DHA Case No. FCP 218663 (Wis. Div. Hearings and Appeals Jul. 24, 2025) (DHS) ↓ Download PDF As stated in the recent DMS Ops Memo 25-07, the state must maintain Medicaid coverage while completing regularly scheduled renewals as long as the renewal is received before the end of the month the renewal is due. In […] 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. FCP 217040 (Wis. Div. Hearings and Appeals Jun. 27, 2025) (DHS) ↓ Download PDF Family Care benefits may be backdated if agency error causes unreasonable delay. In this case, the petitioner was eligible and selected an MCO and enrollment date with the ADRC, but the ADRC worker’s email to the MCO was […] Read more

DHA Case No. FCP 218179 (Wis. Div. Hearings and Appeals Jun. 16, 2025) (DHS) ↓ Download PDF Before disenrolling a member from Family Care, an MCO must give at least ten days’ notice, with the opportunity for the member to request that services be continued pending an appeal. In this case, the petitioner failed to […] Read more

DHA Case No. FCP 216960 (Wis. Div. Hearings and Appeals May 30, 2025) (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 was enrolled in both MAPP and Family Care; when his MAPP renewal resulted in disenrollment, the […] Read more

DHA Case No. CWA 216462 (Wis. Div. Hearings and Appeals May 30, 2025) (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 Family Care enrollment form was completed with the ADRC December 10, but the ADRC failed to […] Read more

DHA Case No. MGE 216015 (Wis. Div. Hearings and Appeals Apr. 11, 2025) (DHS) ↓ Download PDF Family Care benefits cannot begin until the applicant is enrolled in an MCO following an approved application. In this case, the petitioner applied and was approved, but died before actually enrolling in an MCO, about 30 days after […] Read more

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. 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 146016 (Wis. Div. Hearings and Appeals Mar. 5, 2013) (DHS) ↓ Download PDF The divestment penalty period for a Family Care applicant begins on the first date the person (1) has applied for Family Care, (2) “meets the appropriate level of care and functional screen criteria,” and (3) meets all other […] Read more

DHA Case No. MDV 130600 (Wis. Div. Hearings and Appeals May 23, 2011) (DHS) ↓ Download PDF A transfer of income or resources for less than fair market value is a divestment and results in a penalty period, unless the transfer qualifies for an exception. One exception is if the applicant can show a pattern […] 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. MGE 217838 (Wis. Div. Hearings and Appeals Jul. 15, 2025) (DHS) ↓ Download PDF Court-ordered support payments are deducted from income for an “institutionalized person,” according to the Medicaid Eligibility Handbook (MEH). In this case, the petitioner paid $4,059 per month in court-ordered spousal support, had monthly income of $12,089.20 ($8,045.98 from a […] Read more