DHA Case No. CWK 213700 (Wis. Div. Hearings and Appeals Aug. 30, 2024) (DHS) ↓ Download PDF Educational services funded by the Department of Public Instruction cannot also be covered under CLTS’ “Empowerment and Self-Determination Supports” service code. In this case, the petitioner was initially approved to see a one-on-one provider for help with functional […] Read more
Category: Fair Hearing Decisions
DHA Case No. CWA 214423 (Wis. Div. Hearings and Appeals Nov. 6, 2024) (DHS) ↓ Download PDF IRIS funds may only be used for services, supports, or goods that address a long-term support need. In this case, the petitioner asked IRIS to pay for his participant-hired worker’s travel and lodging costs so he could attend […] Read more
DHA Case No. MPA 214372 (Wis. Div. Hearings and Appeals Nov. 15, 2024) (DHS) ↓ Download PDF To approve a prior authorization request, the service must be medically necesary. In this case, the petitioner sought a prior authorization for genetic testing to rule out a certain condition. ALJ Kelly Cochrane concluded the request was properly […] Read more
DHA Case No. MDV 214223 (Wis. Div. Hearings and Appeals Nov. 27, 2024) (DHS) ↓ Download PDF A divestment penalty is generally imposed when an applicant reports a divestment and would be otherwise eligible. In this case, the petitioner originally applied in 2020 after creating an irrevocable trust, but no divestment penalty was imposed because […] Read more
DHA Case No. MDV 214942 (Wis. Div. Hearings and Appeals Nov. 20, 2024) (DHS) ↓ Download PDF The deadline to file an appeal of a denied Medicaid application is 45 days from the notice. If a separate undue harship waiver is requested, the petitioner has 20 days from the request to provide any additional proof […] Read more
DHA Case No. MGE 214870 (Wis. Div. Hearings and Appeals Nov. 19, 2024) (DHS) ↓ Download PDF One exception to the usual divestment rule is if the individual intended to dispose of the resource at fair market value. In this case, the petitioner’s husband had “invested” $275,000 in an online scam, for which the county […] Read more
DHA Case No. MGE 215065 (Wis. Div. Hearings and Appeals Nov. 1, 2024) (DHS) ↓ Download PDF For a single person, up to $1,500 can be exempted as a “burial fund” to the extent other exempt burial assets (burial trusts, life-insurance funded burial contracts, exempt life insurance policies, and burial insurance) do not exceed that […] Read more
DHA Case No. MGE 214773 (Wis. Div. Hearings and Appeals Nov. 1, 2024) (DHS) ↓ Download PDF The county agency is required to verify a Medicaid applicant’s income and assets, including potential divestments. In this case, the petitioner reported a $5,000 transfer to his sister for “paid bills” and his bank statements showed withdrawals of […] Read more
DHA Case No. MGE 215261 (Wis. Div. Hearings and Appeals Oct. 21, 2024) (DHS) ↓ Download PDF Community Waivers members who are eligible for any other full-benefit Medicaid program (such as MAPP) are put in Group A and have no cost share; otherwise, they are put in Group B or B Plus and do have […] Read more
DHA Case No. FCP 212977 (Wis. Div. Hearings and Appeals May 13, 2024) (DHS) ↓ Download PDF When an MCO seeks to reduce services, it has the burden of proof to show the need for the change. In this case, Inclusa sought to restrict the petitioner’s non-medical transportation to see movies in the community to […] Read more
DHA Case No. FCP 212237 (Wis. Div. Hearings and Appeals May 9, 2024) (DHS) ↓ Download PDF Family Care may cover home modifications such as ramps and lifts to provide safe access to the home, reduce risk of injury, and facilitate independence and self-reliance. In this case, the petitioner was an 81-year-old woman unable to […] Read more
DHA Case No. SSO 211439 (Wis. Div. Hearings and Appeals Apr. 2, 2024) (DHS) ↓ Download PDF When recovering a state SSI overpayment, DHS is limited to recovering benefits paid during the twelve months before the overpayment discovery date. Neither the administrative code nor DHS’s SSI policies define “date of discovery.” In the absence of […] Read more
DHA Case No. MKB 211904 (Wis. Div. Hearings and Appeals Mar. 29, 2024) (DHS) ↓ Download PDF To be eligible for the Katie Beckett program, a child must meet the Social Security standards for childhood disability, including “marked and severe functional limitations.” In this case, the petitioner was an eight-year-old child with severe congenital disorders […] Read more
DHA Case No. FCP 211691 (Wis. Div. Hearings and Appeals Mar. 20, 2024) (DHS) ↓ Download PDF To be functionally eligible for Community Waivers long-term care programs, a person must fall into one of the target groups (frail elder, physical disability, or developmental disability) in addition to needing a nursing home level of care. In […] Read more
DHA Case No. CWA 211701 (Wis. Div. Hearings and Appeals Mar. 5, 2024) (DHS) ↓ Download PDF Services provided through the IRIS program must generally be cost-effective and necessary to achieve a long-term care outcome. In this case, the petitioner’s request for twice-weekly mowing was denied. Although she claimed this was necessary to maintain a […] Read more