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

DHA Case No. FCP 218679 (Wis. Div. Hearings and Appeals Sep. 2, 2025) (DHS) ↓ Download PDF As stated in the recent DMS Ops Memo 25-07, 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 […] Read more

DHA Case No. FCP 218663 (Wis. Div. Hearings and Appeals Jul. 24, 2025) (DHS) ↓ Download PDF As stated in the recent DMS Ops Memo 25-07, 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 […] Read more

DHA Case No. FCP 217755 (Wis. Div. Hearings and Appeals Jul. 11, 2025) (DHS) ↓ Download PDF Family Care MCOs must provide services that reasonably and effectively address all of the member’s long-term needs and outcomes while being cost-effective. In this case, the petitioner’s MCO sought to end his placement in an Adult Family Home, […] Read more

DHA Case No. FCP 217978 (Wis. Div. Hearings and Appeals Jul. 9, 2025) (DHS) ↓ Download PDF Income maintenance agencies have a duty to screen members for other bases of eligibility before disenrolling them. In this case, the petitioner became ineligibile for SSI and was therefore disenrolled from MA, losing her Family Care benefits, even […] Read more

DHA Case No. FCP 217040 (Wis. Div. Hearings and Appeals Jun. 27, 2025) (DHS) ↓ Download PDF Family Care benefits may be backdated if agency error causes unreasonable delay. In this case, the petitioner was eligible and selected an MCO and enrollment date with the ADRC, but the ADRC worker’s email to the MCO was […] Read more

DHA Case No. FCP 218179 (Wis. Div. Hearings and Appeals Jun. 16, 2025) (DHS) ↓ Download PDF Before disenrolling a member from Family Care, an MCO must give at least ten days’ notice, with the opportunity for the member to request that services be continued pending an appeal. In this case, the petitioner failed to […] Read more

DHA Case No. FCP 216960 (Wis. Div. Hearings and Appeals May 30, 2025) (DHS) ↓ Download PDF Family Care enrollment can be backdated if agency error by the ADRC or IM causes unreasonable delay. In this case, the petitioner was enrolled in both MAPP and Family Care; when his MAPP renewal resulted in disenrollment, the […] Read more