DHA Case No. FCP 220397 (Wis. Div. Hearings and Appeals Dec. 29, 2025) (DHS) ↓ Download PDF The Family Care program, through MCOs, must generally provide services that reasonably and effectively address all of the recipient’s long-term needs and outcomes, assist the recipient to be as self-reliant and autonomous as possible, and are cost effective. […] Read more
Tag: 5.05.1 Family Care
DHA Case No. FCP 220016 (Wis. Div. Hearings and Appeals Dec. 8, 2025) (DHS) ↓ Download PDF Medicaid appeals must be filed within 45 days of the date of the notice of action. In this case, the petitioner was sent a cost share notice on April 11 but did not file an appeal until September […] Read more
DHA Case No. FCP 220319 (Wis. Div. Hearings and Appeals Nov. 17, 2025) (DHS) ↓ Download PDF MCOs must develop service plans that reasonably and effectively address the member’s long-term needs and outcomes while also being cost-effective. In this case, My Choice sought to end the petitioner’s placement in an AFH in favor of a […] Read more
DHA Case No. FCP 219890 (Wis. Div. Hearings and Appeals Nov. 13, 2025) (DHS) ↓ Download PDF Income received less often than monthly is generally prorated and counted, but the MEH directs: “do not count the prorated income until it is received.” In this case, the petitioner received a yearly annuity payment in January and […] Read more
DHA Case No. FCP 219522 (Wis. Div. Hearings and Appeals Oct. 28, 2025) (DHS) ↓ Download PDF When an MCO reduces a service, it has the burden to prove that the reduction is appropriate. In this case, Inclusa sought to end a lawn care service because it expected the petitioner’s wife to do the yard […] Read more
DHA Case No. FCP 219433 (Wis. Div. Hearings and Appeals Oct. 16, 2025) (DHS) ↓ Download PDF Family Care MCOs must generally cover services that are needed, but those services must also be cost-effective. In this case, the petitioner was 36 years old, had a corporate guardian, was looking for employment in the community, and […] Read more
DHA Case No. FCP 218749 (Wis. Div. Hearings and Appeals Oct. 14, 2025) (DHS) ↓ Download PDF When an agency error causes delay in an individual’s enrollment in an MCO, the Department may adjust the individual’s enrollment date. In this case, the petitioner contacted the ADRC October 28 but an options counselor was not assigned […] Read more
DHA Case No. FCP 219735 (Wis. Div. Hearings and Appeals Nov. 24, 2025) (DHS) ↓ Download PDF The Family Care program must generally provide services that reasonably and effectively address the participant’s long-term needs but are also cost-effective. In this case, the petitioner requested community-based day habilitation services to “remain active and busy in order […] Read more
DHA Case No. FCP 219488 (Wis. Div. Hearings and Appeals Nov. 4, 2025) (DHS) ↓ Download PDF To be covered under Family Care, a service must be cost-effective. In this case, the MCO denied the petitioner’s request for 24/7 supportive home care (SHC), claiming it would be more cost-effective for him to move to a […] Read more
DHA Case No. FCP 218531 (Wis. Div. Hearings and Appeals Sep. 4, 2025) (DHS) ↓ Download PDF The Family Care program must generally cover services that reasonably and effectively address the participant’s long-term needs, but those services must also be cost-effective. In this case, the agency denied the petitioner’s request for coverage of a health […] Read more
DHA Case No. FCP 219093 (Wis. Div. Hearings and Appeals Aug. 25, 2025) (DHS) ↓ Download PDF The Family Care program must generally cover services that reasonably and effectively address the participant’s long-term needs, but those services must also be cost-effective. In this case, the petitioner’s home-delivered meals ended because his plan already included Supportive […] Read more
DHA Case No. MGE 218652 (Wis. Div. Hearings and Appeals Jul. 30, 2025) (DHS) ↓ Download PDF A participant must maintain MA eligibility to remain enrolled in the Family Care program. In this case, the petitioner submitted his renewal and all verification timely, but the agency mistakenly disenrolled him. ALJ Jason Grace ordered Family Care […] Read more
FCP 217987 (06/10/2025)
Petitioner enrolled for 19 days with no services still had to pay cost share
DHA Case No. FCP 217987 (Wis. Div. Hearings and Appeals Jun. 10, 2025) (DHS) ↓ Download PDF A person enrolled in Family Care is required to pay a cost share, though the Department may waive or reduce the requirement if undue financial hardship would result. In this case, the petitioner enrolled in Family Care March […] Read more
DHA Case No. FCP 217858 (Wis. Div. Hearings and Appeals Jun. 2, 2025) (DHS) ↓ Download PDF An individual in the Family Care program must have an Individual Service Plan (ISP) that reasonably and effectively addresses their needs but is also cost-effective. In this case, the petitioner’s MCO (Inclusa) ended coverage of an independent nurse—who […] Read more
DHA Case No. FCP 216652 (Wis. Div. Hearings and Appeals Apr. 14, 2025) (DHS) ↓ Download PDF Aservice that is “duplicative with respect to other services being provided” is not medically necessary. In this case, the petitioner lived in an Adult Family Home (AFH) and attended adult day services at a community provider. The MCO […] Read more