4 Program Administration

DHA Case No. FCP 210269 (Wis. Div. of Hearings and Appeals January 26, 2024) (DHS) ↓ Download PDF Non-medical transportation can be a benefit provided through Family Care when the member needs assistance with transportation. In this case, Inclusa sought to end the petitioner’s non-medical transportation, claiming vaguely that “petitioner may be able to walk […] Read more

DHA Case No. MED 292938 (Wis. Div. of Hearings and Appeals September 3, 2008) (DHS) ↓ Download PDF Gifts received by a Medicaid recipient must be reported within ten days. In this case, the petitioner was disabled with cancer. Her community held a fundraiser and gave her almost $30,000, which she failed to report. Although […] Read more

DHA Case No. FCP 211038 (Wis. Div. of Hearings and Appeals January 31, 2024) (DHS) ↓ Download PDF When an MCO seeks to reduce a member’s supportive home care budget, it has the burden of proof. In this case, the petitioner’s MCO sought to reduce his budget because his son reported some minor improvements. ALJ […] Read more

DHA Case No. MPA 206485 (Wis. Div. of Hearings and Appeals March 1, 2023) (DHS) ↓ Download PDF The number of Personal Care Worker hours approved depends on what activities a member needs help with. In this case, DMS relied solely on a functional screen to conclude the petitioner did not need help with upper-body […] Read more

DHA Case No. MPA 207369 (Wis. Div. of Hearings and Appeals February 28, 2023) (DHS) ↓ Download PDF AMedicaid recipient cannot be held personally liable for a service requiring prior authorization unless he has notice of the prior authorization denial before provision of the service. In this case, the petitioner’s doctor ordered an MRI and went […] Read more

DHA Case No. MPA 206520 (Wis. Div. of Hearings and Appeals February 7, 2023) (DHS) ↓ Download PDF Personal Care Worker hours can be increased if assistance takes extra time because of the member’s behaviors. In this case, the petitioner was an eight-year-old girl with Down syndrome who was aggressive and resistive during cares, but […] Read more

DHA Case No. FCP 206451 (Wis. Div. of Hearings and Appeals January 30, 2023) (DHS) ↓ Download PDF A medically necessary service must not be duplicative of other services already being provided. In this case, the petitioner had been in a program for 14 years that allowed him to participate in 3 community events every […] Read more

DHA Case No. SSO 206537 (Wis. Div. of Hearings and Appeals January 18, 2023) (DHS) ↓ Download PDF In a fair hearing on an overpayment determination, the agency has the burden of proof. In this case, the petitioner lived in her car and drove to Arizona for the winter. She continued to receive federal SSI […] Read more

DHA Case No. FCP 206397 (Wis. Div. of Hearings and Appeals January 17, 2023) (DHS) ↓ Download PDF Family Care generally does not cover household repairs or improvements that are not directly related to the member’s care. In this case, the petitioner’s carpet was fouled and beyond cleaning, so she asked her MCO to replace […] Read more

DHA Case No. HMO 206640 (Wis. Div. of Hearings and Appeals January 5, 2023) (DHS) ↓ Download PDF Medicaid HMOs must provide the same services as fee-for-service MA or BadgerCare Plus—they must cover services that are medically necessary. In this case, the petitioner wanted her HMO to cover an out-of-network doctor when in-network doctors either […] Read more

DHA Case No. FCP 210973 (Wis. Div. of Hearings and Appeals January 16, 2024) (DHS) ↓ Download PDF Family Care enrollment can be backdated if agency error by the ADRC or IM causes unreasonable delay. In this case, the petitioner’s authorized representative failed to complete his renewal: she “apparently left employment with her payee company, […] Read more

DHA Case No. MGE 209328 (Wis. Div. of Hearings and Appeals December 5, 2023) (DHS) ↓ Download PDF An application for Institutional MA can be backdated up to three months before the month of application. The MEH provides that an application faxed and received by the agency after business hours counts as filed on the […] Read more

DHA Case No. MGE 209372 (Wis. Div. of Hearings and Appeals August 11, 2023) (DHS) ↓ Download PDF In general, a member must have at least ten days to provide required verification during a renewal. In this case, the agency sent a notice on July 3 requesting verification by July 10. Although he should have […] Read more

DHA Case No. CWA 208861 (Wis. Div. of Hearings and Appeals November 10, 2023) (DHS) ↓ Download PDF In general, a service covered by IRIS must be necessary and cost-effective. In this case, the petitioner sought an increase in the rate paid to his AFH from $194.37 per day to $309.20 per day. Thanks largely […] Read more