DHA Case No. MQB 215664 (Wis. Div. Hearings and Appeals Dec. 16, 2024) (DHS) ↓ Download PDF Medicaid fair hearing appeals must be filed within 45 days of the negative action. An appeal is considered filed when the written and signed fair hearing request is received by the agency or on its postmarked date, if […] Read more

DHA Case No. CWK 215379 (Wis. Div. Hearings and Appeals Dec. 12, 2024) (DHS) ↓ Download PDF Under the approved Waiver, DHS does not allow for the use of personal restraints and strictly limits the use of protective equipment. In this case, the petitioner was an 8-year-old autistic child who needed a diaper but exhibited […] Read more

DHA Case No. MPA 215583 (Wis. Div. Hearings and Appeals Dec. 9, 2024) (DHS) ↓ Download PDF Medicaid covers prescriptions drugs that are medically necessary, guided by agency policy on the effective, appropriate, and cost-effective use of the drug. For anti-obesity drugs, specifically Wegovy, agency policy limits coverage to 12 continuous months, after which the […] Read more

DHA Case No. CWA 213491 (Wis. Div. Hearings and Appeals Oct. 24, 2024) (DHS) ↓ Download PDF Home modifications for an IRIS participant must be cost-effective. In this case, the petitioner asked that his tub/shower be replaced with a walk-in shower. The accessibility study concluded this was needed and explained why less expensive options would […] Read more

DHA Case No. CWK 211705 (Wis. Div. Hearings and Appeals Sep. 10, 2024) (DHS) ↓ Download PDF Individual choice of provider is a main tenet of the CLTS program. Even when a county has concerns about a provider, the County Waiver Agency must respect the participant’s choice “unless there is compelling justification not to do […] Read more

DHA Case No. MGE 212301 (Wis. Div. Hearings and Appeals Sep. 16, 2024) (DHS) ↓ Download PDF The agency can deny Medicaid when the applicant or recipient is able to produce required verifications but refuses or fails to do so. In this case, the petitioner failed to verify, at his renewal, one of his vehicles, […] Read more

DHA Case No. FCP 216075 (Wis. Div. Hearings and Appeals Feb. 24, 2025) (DHS) ↓ Download PDF When an MCO seeks to reduce services, it has the burden of proof and must justify its action. In this case, an Inclusa representative justified its reduction of Supportive Home Care (SHC) hours from 496 to 446 per […] Read more

DHA Case No. CWA 216242 (Wis. Div. Hearings and Appeals Feb. 14, 2025) (DHS) ↓ Download PDF Before taking any negative action, the Medicaid agency must give adequate notice. In this case, TMG mailed notice of IRIS disenrollment due to a missed renewal to the wrong address. ALJ Brian Schneider concluded the petitioner did not […] Read more

DHA Case No. BCS 216058 (Wis. Div. Hearings and Appeals Feb. 14, 2025) (DHS) ↓ Download PDF When verifying income with BadgerCare Plus, the agency must “advise the applicant of the specific verification required.” If the applicant “is able to produce required verifications but refuses or fails to do so,” the benefits will be denied […] Read more

DHA Case No. FCP 216208 (Wis. Div. Hearings and Appeals Feb. 21, 2025) (DHS) ↓ Download PDF In the Family Care program, the MCO must develop an Individual Service Plan that reasonably and effectively addresses all of the client’s long-term needs—but it must also be cost effective, and it can exclude a service the client […] Read more

DHA Case No. BCS 215656 (Wis. Div. Hearings and Appeals Dec. 27, 2024) (DHS) ↓ Download PDF A notice requesting verification must be in writing, specific as to the verification required, and allow a minimum of 20 days to provide it. A notice of adverse action must be mailed at least 10 calendar days before […] Read more

DHA Case No. BCS 215161 (Wis. Div. Hearings and Appeals Dec. 18, 2024) (DHS) ↓ Download PDF To be eligible for BadgerCare Plus, a person must meet certain financial and non-financial requirements, including verification of income for self-employment. In this case, the petitioner verified her self-employment income with a partial, unsigned copy of her tax […] Read more

DHA Case No. CWA 215956 (Wis. Div. Hearings and Appeals Feb. 28, 2025) (DHS) ↓ Download PDF To be approved as part of an IRIS budget, services must generally be cost-effective. In this case, the petitioner requested a budget amendment to pay $30 and $35 per hour for Supportive Home Care (SHC) services. The agency […] Read more

DHA Case No. CWA 215403 (Wis. Div. Hearings and Appeals Feb. 5, 2025) (DHS) ↓ Download PDF The IRIS program can pay for residential services, such as those provided in an adult family home (AFH), but “residential services” does not include the cost of room and board. In this case, the petitioner asked to increase […] Read more