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
Tag: 5.05.1 Family Care
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
DHA Case No. FCP 217068 (Wis. Div. Hearings and Appeals Apr. 7, 2025) (DHS) ↓ Download PDF Aservice that is “duplicative with respect to other services being provided” is not medically necessary. In this case, the petitioner attended adult day services with a certain provider while living with her siblings for several years. But when […] Read more
DHA Case No. FCP 216051 (Wis. Div. Hearings and Appeals Mar. 28, 2025) (DHS) ↓ Download PDF Whether Family Care must cover placement in an Adult Family Home (AFH) or other group home setting depends on the general criteria of medical necessity and cost-effectivness, among others. In this case, the petitioner lived in an apartment […] Read more
DHA Case No. FCP 216227 (Wis. Div. Hearings and Appeals Mar. 27, 2025) (DHS) ↓ Download PDF A participant in Family Care cannot be disenrolled without proper advance notice. In this case, the petitioner apparently missed a yearly renewal due in August and had difficulty navigating the re-enrollment process with the ADRC (“sometime in December […] Read more
DHA Case No. CWA 216153 (Wis. Div. Hearings and Appeals Mar. 26, 2025) (DHS) ↓ Download PDF When a petitioner is disenrolled due to agency error, ALJs often correct the error by ordering continued enrollment. In this case, the petitioner made numerous attempts to timely complete a renewal but was unable to due to agency […] Read more
DHA Case No. FCP 216638 (Wis. Div. Hearings and Appeals Feb. 20, 2025) (DHS) ↓ Download PDF Aperson is functionally eligible for Community Waivers long-term care programs if, among other criteria, the person cannot safely or appropriately perform 5 or more IADLs. In this case, the petitioner’s functional screen clearly indicated she needed help with […] Read more
DHA Case No. MGE 215707 (Wis. Div. Hearings and Appeals Jan. 17, 2025) (DHS) ↓ Download PDF 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 […] Read more
DHA Case No. FCP 218386 (Wis. Div. Hearings and Appeals Sep. 23, 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 switched from the IRIS program to the Family Care program with the […] Read more