DHA Case No. FCP 220772 (Wis. Div. Hearings and Appeals Mar. 20, 2026) (DHS) ↓ Download PDF In the Family Care program, MCOs may not deny a service that is reasonable and necessary to cost-effectively support the member’s long-term care outcomes. In this case, the petitioner’s Community Support Program services ended when the agency determined […] Read more

DHA Case No. FCP 221245 (Wis. Div. Hearings and Appeals Mar. 19, 2026) (DHS) ↓ Download PDF In the Family Care program, the MCO does not have to provide a service the participant wants if there are less expensive alternatives that achieve the same results. In this case, the MCO terminated the petitioner’s AFH funding […] Read more

DHA Case No. FCP 220220 (Wis. Div. Hearings and Appeals Mar. 19, 2026) (DHS) ↓ Download PDF An MCO may not deny a service that is reasonable and necessary to cost-effectively support a member’s long-term care outcomes. In this case, the petitioner had been living at home and receiving adult day care services. When she […] Read more

DHA Case No. FCP 220856 (Wis. Div. Hearings and Appeals Mar. 9, 2026) (DHS) ↓ Download PDF All individuals, including family members, who provide paid care to Family Care participants must undergo a background check. In this case, the petitioner was enrolled in Family Care July 1, but his guardian and caregiver did not complete […] Read more

DHA Case No. FCP 220671 (Wis. Div. Hearings and Appeals Mar. 31, 2026) (DHS) ↓ Download PDF An individual’s functional eligibility for Family Care is determined by a functional screen, an interview that scores the person’s ability to perform tasks independently. In this case, the petitioner was determined functionally ineligible after a yearly renewal screen […] Read more

DHA Case No. FCP 221429 (Wis. Div. Hearings and Appeals Mar. 26, 2026) (DHS) ↓ Download PDF Community Waivers members in Group A have no cost share. In this case, the petitioner moved from Group A to Group B when she lost her eligibility for the Widow/Widower Group (a special status class of full-benefit Medicaid) […] Read more

DHA Case No. FCP 221622 (Wis. Div. Hearings and Appeals Mar. 19, 2026) (DHS) ↓ Download PDF In the Family Care program, the services provided must reasonably and effectively address all long-term needs to assist the client to be as self-reliant and autonomous as possible, but it must also be cost-effective. In this case, the […] Read more

DHA Case No. MGE 220677 (Wis. Div. Hearings and Appeals Mar. 17, 2026) (DHS) ↓ Download PDF Enrollment in Family Care may be backdated if an unreasonable delay was caused by agency error. In this case, the petitioner applied for Medicaid, requested Community Waivers, and was financially eligible on July 15, 2025. But, due to […] Read more

DHA Case No. FCP 220337 (Wis. Div. Hearings and Appeals Mar. 17, 2026) (DHS) ↓ Download PDF Enrollment in Family Care may be backdated if an unreasonable delay was caused by agency error. In this Milwaukee County case, the ADRC took four months to complete a functional screen and another three months to complete enrollment. […] Read more

DHA Case No. FCP 221117 (Wis. Div. Hearings and Appeals Feb. 23, 2026) (DHS) ↓ Download PDF Residential care services provided through Family Care MCOs may be authorized only when a member’s long-term care outcomes cannot be cost-effectively supported in the member’s home, or when a member’s health and safety cannot be adequately safe guarded […] Read more

DHA Case No. MGE 221661 (Wis. Div. Hearings and Appeals Feb. 20, 2026) (DHS) ↓ Download PDF 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 […] Read more

DHA Case No. MGE 220385 (Wis. Div. Hearings and Appeals Jan. 26, 2026) (DHS) ↓ Download PDF Enrollment in Family Care may be backdated if an unreasonable delay was caused by agency error. In this case, the petitioner was disenrolled when she failed to complete her renewal, then reapplied and was enrolled again eight months […] Read more

DHA Case No. MGE 220307 (Wis. Div. Hearings and Appeals Jan. 12, 2026) (DHS) ↓ Download PDF To be eligible for Family Care, an applicant must have a long-term care functional screen to determine his or her functional eligibility. In this case, the petitioner submitted an online ACCESS application indicating that she needed help with […] Read more

DHA Case No. FCP 220551 (Wis. Div. Hearings and Appeals Jan. 9, 2026) (DHS) ↓ Download PDF MCOs may not deny a service that is reasonable and necessary, and in an amount, scope, and duration needed to cost-effectively support the member’s long-term care outcomes. In this case, the petitioner lived in a 1-2 bed adult […] Read more