DHA Case No. FCP 215537 (Wis. Div. Hearings and Appeals Jan. 24, 2025) (DHS) ↓ Download PDF Family Care services must generally be from appropriate and qualified providers, be fair and safe, serve to maintain community connections, and be cost effective. In this sympathetic case, the petitioner—a competent 43-year-old man with muscular dystrophy, severe respiratory […] 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. MGE 215615 (Wis. Div. Hearings and Appeals Jan. 6, 2025) (DHS) ↓ Download PDF To pay a relative for services in amounts exceeding 10% of the maximum Community Spouse Asset Share requires a written, notarized contract at the time the services were provided. In this case, petitioners were a married couple, both […] Read more

DHA Case No. MDV 137218 (Wis. Div. Hearings and Appeals Feb. 7, 2012) (DHS) ↓ Download PDF When an institutionalized person fails to claim his or her share of a deceased spouse’s estate, it is generally a divestment. In this case, the petitioner’s wife created a revocable trust after his enrollment that included no share […] Read more

DHA Case No. MDV 149517 (Wis. Div. Hearings and Appeals Jul. 26, 2013) (DHS) ↓ Download PDF Money spent for fair market value is generally not a divestment, but the agency may require verification of large cash withdrawals. In this case, the petitioner’s daughter attempted to verify $22,219.40 in cash withdrawals with a spreadsheet. ALJ […] Read more

DHA Case No. MDV 147776 (Wis. Div. Hearings and Appeals Jul. 12, 2013) (DHS) ↓ Download PDF The divestment penalty period for an Institutional MA applicant begins on the first date the person (1) is institutionalized, (2) has applied for Medicaid, and (3) is otherwise eligible for Medicaid. In this case, the petitioner applied on […] Read more

DHA Case No. FCP 217629 (Wis. Div. Hearings and Appeals May 5, 2025) (DHS) ↓ Download PDF When a Family Care member has a significant change in circumstances, the MCO must reassess the member’s care needs. In this case, the petitioner had multiple emergency room visits and was ultimately hospitalized, resulting in a reassessment and […] 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. FCP 216187 (Wis. Div. Hearings and Appeals Apr. 25, 2025) (DHS) ↓ Download PDF In the Family Care program, the MCO may not deny a service that is reasonable and necessary to support the member’s long-term care outcomes—but it must also be cost-effective, and it can exclude a service the client wants […] 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

DHA Case No. CWA 215749 (Wis. Div. Hearings and Appeals May 16, 2025) (DHS) ↓ Download PDF Federal regulations require that Medicaid notices of a negative action include an explanation of the right to appeal. In this case, the petitioner received three notices that informed him of a pending disenrollment but said nothing about a […] Read more

DHA Case No. CWA 216742 (Wis. Div. Hearings and Appeals May 14, 2025) (DHS) ↓ Download PDF One service IRIS can provide is Daily Living Skills (DLS), which teaches and improves skills to improve the participant’s independence in daily life. Because it is educational, the service is monitored to ensure progress is being made. In […] Read more