DHA Case No. FCP 213572 (Wis. Div. Hearings and Appeals Sep. 24, 2024) (DHS) ↓ Download PDF A service that is “duplicative with respect to other services being provided” is not medically necessary. In this case, the petitioner attended after-hours recreational activities in the community while living with her mother for many years. But when […] Read more

DHA Case No. CWA 208558 RHG (Wis. Div. Hearings and Appeals Sep. 5, 2023) (DHS) (decision on rehearing) ↓ Download PDF Participants in IRIS may submit a budget amendment (BA) request to increase their budget to pay for an ongoing need not met within the current budget. In this case, the petitioner submitted a BA […] Read more

DHA Case No. CWA 208558 (Wis. Div. Hearings and Appeals Jul. 26, 2023) (DHS) ↓ Download PDF Participants in the IRIS program have certain rights to appeal that do not extend to providers. In this case, the petitioner appealed the denial of his budget amendment request to increase the rate paid to his supportive home […] Read more

DHA Case No. CWA 212780 (Wis. Div. of Hearings and Appeals June 10, 2024) (DHS) ↓ Download PDF When the Department reduces benefits, it has the burden of proof and must at least present a prima facie case for its decision. In this case, the agency reduced services it had previously deemed necessary and appropriate […] Read more

DHA Case No. CWA 212112 (Wis. Div. of Hearings and Appeals June 7, 2024) (DHS) ↓ Download PDF IRIS may pay for a vehicle modification as a one-time expense (OTE) request, but it must be cost-effective and all other options for funding must be exhausted first. In this case, the 20-year-old petitioner requested a $102,000 […] Read more

DHA Case No. FCP 211741 (Wis. Div. of Hearings and Appeals April 17, 2024) (DHS) ↓ Download PDF Beginning on the date of enrollment, an MCO must pay for needed services, including the continuation of current services “necessary to ensure health and safety and continuity of care,” until the full assessment and member-centered plan are […] Read more

DHA Case No. FCP 211940 (Wis. Div. of Hearings and Appeals March 19, 2024) (DHS) ↓ Download PDF In general, all Family Care services must be authorized before they are provided. In this case, the petitioner’s assisted living facility closed and he had to move to a new one. My Choice staff met with him […] Read more

DHA Case No. CWK 210726 (Wis. Div. of Hearings and Appeals March 15, 2024) (DHS) ↓ Download PDF Individual choice of provider is a main tenet of the CLTS program. Even when a background check on a proposed provider reveals negative—but not disqualifying—findings, the County Waiver Agency must respect the participant’s choice “unless there is […] Read more

DHA Case No. MNP 211393 (Wis. Div. of Hearings and Appeals March 8, 2024) (DHS) ↓ Download PDF Wisconsin Medicaid covers emergency out-of-state services, even if the provider is not certified with Wisconsin Medicaid. In this case, the petitioner had a seizure while in Florida with her family and was transported by ambulance. The ambulance […] Read more

DHA Case No. MPP 211770 (Wis. Div. of Hearings and Appeals February 21, 2024) (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 […] Read more

DHA Case No. FCP 211094 (Wis. Div. of Hearings and Appeals February 12, 2024) (DHS) ↓ Download PDF An MCO must develop an individual service plan that reasonably and effectively addresses the enrollee’s long-term care needs and outcomes, including needs for socialization and activities. In this case, the petitioner’s MCO stopped paying for adult day […] Read more

DHA Case No. CWK 210573 (Wis. Div. of Hearings and Appeals January 9, 2024) (DHS) ↓ Download PDF The CLTS program can cover respite care to ease “the daily stress and care demands” for the participant’s family “on a short-term basis.” In this case, the petitioner was an 8-year-old with autism. His mother had a […] Read more

DHA Case No. HMO 210862 (Wis. Div. of Hearings and Appeals January 10, 2024) (DHS) ↓ Download PDF Although orthodontia is not usually covered by MA, it must be covered for recipients under age 21 if the Early and Periodic Screening, Diagnosis and Treatment (EPSDT) health assessment and evaluation indicates that it is medically necessary. […] Read more

DHA Case No. FCP 210267 (Wis. Div. of Hearings and Appeals January 25, 2024) (DHS) ↓ Download PDF Supportive Home Care (SHC) can be a benefit provided through Family Care when the member needs assistance with chores. In this case, Inclusa sought to end the petitioner’s SHC, claiming vaguely that “petitioner may be able to […] Read more