DHA Case No. CWK 213700 (Wis. Div. Hearings and Appeals Aug. 30, 2024) (DHS) ↓ Download PDF Educational services funded by the Department of Public Instruction cannot also be covered under CLTS’ “Empowerment and Self-Determination Supports” service code. In this case, the petitioner was initially approved to see a one-on-one provider for help with functional […] Read more

DHA Case No. CWA 214423 (Wis. Div. Hearings and Appeals Nov. 6, 2024) (DHS) ↓ Download PDF IRIS funds may only be used for services, supports, or goods that address a long-term support need. In this case, the petitioner asked IRIS to pay for his participant-hired worker’s travel and lodging costs so he could attend […] Read more

DHA Case No. MPA 214372 (Wis. Div. Hearings and Appeals Nov. 15, 2024) (DHS) ↓ Download PDF To approve a prior authorization request, the service must be medically necesary. In this case, the petitioner sought a prior authorization for genetic testing to rule out a certain condition. ALJ Kelly Cochrane concluded the request was properly […] Read more

DHA Case No. MDV 214223 (Wis. Div. Hearings and Appeals Nov. 27, 2024) (DHS) ↓ Download PDF A divestment penalty is generally imposed when an applicant reports a divestment and would be otherwise eligible. In this case, the petitioner originally applied in 2020 after creating an irrevocable trust, but no divestment penalty was imposed because […] Read more

DHA Case No. MDV 214942 (Wis. Div. Hearings and Appeals Nov. 20, 2024) (DHS) ↓ Download PDF The deadline to file an appeal of a denied Medicaid application is 45 days from the notice. If a separate undue harship waiver is requested, the petitioner has 20 days from the request to provide any additional proof […] Read more

DHA Case No. MGE 214870 (Wis. Div. Hearings and Appeals Nov. 19, 2024) (DHS) ↓ Download PDF One exception to the usual divestment rule is if the individual intended to dispose of the resource at fair market value. In this case, the petitioner’s husband had “invested” $275,000 in an online scam, for which the county […] Read more

DHA Case No. MGE 214773 (Wis. Div. Hearings and Appeals Nov. 1, 2024) (DHS) ↓ Download PDF The county agency is required to verify a Medicaid applicant’s income and assets, including potential divestments. In this case, the petitioner reported a $5,000 transfer to his sister for “paid bills” and his bank statements showed withdrawals of […] Read more

DHA Case No. FCP 212977 (Wis. Div. Hearings and Appeals May 13, 2024) (DHS) ↓ Download PDF When an MCO seeks to reduce services, it has the burden of proof to show the need for the change. In this case, Inclusa sought to restrict the petitioner’s non-medical transportation to see movies in the community to […] Read more

DHA Case No. FCP 212237 (Wis. Div. Hearings and Appeals May 9, 2024) (DHS) ↓ Download PDF Family Care may cover home modifications such as ramps and lifts to provide safe access to the home, reduce risk of injury, and facilitate independence and self-reliance. In this case, the petitioner was an 81-year-old woman unable to […] Read more

DHA Case No. SSO 211439 (Wis. Div. Hearings and Appeals Apr. 2, 2024) (DHS) ↓ Download PDF When recovering a state SSI overpayment, DHS is limited to recovering benefits paid during the twelve months before the overpayment discovery date. Neither the administrative code nor DHS’s SSI policies define “date of discovery.” In the absence of […] Read more

DHA Case No. CWA 211701 (Wis. Div. Hearings and Appeals Mar. 5, 2024) (DHS) ↓ Download PDF Services provided through the IRIS program must generally be cost-effective and necessary to achieve a long-term care outcome. In this case, the petitioner’s request for twice-weekly mowing was denied. Although she claimed this was necessary to maintain a […] Read more

DHA Case No. FCP 211227 (Wis. Div. Hearings and Appeals Feb. 15, 2024) (DHS) ↓ Download PDF In the Family Care program, MCOs must provide medically necessary services that reasonably and effectively address the participant’s long-term care outcomes. In this case, the petitioner wanted to attend a summer camp that cost $2,970. His MCO denied […] Read more

DHA Case No. CWK 210876 (Wis. Div. Hearings and Appeals Feb. 2, 2024) (DHS) ↓ Download PDF Relocation services under the CLTS program include “supports and essential items needed to establish a community living arrangement.” In this case, the petitioner asked for reimbursement for significant time spent by several people in packing, moving, and unpacking […] Read more

DHA Case No. CWA 211040 (Wis. Div. Hearings and Appeals Feb. 2, 2024) (DHS) ↓ Download PDF A budget amendment may be denied if it requests services that are duplicative of services already provided. In this case, the petitioner, an 18-year-old with Down Syndrome, requested a budget amendment to allow her to attend a 9-month […] Read more