The state must maintain Medicaid coverage while completing regularly scheduled renewals as long as the renewal is received before the end of the month the renewal is due. In this case, the petitioner was enrolled in Family Care with a renewal due by the end of December. He submitted his renewal in November and gave the needed verification to his MCO, which faxed it in on December 30. It was not processed until January 2, resulting in several days of lapsed Family Care coverage. ALJ Brian Schneider concluded that the petitioner’s Family Care enrollment was terminated incorrectly becuase the verification was received by the deadline and it was only due to the holidays that it was not processed timely.
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 January 22, 2026, under Wis. Stat., §49.45(5), to review a decision by Milwaukee Enrollment Services (MES) regarding Medical Assistance (MA), a hearing was held on February 19, 2026, by telephone.
The issue for determination is whether petitioner’s IRIS was closed correctly.
PARTIES IN INTEREST:
Petitioner:
—
Respondent:
Department of Health Services
201 E. Washington Ave.
Madison, WI 53703
By: Kyra Oberg
Milwaukee Enrollment Services
6055 N. 64th Street
Milwaukee, WI 53218
Also Appearing: Mary Swab, My Choice Family Care
ADMINISTRATIVE LAW JUDGE:
Brian C. Schneider
Division of Hearings and Appeals
Findings of Fact
- Petitioner (CARES # —) is a resident of Milwaukee County.
- Petitioner is eligible for the Family Care Program (FCP) with My Choice Family Care as his managed care organization (MCO). His FCP eligibility is tied in with his MA eligibility.
- Petitioner was due for an MA renewal by the end of December, 2025. He submitted the renewal in November, and the agency requested verification of his bank accounts. The verification was given to his FCP case manager, who faxed it to MES. A problem occurred there and it was not accepted. The case manager faxed the verification again on December 30, 2025. It was received that date at MES and processed on January 2, 2026.
- Because the verification was not processed until January 2, petitioner’s MA closed. That closure caused his FCP eligibility to lapse.
- Petitioner’s MA was reopened on January 8, 2026, backdated to January 1. However, his FCP was reopened on January 9 but could not be backdated by the MCO, so petitioner had a lapse of FCP coverage from January 1 to January 8, 2026.
Discussion
Although this case is coded as an MA appeal, the issue is whether the FCP was closed correctly. The MA issue was resolved with no lapse in coverage.
The issue for FCP is resolved easily. Petitioner provided the requested verification to the MCO timely. The delay was caused by a mix-up between the MCO and MES. Even with the delay, MES received the verification before petitioner’s case closed, and it was only due to holidays that it was not processed timely.
I conclude that petitioner’s FCP was closed erroneously. This is not an instance where FCP closed correctly and thus by law cannot be backdated. The closure itself was incorrect. I thus will order that the agency take action to grant FCP for the period January 1-8, 2026.
Conclusions of Law
Petitioner’s FCP eligibility was terminated incorrectly effective January 1, 2026.
THEREFORE, it is
Ordered
That the matter be remanded to the agency with instructions to restore petitioner’s FCP eligibility and its services effective January 1, 2026. It shall do so within 10 days of this decision.
[Request for a rehearing and appeal to court instructions omitted.]
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