DHA Case No. MGE 218539 (Wis. Div. Hearings and Appeals Aug. 20, 2025) (DHS) ↓ Download PDF It is well-settled precedent that beneficiaries must be given at least 10 days advance notice prior to an adverse action, such as a reduction or termination in benefits. In this case, the petitioner lost her eligibility for SSI […] Read more

DHA Case No. MDV 217177 (Wis. Div. Hearings and Appeals Jul. 11, 2025) (DHS) ↓ Download PDF Medicaid fair hearing appeals must be filed within 45 days of the negative action. In this case, the incapacitated, nursing-home-bound petitioner—really, those acting on his behalf—went through a long period of multiple applications and denials. At first the […] Read more

DHA Case No. MNP 218271 (Wis. Div. Hearings and Appeals Jul. 21, 2025) (DHS) ↓ Download PDF A valid notice must be sent at least 10 days before the adverse action and provide information about the right to appeal, including the right to continue benefits while the appeal is pending. In this case, the petitioner […] Read more

DHA Case No. FCP 217978 (Wis. Div. Hearings and Appeals Jul. 9, 2025) (DHS) ↓ Download PDF Income maintenance agencies have a duty to screen members for other bases of eligibility before disenrolling them. In this case, the petitioner became ineligibile for SSI and was therefore disenrolled from MA, losing her Family Care benefits, even […] Read more

DHA Case No. FCP 218179 (Wis. Div. Hearings and Appeals Jun. 16, 2025) (DHS) ↓ Download PDF Before disenrolling a member from Family Care, an MCO must give at least ten days’ notice, with the opportunity for the member to request that services be continued pending an appeal. In this case, the petitioner failed to […] Read more

DHA Case No. MGE 216012 (Wis. Div. Hearings and Appeals Feb. 18, 2025) (DHS) ↓ Download PDF A notice is not adequate if it does not expressly identify the program for which benefits are denied. Also, an application cannot be denied merely because the applicant lacks the power to produce verification. In this case, the […] Read more

DHA Case No. MQB 216374 (Wis. Div. Hearings and Appeals Feb. 10, 2025) (DHS) ↓ Download PDF The SLMB+ Medicare savings program has higher income limits but is only available to those not enrolled in a full-benefit Medicaid program, such as MAPP. In this case, the petitioner was initially enrolled in MAPP and therefore not […] Read more

DHA Case No. MAP 216062 (Wis. Div. Hearings and Appeals Feb. 4, 2025) (DHS) ↓ Download PDF The agency may not require one particular type of verification when various types are adequate and available. In this case, the petitioner owned a newly incorporated business with no previous tax filings. Instead of submitting a self-employment income […] Read more

DHA Case No. CWA 215899 (Wis. Div. Hearings and Appeals Jan. 30, 2025) (DHS) ↓ Download PDF An appeal of an adverse benefit determination by an MCO must generally be filed within 90 days. Additionally, issues that have been decided in a previous appeal are precluded. In this case, the petitioner faxed her appeal of […] Read more

DHA Case No. CWA 215921 (Wis. Div. Hearings and Appeals Jan. 22, 2025) (DHS) ↓ Download PDF Providers are generally not allowed to restrain MA participants, but this rule can be waived after an application to the Department. In this case, the petitioner had a waiver that expired June 21, 2024. Although his mother reapplied […] Read more

DHA Case No. CWA 216742 (Wis. Div. Hearings and Appeals Aug. 4, 2025) (DHS) ↓ Download PDF Under the Wisconsin Equal Access to Justice Act (WEAJA), petitioners who prevail in a fair hearing are entitled to an award of costs unless the agency’s action was “substantially justified.” In this case, the petitioner successfully appealed the […] Read more

DHA Case No. MGE 215665 (Wis. Div. Hearings and Appeals Mar. 20, 2025) (DHS) ↓ Download PDF In general, agencies must process Medicaid applications within 30 days, allow at least 20 days for additional verifications, and may not request excessive or unnecessary verification. In this case, the petitioner applied for Family Care on July 16. […] Read more

DHA Case No. MGE 214557 (Wis. Div. Hearings and Appeals Jan. 15, 2025) (DHS) ↓ Download PDF Medicaid participants are entitled to proper notice before disenrollment. In this case, the petitioner’s deadline to provide verification for a renewal was March 28, 2024. Her authorized representative tried to call IM twice that day but did not […] Read more

DHA Case No. CWA 212475 (Wis. Div. Hearings and Appeals Jan. 15, 2025) (DHS) ↓ Download PDF For Community Waivers benefits to be backdated, a delay in enrollment must be caused by agency error. In this case, the petitioner argued notices regarding her renewal were defective for various reasons, making some creative arguments. She also […] Read more