DHA Case No. CWK 220881 (Wis. Div. Hearings and Appeals Feb. 6, 2026) (DHS) ↓ Download PDF To be functionally eligible for the Children’s Long-Term Support Program, a child with a developmental disability who needs intermediate care must demonstrate substantial functional limitations in three areas. In this case, the petitioner was a 7-year-old with autism who […] Read more

DHA Case No. BCS 221175 (Wis. Div. Hearings and Appeals Feb. 4, 2026) (DHS) ↓ Download PDF When applying for MAPP, an applicant may be determined presumptively disabled. A presumptive disability decision stands until the DDB makes a final disability determination, at which point IM must send a manual notice. In this case, the petitioner […] Read more

DHA Case No. MGE 220279 (Wis. Div. Hearings and Appeals Jan. 28, 2026) (DHS) ↓ Download PDF To be eligible for Wisconsin Medicaid, a person must be a Wisconsin resident. In this case, the petitioner initially resided in an nursing home in Wisconsin and attempted to exempt more than $1,500 in burial funds. When the […] Read more

DHA Case No. BCS 220537 (Wis. Div. Hearings and Appeals Jan. 9, 2026) (DHS) ↓ Download PDF Neither the administrative code nor the federal regulations include a right to a fair hearing regarding an agency’s failure to close a case promptly when asked to do so by a benefit recipient. In this case, the petitioner […] Read more

DHA Case No. CWK 221068 (Wis. Div. Hearings and Appeals Feb. 20, 2026) (DHS) ↓ Download PDF A “Notice of Action” must be provided to CLTS participants at least fifteen days before a reduction or termination of services, which participants have the right to appeal. In this case, the petitioner’s respite services were terminated effective […] Read more

DHA Case No. FCP 219586 (Wis. Div. Hearings and Appeals Jan. 16, 2026) (DHS) ↓ Download PDF Participants in Family Care have the right to appeal any adverse benefit determination. In this case, the petitioner’s MCO involuntarily ended her ability to self-direct her services and claimed this was not appealable because it was not an […] Read more

DHA Case No. FCP 153514 (Wis. Div. Hearings and Appeals Jun. 10, 2014) (DHS) (final decision on cost motion) ↓ Download PDF Apetitioner who wins a contested fair hearing is entitled to costs (including attorney fees) unless the agency was “substantially justified,” which means having a reasonable basis in law and fact. In this case, […] Read more

DHA Case No. MDV 5/105182 (Wis. Div. Hearings and Appeals 2009) (DHS) ↓ Download PDF Agift that occurred during the lookback period and was made by either the institutionalized person or his or her spouse is a divestment. In this case, the petitioner’s husband amended their revocable trust to transfer their home to a new […] Read more

DHA Case No. FCP 220016 (Wis. Div. Hearings and Appeals Dec. 8, 2025) (DHS) ↓ Download PDF Medicaid appeals must be filed within 45 days of the date of the notice of action. In this case, the petitioner was sent a cost share notice on April 11 but did not file an appeal until September […] Read more

DHA Case No. HMO 220155 (Wis. Div. Hearings and Appeals Dec. 26, 2025) (DHS) ↓ Download PDF Wisconsin Medicaid does not cover experimental services, a determination the Department makes on its own. In this case, the petitioner requested an Occipital Nerve Block, which was denied as experimental. While recognizing that past decisions have considered experimental […] Read more

DHA Case No. CWK 219225 (Wis. Div. Hearings and Appeals Dec. 26, 2025) (DHS) ↓ Download PDF For the Children’s Community Options Program, the right to appeal is limited to the denial of eligibility for services, or a reduction or termination of services. In this case, the petitioner requested coverage of a safety wagon. ALJ […] Read more

DHA Case No. CWA 220073 (Wis. Div. Hearings and Appeals Dec. 5, 2025) (DHS) ↓ Download PDF When the IRIS program ends a participant’s enrollment involuntarily, it bears the burden of proof to show that the disenrollment was proper. In this case, the IRIS Consultant (IC) submitted only an unsigned, unsworn written statement about an […] Read more

DHA Case No. BCS 219426 (Wis. Div. Hearings and Appeals Oct. 15, 2025) (DHS) ↓ Download PDF Medicaid recipients are entitled to at least 10 days’ notice before any adverse action. In this case, the petitioner failed to provide verification due August 4, so on August 5 the agency issued a notice terminating benefits as […] Read more

DHA Case No. CWK 219831 (Wis. Div. Hearings and Appeals Nov. 20, 2025) (DHS) ↓ Download PDF CLTS policy requires advance notice of any adverse action at least 15 days before the effective date. In this case, the petitioner was found functionally ineligible and the notice was sent by the county only six days before […] Read more