DHA Case No. MGE 218833 (Wis. Div. Hearings and Appeals Sep. 5, 2025) (DHS) ↓ Download PDF For a single person in the Institutional MA program, the items that may be subtracted from income in determining patient liability are limited. In this case, the petitioner asked that his $70/month life insurance premiums be deducted, noting […] Read more

DHA Case No. FCP 218531 (Wis. Div. Hearings and Appeals Sep. 4, 2025) (DHS) ↓ Download PDF The Family Care program must generally cover services that reasonably and effectively address the participant’s long-term needs, but those services must also be cost-effective. In this case, the agency denied the petitioner’s request for coverage of a health […] Read more

DHA Case No. FCP 219093 (Wis. Div. Hearings and Appeals Aug. 25, 2025) (DHS) ↓ Download PDF The Family Care program must generally cover services that reasonably and effectively address the participant’s long-term needs, but those services must also be cost-effective. In this case, the petitioner’s home-delivered meals ended because his plan already included Supportive […] Read more

DHA Case No. CWA 219215 (Wis. Div. Hearings and Appeals Aug. 22, 2025) (DHS) ↓ Download PDF Any negative action regarding a person enrolled in Medicaid must be preceded by proper notice that includes appeal rights. In this case, the petitioner lost her SSI eligibility but the agency never sent a notice with appeal rights […] Read more

DHA Case No. CWK 218372 (Wis. Div. Hearings and Appeals Aug. 11, 2025) (DHS) ↓ Download PDF Achild in the Children’s Long-Term Support (CLTS) program must be recertified annually, including an updated functional screen. In this case, the petitioner (a 12-year-old diagnosed with ADD and ADHD) was found functionally ineligible at her recertification, based on […] Read more

DHA Case No. CWA 218425 (Wis. Div. Hearings and Appeals Aug. 11, 2025) (DHS) ↓ Download PDF Prevocational services may be funded through IRIS, but the participant must have a goal of community-integrated employment. In this case, the petitioner received prevocational services for three years as part of his IRIS budget (and it appears he […] Read more

DHA Case No. MGE 218210 (Wis. Div. Hearings and Appeals Aug. 6, 2025) (DHS) ↓ Download PDF Financial eligibility for Medicaid generally requires a single individual’s countable, available assets to be less than $2,000. In this case, the petitioner submitted a bank statement in her sole name with a balance of more than $69,000, but […] Read more

DHA Case No. MGE 218652 (Wis. Div. Hearings and Appeals Jul. 30, 2025) (DHS) ↓ Download PDF A participant must maintain MA eligibility to remain enrolled in the Family Care program. In this case, the petitioner submitted his renewal and all verification timely, but the agency mistakenly disenrolled him. ALJ Jason Grace ordered Family Care […] Read more

DHA Case No. CWA 218656 (Wis. Div. Hearings and Appeals Jul. 30, 2025) (DHS) ↓ Download PDF To be functionally eligible for community waivers programs, an individual must require a “nursing home” level of care and be part of a target group. In this case, the petitioner had a unique diagnosis of Functional Neurologic Disorder/Conversion […] Read more

DHA Case No. CWA 218446 (Wis. Div. Hearings and Appeals Jul. 17, 2025) (DHS) ↓ Download PDF A participant in IRIS may be disenrolled if they lose their Medicaid eligibility after a renewal. In this case, the petitioner completed a FoodShare renewal that the agency mistakenly processed as a Medicaid renewal, even though her Medicaid […] Read more

DHA Case No. MGE 217939 (Wis. Div. Hearings and Appeals Jul. 3, 2025) (DHS) ↓ Download PDF Aparticipant in Institutional MA may have their patient liability reduced to allow them to pay medical or remedial expenses. In this case, the petitioner owed $22,504 in unpaid patient liability due to his brother/POA’s mismanagement, or perhaps theft […] Read more

DHA Case No. CWA 217836 (Wis. Div. Hearings and Appeals Jul. 1, 2025) (DHS) ↓ Download PDF An IRIS participant may be involuntarily disenrolled for mismanagement of budget authority or employer authority. In this case, the petitioner was disenrolled because his family caregivers continually billed excess hours for supportive home care, overspending his budget by […] Read more

DHA Case No. CWA 217841 (Wis. Div. Hearings and Appeals Jun. 27, 2025) (DHS) ↓ Download PDF IRIS participants may submit one-time expense requests to pay for goods or services, including adaptive aids such as vehicle modifications. In this case, the petitioner requested a wheelchair conversion for a new SUV, which TMG denied as not […] Read more

DHA Case No. CWK 218183 (Wis. Div. Hearings and Appeals Jun. 17, 2025) (DHS) ↓ Download PDF The Children’s Long-Term Support Program (CLTS) can cover health and wellness activities, but services generally cannot be duplicative and payments cannot be made directly to the participant or to another person on behalf of the participant. In this […] Read more