5.05.8 Groups and cost sharing

FCP 209188 (09/05/2023)
Untimely appeal dismissed, despite tragic circumstances

Tags: 4 Program Administration, 4.7 Notices & fair hearings, 5 Subprograms, 5.05 Home and Community-Based Waivers Long-Term Care, 5.05.1 Family Care, 5.05.8 Groups and cost sharing, ALJ Jason M. Grace

DHA Case No. FCP 209188 (Wis. Div. of Hearings and Appeals September 5, 2023) (DHS) ↓ Download PDF An appeal of a negative MA decision must be filed, at most, within 90 days (for most decisions it’s 45 days). In this case, the petitioner’s cost share was increased by notices effective September 1, 2022 and […] Read more

MGE 209688 (10/19/2023)
IRIS correctly calculated a high cost share

Tags: 5 Subprograms, 5.05 Home and Community-Based Waivers Long-Term Care, 5.05.4 IRIS, 5.05.8 Groups and cost sharing, ALJ Beth Whitaker

DHA Case No. MGE 209688 (Wis. Div. of Hearings and Appeals October 19, 2023) (DHS) ↓ Download PDF A recipient of IRIS must usually pay a cost share after deducting a basic needs allowance, a special housing amount, health insurance premiums, and certain out-of-pocket medical/remedial expenses. In this case, the petitioner had fairly high income […] Read more

FCP 206604 (01/05/2023)
Family Care cost share and MAPP eligibility flip-flopping

Tags: 5 Subprograms, 5.03 Medicaid Purchase Plan, 5.05 Home and Community-Based Waivers Long-Term Care, 5.05.1 Family Care, 5.05.5 Fiscal test group, 5.05.8 Groups and cost sharing, ALJ Teresa A. Perez

DHA Case No. FCP 206604 (Wis. Div. of Hearings and Appeals January 5, 2023) (DHS) ↓ Download PDF Family Care members in Group A (due to eligibility for MAPP, for example) do not have a cost share. In this complex case, the petitioner lost MAPP eligibility when her child turned 18 and her fiscal test […] Read more

FCP 208218 (06/12/2023)
Cost share not reduced retroactively when shelter expenses reported late

Tags: 3 Financial Eligibility, 3.1 Income, 3.1.8 Income deductions, 3.1.8.1 Maintaining home or apartment, 5 Subprograms, 5.05 Home and Community-Based Waivers Long-Term Care, 5.05.1 Family Care, 5.05.8 Groups and cost sharing, ALJ Beth Whitaker

DHA Case No. FCP 208218 (Wis. Div. of Hearings and Appeals June 12, 2023) (DHS) ↓ Download PDF Cost share reductions are effective the month of the change report, even if the actual change in income or expense was earlier. In this case, the petitioner enrolled in Family Care with a cost share effective November […] Read more

CWA 208193 (10/02/2023)
Cost share reduced, agency did not meet burden of proof

Tags: 5 Subprograms, 5.05 Home and Community-Based Waivers Long-Term Care, 5.05.4 IRIS, 5.05.8 Groups and cost sharing, ALJ John P. Tedesco

DHA Case No. CWA 208193 (Wis. Div. of Hearings and Appeals October 2, 2023) (DHS) ↓ Download PDF When DHS increases a member’s cost share, it has the burden of proof on appeal. In this rather messy case, it was clear that the cost share should have been lower but it was not clear whose […] Read more

MPC 13/78330 (11/01/2006)
Assignment of income to SNT reduced income for Group B/C eligibility determination

Tags: 3 Financial Eligibility, 3.1 Income, 5 Subprograms, 5.05 Home and Community-Based Waivers Long-Term Care, 5.05.2 Family Care Partnership, 5.05.8 Groups and cost sharing, ALJ Kenneth D. Duren

DHA Case No. MPC-13/78330 (Wis. Div. of Hearings and Appeals November 1, 2006) (DHS) ↓ Download PDF In Community Waivers cases, countable income is first used in eligibility determinations to place an applicant into a group; then the post-eligibility cost share is calculated based on the formula for that group. In this case, the petitioner’s […] Read more

FCP 155113 (05/14/2014)
Overnight supervision allowed as a remedial expense in calculating cost share

Tags: 3 Financial Eligibility, 3.1 Income, 3.1.8 Income deductions, 3.1.8.5 Medical and remedial expenses, 5 Subprograms, 5.05 Home and Community-Based Waivers Long-Term Care, 5.05.1 Family Care, 5.05.8 Groups and cost sharing, ALJ Debra Bursinger

DHA Case No. FCP 155113 (Wis. Div. of Hearings and Appeals May 14, 2014) (DHS) ↓ Download PDF The issue in this case was whether overnight caregiver costs counted as a remedial expense, which could be deducted from income before determining the cost share. The agency argued these could not be a remedial expense, relying […] Read more

FCP 197076 (02/28/2020)
Cost share reduced by hardship waiver

Tags: 3 Financial Eligibility, 3.1 Income, 3.1.5 Unearned income, 3.1.5.23 Rental income, 3.1.8 Income deductions, 3.1.8.1 Maintaining home or apartment, 4 Program Administration, 4.5 Undue hardship, 5 Subprograms, 5.05 Home and Community-Based Waivers Long-Term Care, 5.05.2 Family Care Partnership, 5.05.8 Groups and cost sharing, ALJ Peter McCombs

DHA Case No. FCP 197076 (Wis. Div. Hearings and Appeals Feb. 28, 2020) (DHS) ↓ Download PDF In this case, the petitioner had a life estate in two properties, one in California and one in Wisconsin. Both were rented. But Dane County DHS did not reduce the petitioner’s cost share to allow her to pay […] Read more