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

DHA Case No. BCS 220537 (Wis. Div. Hearings and Appeals Jan. 9, 2026) (DHS) ↓ Download PDF Neither the administrative code nor the federal regulations include a right to a fair hearing regarding an agency’s failure to close a case promptly when asked to do so by a benefit recipient. In this case, the petitioner […] Read more

DHA Case No. FCP 220498 (Wis. Div. Hearings and Appeals Jan. 5, 2026) (DHS) ↓ Download PDF Services provided through the Family Care program must be cost-effective. In this case, the petitioner lived at an AFH and attended a nearby adult day service program that proved very beneficial. When he moved to a different AFH, […] Read more

DHA Case No. CWA 221013 (Wis. Div. Hearings and Appeals Feb. 25, 2026) (DHS) ↓ Download PDF IRIS funds approved through the budget amendment process must be used for the requested service and cannot be transferred to a different service or service type, or a different provider type. In this case, the petitioner was enrolled […] Read more

DHA Case No. CWK 221068 (Wis. Div. Hearings and Appeals Feb. 20, 2026) (DHS) ↓ Download PDF A “Notice of Action” must be provided to CLTS participants at least fifteen days before a reduction or termination of services, which participants have the right to appeal. In this case, the petitioner’s respite services were terminated effective […] Read more

DHA Case No. FCP 219708 (Wis. Div. Hearings and Appeals Feb. 17, 2026) (DHS) ↓ Download PDF To be eligible for full services through an MCO, a Family Care member must require a “nursing home” level of care. In this case, the petitioner was enrolled in Family Care with Lakeland as her MCO, had an […] Read more

DHA Case No. MGE 220918 (Wis. Div. Hearings and Appeals Feb. 6, 2026) (DHS) ↓ Download PDF The MEH says a faxed application received after business hours is considered filed on the next business day, but a 2023 fair hearing decision—adopted as final by the DHS secretary—concluded it should be considered filed the day it […] Read more

DHA Case No. MGE 220701 (Wis. Div. Hearings and Appeals Feb. 3, 2026) (DHS) ↓ Download PDF A person’s income and assets are mandatory verification items at the time of a Medicaid application and at annual renewals. In this case, the petitioner provided, over several rounds of requests, verification of her various assets and spend-down; […] Read more

DHA Case No. MAP 219995 (Wis. Div. Hearings and Appeals Jan. 27, 2026) (DHS) ↓ Download PDF Payment of a monthly premium is a condition of eligibility for MAPP, though a member may ask for a temporary hardship waiver that cannot exceed 12 months “for the same hardship reason.” Regular, recurring expenses that are not […] Read more

DHA Case No. MGE 220759 (Wis. Div. Hearings and Appeals Jan. 23, 2026) (DHS) ↓ Download PDF The deductions available in calculating patient liability are limited and do not include any allowance for estimated income tax payments or withholding. In this case, the petitioner was granted a six-month home expense deduction but asked that his […] Read more

DHA Case No. FCP 219586 (Wis. Div. Hearings and Appeals Jan. 16, 2026) (DHS) ↓ Download PDF Participants in Family Care have the right to appeal any adverse benefit determination. In this case, the petitioner’s MCO involuntarily ended her ability to self-direct her services and claimed this was not appealable because it was not an […] Read more

DHA Case No. MRA 220384 (Wis. Div. Hearings and Appeals Jan. 7, 2026) (DHS) ↓ Download PDF In general, all gross income is counted when determining eligibility and cost share for Family Care. In this case, the petitioner was enrolled in Institutional MA and allocated the maximum amount of income to her community spouse, who […] Read more

DHA Case No. CWA 220139 (Wis. Div. Hearings and Appeals Jan. 2, 2026) (DHS) ↓ Download PDF To be functionally eligible for the IRIS program, an individual must belong to one of the following target groups (in addition to needing a nursing home level of care): frail elderly, adult with a physical disability, or adult […] Read more

DHA Case No. MRA 13/102709 (Wis. Div. Hearings and Appeals 2009) (DHS) ↓ Download PDF An ALJ may increase the community spouse income allocation (CSIA) if the community spouse does not have enough income to pay his or her “necessary and basic maintenance needs.” In this case, the petitioner’s wife established that she had income […] Read more