Wisconsin Medicaid Home and Community Based Services Terminations

Problem Statement

In January 2017, Wisconsin began using an automated system to determine if someone fit the regulatory definition of having an intellectual or developmental disability (IDD). The IDD designation is used for eligibility in two of the state’s Medicaid home and community based services (HCBS) programs for adults. Prior to 2017, human screeners manually determined IDD designations for individuals. But the automated system’s logic was different from the federally mandated eligibility requirements for determining IDD designation.

Shortly after implementation, many people with disabilities received notices terminating them from the programs. Almost all of the terminations were because the person no longer met the “federal definition” of IDD, even though the combination of their limitations and diagnosis did in fact qualify them under the federal regulatory definition. Over 100 people appealed their terminations. All of those represented by counsel won, as did almost all of those who appealed without counsel. In all cases where the administrative law judge compared the computerized determination with the person’s individual characteristics and the actual federal regulatory definition of IDD, the decision was that the computer was wrong.

Advocates from Disability Rights Wisconsin worked with the state to ultimately fix the automated system, but the fix was not fully implemented until July 2019. Until then, individuals who had won their hearings were sometimes terminated by the computer system again and the system continued to deny or terminate eligibility for others. However, the state was manually reviewing cases prior to the fix to the computer logic and corrected the computer eligibility errors.

Status of Issue

The logic issue with how the system was operationalizing the eligibility requirements was resolved fully in July 2019 through cooperation with the state and individual appeal

Links to More Information

None public