Fair Hearing Decisions

DHA Case No. HMO 209172 (Wis. Div. of Hearings and Appeals July 27, 2023) (DHS) ↓ Download PDF When a member disagrees with a Medicaid HMO’s decision, the member must first appeal to the HMO. The Division of Hearings and Appeals does not have jurisdiction until there is a final determination by the HMO’s internal […] Read more

DHA Case No. MDV 209022 (Wis. Div. of Hearings and Appeals August 25, 2023) (DHS) ↓ Download PDF An appeal of a divestment penalty must be filed within 45 days; an appeal of a hardship waiver denial must also be filed within 45 days. In this case, the agency imposed a divestment penalty when the […] Read more

DHA Case No. MPA 208980 (Wis. Div. of Hearings and Appeals November 9, 2023) (DHS) ↓ Download PDF Wisconsin Medicaid covers gender-affirming medical and surgical treatments when medically necessary. In this case, the petitioner sought a prior authorization for six sessions of laser hair removal from the face as part of gender-affirming care. The Department […] Read more

DHA Case No. MGE 207999 (Wis. Div. of Hearings and Appeals May 10, 2023) (DHS) ↓ Download PDF When a consumer is discharged from the Comprehensive Community Services (CCS) program and receives MA, they must first exhaust the grievance procedure at the local level before appealing to a fair hearing. The notice of discharge, however, […] Read more

DHA Case No. MGE 210503 (Wis. Div. of Hearings and Appeals December 19, 2023) (DHS) ↓ Download PDF After enrollment in a long-term care Medicaid program, the institutionalized spouse must spend down or transfer resources to the community spouse to get below $2,000 by the first renewal. In this case, the petitioner failed to do […] Read more

DHA Case No. FCP 210574 (Wis. Div. of Hearings and Appeals November 30, 2023) (DHS) ↓ Download PDF An MCO must give ten days’ notice of any adverse benefit determination. In this case, the petitioner’s MCO issued a notice on September 29 disenrolling her retroactive to August 21. ALJ Brian Schneider concluded the MCO had not […] Read more

DHA Case No. SSO 209011 (Wis. Div. of Hearings and Appeals September 18, 2023) (DHS) ↓ Download PDF DHS cannot recover state SSI benefits that were incorrectly paid more than 12 months before the “date of discovery” of the overpayment. In this case, the Social Security Administration retroactively terminated the petitioner’s SSI eligibility for January […] Read more

DHA Case No. CWA 208939 (Wis. Div. of Hearings and Appeals August 21, 2023) (DHS) ↓ Download PDF When a person must use adaptive aids to perform an activity of daily living (ADL), this counts as needing assistance with the ADL for functional eligibility. In this case, the petitioner was disenrolled from IRIS after a […] Read more

DHA Case No. CWA 210286 (Wis. Div. of Hearings and Appeals November 2, 2023) (DHS) ↓ Download PDF The Department may deny an IRIS application for an inability or unwillingness to develop an Individual Support and Service Plan (ISSP) that ensures the participant’s health and safety. In this case, the petitioner was previously disenrolled in […] Read more

DHA Case No. MGE 210128 (Wis. Div. of Hearings and Appeals November 22, 2023) (DHS) ↓ Download PDF An asset is not available if the member lacks the ability to provide legal access to it. In this case, the petitioner had a life insurance policy with a cash value greater than $2,000; he also had […] Read more

DHA Case No. MDV 209376 (Wis. Div. of Hearings and Appeals October 27, 2023) (DHS) ↓ Download PDF Institutional MA eligibility can be backdated up to three months prior to the the month of application. In this case, the petitioner requested an asset assessment in January 2023 but didn’t apply until May. ALJ Peter McCombs […] Read more

DHA Case No. MGE 210319 (Wis. Div. of Hearings and Appeals October 20, 2023) (DHS) ↓ Download PDF In general, all available assets are counted and counted assets are not reduced by outstanding debt. In this case, the petitioner had excess assets at her renewal and an overpayment claim that was pending but not yet […] Read more

DHA Case No. MLL 209431 (Wis. Div. of Hearings and Appeals August 28, 2023) (DHS) ↓ Download PDF An applicant for a hardship waiver of estate recovery must file his or her application within 45 days of estate recovery’s claim, after which the applicant has 60 days to submit additional information. And if the applicant […] Read more

DHA Case No. MGE 210257 (Wis. Div. of Hearings and Appeals December 7, 2023) (DHS) ↓ Download PDF An appeal must be filed within 45 days of a Medicaid application denial for the Division of Hearings and Appeals to have jurisdiction. In this case, the deadline to appeal the initial denial of the Medicaid application […] Read more