DHA Case No. MDV 220070 (Wis. Div. Hearings and Appeals Dec. 10, 2025) (DHS) ↓ Download PDF The action of avoiding the receipt of income that a Medicaid member is entitled to is a divestment. In this case, the petitioner revocably renounced a VA survivor’s pension, which was $948 normal pension and $567 Aid and […] Read more

DHA Case No. CWA 220073 (Wis. Div. Hearings and Appeals Dec. 5, 2025) (DHS) ↓ Download PDF When the IRIS program ends a participant’s enrollment involuntarily, it bears the burden of proof to show that the disenrollment was proper. In this case, the IRIS Consultant (IC) submitted only an unsigned, unsworn written statement about an […] Read more

DHA Case No. FCP 220319 (Wis. Div. Hearings and Appeals Nov. 17, 2025) (DHS) ↓ Download PDF MCOs must develop service plans that reasonably and effectively address the member’s long-term needs and outcomes while also being cost-effective. In this case, My Choice sought to end the petitioner’s placement in an AFH in favor of a […] Read more

DHA Case No. FCP 219890 (Wis. Div. Hearings and Appeals Nov. 13, 2025) (DHS) ↓ Download PDF Income received less often than monthly is generally prorated and counted, but the MEH directs: “do not count the prorated income until it is received.” In this case, the petitioner received a yearly annuity payment in January and […] Read more

DHA Case No. CWA 219687 (Wis. Div. Hearings and Appeals Nov. 13, 2025) (DHS) ↓ Download PDF While ADRCs do not have primary responsibility for assisting people with Medicaid applications, they are contracted to provide general assistance, including assistance with obtaining verification. In this case, the ADRC faxed verification documents for the petitioner to Income […] Read more

DHA Case No. MDV 220057 (Wis. Div. Hearings and Appeals Nov. 10, 2025) (DHS) ↓ Download PDF A divestment does not affect eligibility if the resource was “transferred exclusively for some purpose other than to become eligible for MA.” In this case, the petitioner gave $5,000 to each of her three daughters (to one for […] Read more

DHA Case No. MAP 219997 (Wis. Div. Hearings and Appeals Oct. 31, 2025) (DHS) ↓ Download PDF An employer-sponsored retirement plan is not counted as an available asset if the individual is still working and would have to quit their job to obtain funds. In this case, the petitioner had a 401(k) with a balance […] Read more

DHA Case No. FCP 219522 (Wis. Div. Hearings and Appeals Oct. 28, 2025) (DHS) ↓ Download PDF When an MCO reduces a service, it has the burden to prove that the reduction is appropriate. In this case, Inclusa sought to end a lawn care service because it expected the petitioner’s wife to do the yard […] Read more

DHA Case No. MGE 219667 (Wis. Div. Hearings and Appeals Oct. 21, 2025) (DHS) ↓ Download PDF When a person receiving SSI and Medicaid loses SSI eligibility because they start receiving SSDI Disabled Adult Child (DAC) payments, the Medicaid program must treat the person as if they were still receiving SSI. In this case, that […] Read more

DHA Case No. FCP 219433 (Wis. Div. Hearings and Appeals Oct. 16, 2025) (DHS) ↓ Download PDF Family Care MCOs must generally cover services that are needed, but those services must also be cost-effective. In this case, the petitioner was 36 years old, had a corporate guardian, was looking for employment in the community, and […] Read more

DHA Case No. BCS 219426 (Wis. Div. Hearings and Appeals Oct. 15, 2025) (DHS) ↓ Download PDF Medicaid recipients are entitled to at least 10 days’ notice before any adverse action. In this case, the petitioner failed to provide verification due August 4, so on August 5 the agency issued a notice terminating benefits as […] Read more

DHA Case No. FCP 218749 (Wis. Div. Hearings and Appeals Oct. 14, 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 contacted the ADRC October 28 but an options counselor was not assigned […] Read more

DHA Case No. CWA 219315 (Wis. Div. Hearings and Appeals Oct. 9, 2025) (DHS) ↓ Download PDF The IRIS program must generally cover services that are needed and cost-effective. In this case, the petitioner had severe violent behavior that culminated in felony charges after attacking a staff member. After that, only one AFH was both […] Read more

DHA Case No. CWA 219173 (Wis. Div. Hearings and Appeals Oct. 1, 2025) (DHS) ↓ Download PDF When a person’s eligibility for SSI ends, agency policy is to automatically run Medicaid eligibility under other criteria. In this case, the petitioner’s SSI ended and she even received a notice saying she didn’t need to do anything […] Read more