program (FCP) is a MA waiver program that provides appropriate long-term care services for elderly or disabled adults. Wis. Stat. §46.286; see also Wis. Admin. Code, Chapter DHS 10. To be eligible, a person must meet the program’s financial and non-financial criteria, including functional criteria. Wis. Admin. Code, §§DHS 10.32(1)(d) and (e). A participant must maintain MA eligibility to remain enrolled in the Family Care program.

At hearing, the IM representative indicated that the Petitioner was incorrectly disenrolled from MA/Community Waivers due to agency error in processing his annual healthcare renewal. It was further indicated that the Petitioner maintained eligibility for MA/Community Waivers and that his benefits should be backdated to May 1, 2025.

Based on the record before me, the Petitioner was incorrectly disenrolled from the Family Care program. As such, I am remanding this matter to the respondent / Department to reinstate Family Care enrollment and benefits retroactive to May 1, 2025. There should be no gap or lapse in Family Care enrollment or benefits.

Conclusions of Law

The Petitioner was incorrectly disenrolled from the Family Care program on April 30, 2025.

THEREFORE, it is

Ordered

That the matter is remanded to respondent / Department to take all administrative steps to reinstate Petitioner’s Family Care enrollment and benefits retroactive to May 1, 2025. This action shall be completed within 10 days of the date of this Decision.