DHA Case No. CWA 216047 (Wis. Div. Hearings and Appeals Feb. 3, 2025) (DHS) ↓ Download PDF IRIS benefits may be backdated if agency error causes unreasonable delay. In this case, the petitioner applied September 4 but did not complete verification until October 14, resulting in an enrollment date of November 1. Although the petitioner’s […] Read more

DHA Case No. CWA 215937 (Wis. Div. Hearings and Appeals Jan. 31, 2025) (DHS) ↓ Download PDF IRIS benefits may be backdated if agency error causes unreasonable delay. In this case, the petitioner applied August 27, verified assets on October 3, and finished verification with proof of medical premiums November 5. Although the petitioner’s guardian […] Read more

DHA Case No. MGE 213928 (Wis. Div. Hearings and Appeals Jan. 17, 2025) (DHS) ↓ Download PDF The cash surrender value of life insurance is generally a countable asset (unless the total face value of all policies does not exceed $1,500). In this case, the petitioner applied for MA and listed two life insurance policies […] Read more

DHA Case No. MPP 215826 (Wis. Div. Hearings and Appeals Jan. 16, 2025) (DHS) ↓ Download PDF If a Medicaid recipient knowingly obtains health care that exceeds program limits or is not medically necessary, the Department may enroll the recipient in the “lock-in program,” which limits the recipient to one prescriber and one pharmacy for […] Read more

DHA Case No. MNP 216025 (Wis. Div. Hearings and Appeals Jan. 13, 2025) (DHS) ↓ Download PDF Fair hearings allow recipients to appeal department actions that result in the denial, discontinuation, termination, suspension, or reduction of benefits. They are not for lodging complaints against providers. In this case, the petitioner filed a fair hearing that […] Read more

DHA Case No. CWA 218226 (Wis. Div. Hearings and Appeals Oct. 30, 2025) (DHS) ↓ Download PDF Home modifications may be an allowable service covered by IRIS if they are needed, safe, and cost-effective. In this case, the petitioner needed a way to access the first floor of her home but could not safely use […] Read more

DHA Case No. BCS 219604 (Wis. Div. Hearings and Appeals Sep. 29, 2025) (DHS) ↓ Download PDF In this case, the petitioners filed a Marketplace application for health insurance that erroneously omitted their income. They corrected this within an hour, but not before the system sent their no-income application to the consortium for BadgerCare Plus, […] Read more

DHA Case No. MGE 218412 (Wis. Div. Hearings and Appeals Aug. 25, 2025) (DHS) ↓ Download PDF If a married applicant’s spouse refuses to cooperate with signing the Medicaid application or providing information, the applicant can request an undue hardship waiver of the application denial. That undue hardship request must describe and document “all attempts […] Read more

DHA Case No. MGE 218539 (Wis. Div. Hearings and Appeals Aug. 20, 2025) (DHS) ↓ Download PDF It is well-settled precedent that beneficiaries must be given at least 10 days advance notice prior to an adverse action, such as a reduction or termination in benefits. In this case, the petitioner lost her eligibility for SSI […] Read more

DHA Case No. MDV 217177 (Wis. Div. Hearings and Appeals Jul. 11, 2025) (DHS) ↓ Download PDF Medicaid fair hearing appeals must be filed within 45 days of the negative action. In this case, the incapacitated, nursing-home-bound petitioner—really, those acting on his behalf—went through a long period of multiple applications and denials. At first the […] Read more

DHA Case No. MNP 218271 (Wis. Div. Hearings and Appeals Jul. 21, 2025) (DHS) ↓ Download PDF A valid notice must be sent at least 10 days before the adverse action and provide information about the right to appeal, including the right to continue benefits while the appeal is pending. In this case, the petitioner […] Read more

DHA Case No. FCP 217755 (Wis. Div. Hearings and Appeals Jul. 11, 2025) (DHS) ↓ Download PDF Family Care MCOs must provide services that reasonably and effectively address all of the member’s long-term needs and outcomes while being cost-effective. In this case, the petitioner’s MCO sought to end his placement in an Adult Family Home, […] Read more

DHA Case No. FCP 217978 (Wis. Div. Hearings and Appeals Jul. 9, 2025) (DHS) ↓ Download PDF Income maintenance agencies have a duty to screen members for other bases of eligibility before disenrolling them. In this case, the petitioner became ineligibile for SSI and was therefore disenrolled from MA, losing her Family Care benefits, even […] Read more

DHA Case No. MGE 217686 (Wis. Div. Hearings and Appeals Jun. 17, 2025) (DHS) ↓ Download PDF Eligibility for Institutional MA can be backdated up to three months before the month of application. In this case, the petitioner applied several times over many months and repeatedly failed to provide required verification by the deadline. Ultimately, […] Read more