DHA Case No. CWK 215882 (Wis. Div. Hearings and Appeals Feb. 3, 2025) (DHS) ↓ Download PDF In the CLTS program, the County Waiver Agency plays a limited role in qualifying and authorizing participants’ chosen service providers, including checking certifications and licensure and conducting a background check. In this case, the county denied the petitioner’s […] Read more

DHA Case No. CWA 216047 (Wis. Div. Hearings and Appeals Feb. 3, 2025) (DHS) ↓ Download PDF IRIS benefits may be backdated if agency error causes unreasonable delay. In this case, the petitioner applied September 4 but did not complete verification until October 14, resulting in an enrollment date of November 1. Although the petitioner’s […] Read more

DHA Case No. CWA 215937 (Wis. Div. Hearings and Appeals Jan. 31, 2025) (DHS) ↓ Download PDF IRIS benefits may be backdated if agency error causes unreasonable delay. In this case, the petitioner applied August 27, verified assets on October 3, and finished verification with proof of medical premiums November 5. Although the petitioner’s guardian […] Read more

DHA Case No. MGE 215707 (Wis. Div. Hearings and Appeals Jan. 17, 2025) (DHS) ↓ Download PDF A person who has a cost share but fails to pay it is ineligible for Family Care. In this case, the petitioner lost eligibility for MAPP and thus had a cost share imposed. At the time of the […] Read more

DHA Case No. MGE 213928 (Wis. Div. Hearings and Appeals Jan. 17, 2025) (DHS) ↓ Download PDF The cash surrender value of life insurance is generally a countable asset (unless the total face value of all policies does not exceed $1,500). In this case, the petitioner applied for MA and listed two life insurance policies […] Read more

DHA Case No. MPP 215826 (Wis. Div. Hearings and Appeals Jan. 16, 2025) (DHS) ↓ Download PDF If a Medicaid recipient knowingly obtains health care that exceeds program limits or is not medically necessary, the Department may enroll the recipient in the “lock-in program,” which limits the recipient to one prescriber and one pharmacy for […] Read more

DHA Case No. MNP 216025 (Wis. Div. Hearings and Appeals Jan. 13, 2025) (DHS) ↓ Download PDF Fair hearings allow recipients to appeal department actions that result in the denial, discontinuation, termination, suspension, or reduction of benefits. They are not for lodging complaints against providers. In this case, the petitioner filed a fair hearing that […] Read more

DHA Case No. CWA 215724 (Wis. Div. Hearings and Appeals Jan. 10, 2025) (DHS) ↓ Download PDF A person is functionally eligible for Community Waivers long-term care programs if, among other criteria, the person cannot safely or appropriately perform 5 or more IADLs or 4 IADLs and has a cognitive impairment. In this case, the […] Read more

DHA Case No. CWA 218226 (Wis. Div. Hearings and Appeals Oct. 30, 2025) (DHS) ↓ Download PDF Home modifications may be an allowable service covered by IRIS if they are needed, safe, and cost-effective. In this case, the petitioner needed a way to access the first floor of her home but could not safely use […] Read more

DHA Case No. MDV 218743 (Wis. Div. Hearings and Appeals Oct. 22, 2025) (DHS) ↓ Download PDF A refusal to claim property of a deceased spouse that a Medicaid applicant or member is entitled to is a divestment. In this case, the petitioner’s husband used nearly all the money in a joint revocable trust to […] Read more

DHA Case No. BCS 219604 (Wis. Div. Hearings and Appeals Sep. 29, 2025) (DHS) ↓ Download PDF In this case, the petitioners filed a Marketplace application for health insurance that erroneously omitted their income. They corrected this within an hour, but not before the system sent their no-income application to the consortium for BadgerCare Plus, […] Read more

DHA Case No. FCP 218386 (Wis. Div. Hearings and Appeals Sep. 23, 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 switched from the IRIS program to the Family Care program with the […] Read more

DHA Case No. BCS 219279 (Wis. Div. Hearings and Appeals Sep. 15, 2025) (DHS) ↓ Download PDF A migrant worker can qualify for Emergency Services MA if he is currently working in Wisconsin and qualifies for BadgerCare Plus under a category other than childless adult. In this case, the petitioner was a migrant working in […] Read more

DHA Case No. FCP 218679 (Wis. Div. Hearings and Appeals Sep. 2, 2025) (DHS) ↓ Download PDF As stated in the recent DMS Ops Memo 25-07, the state must maintain Medicaid coverage while completing regularly scheduled renewals as long as the renewal is received before the end of the month the renewal is due. In […] Read more