DHA Case No. MGE 221661 (Wis. Div. Hearings and Appeals Feb. 20, 2026) (DHS) ↓ Download PDF 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 this case, the petitioner was enrolled in Family Care […] Read more

DHA Case No. MGE 220385 (Wis. Div. Hearings and Appeals Jan. 26, 2026) (DHS) ↓ Download PDF Enrollment in Family Care may be backdated if an unreasonable delay was caused by agency error. In this case, the petitioner was disenrolled when she failed to complete her renewal, then reapplied and was enrolled again eight months […] Read more

DHA Case No. MGE 220307 (Wis. Div. Hearings and Appeals Jan. 12, 2026) (DHS) ↓ Download PDF To be eligible for Family Care, an applicant must have a long-term care functional screen to determine his or her functional eligibility. In this case, the petitioner submitted an online ACCESS application indicating that she needed help with […] Read more

DHA Case No. FCP 220551 (Wis. Div. Hearings and Appeals Jan. 9, 2026) (DHS) ↓ Download PDF MCOs may not deny a service that is reasonable and necessary, and in an amount, scope, and duration needed to cost-effectively support the member’s long-term care outcomes. In this case, the petitioner lived in a 1-2 bed adult […] Read more

DHA Case No. FCP 220498 (Wis. Div. Hearings and Appeals Jan. 5, 2026) (DHS) ↓ Download PDF Services provided through the Family Care program must be cost-effective. In this case, the petitioner lived at an AFH and attended a nearby adult day service program that proved very beneficial. When he moved to a different AFH, […] Read more

DHA Case No. FCP 219586 (Wis. Div. Hearings and Appeals Jan. 16, 2026) (DHS) ↓ Download PDF Participants in Family Care have the right to appeal any adverse benefit determination. In this case, the petitioner’s MCO involuntarily ended her ability to self-direct her services and claimed this was not appealable because it was not an […] Read more

DHA Case No. MRA 220384 (Wis. Div. Hearings and Appeals Jan. 7, 2026) (DHS) ↓ Download PDF In general, all gross income is counted when determining eligibility and cost share for Family Care. In this case, the petitioner was enrolled in Institutional MA and allocated the maximum amount of income to her community spouse, who […] Read more

DHA Case No. FCP 153514 (Wis. Div. Hearings and Appeals Jan. 31, 2014) (DHS) ↓ Download PDF The Medicaid Eligibility Handbook provides that spouses who live together are part of each other’s fiscal test group. In this case, the petitioner resided in assisted living on Family Care while his spouse resided in a separate home. […] Read more

DHA Case No. FCP 220397 (Wis. Div. Hearings and Appeals Dec. 29, 2025) (DHS) ↓ Download PDF The Family Care program, through MCOs, must generally provide services that reasonably and effectively address all of the recipient’s long-term needs and outcomes, assist the recipient to be as self-reliant and autonomous as possible, and are cost effective. […] Read more

DHA Case No. FCP 220016 (Wis. Div. Hearings and Appeals Dec. 8, 2025) (DHS) ↓ Download PDF Medicaid appeals must be filed within 45 days of the date of the notice of action. In this case, the petitioner was sent a cost share notice on April 11 but did not file an appeal until September […] Read more

DHA Case No. FCP 220319 (Wis. Div. Hearings and Appeals Nov. 17, 2025) (DHS) ↓ Download PDF MCOs must develop service plans that reasonably and effectively address the member’s long-term needs and outcomes while also being cost-effective. In this case, My Choice sought to end the petitioner’s placement in an AFH in favor of a […] Read more

DHA Case No. FCP 219890 (Wis. Div. Hearings and Appeals Nov. 13, 2025) (DHS) ↓ Download PDF Income received less often than monthly is generally prorated and counted, but the MEH directs: “do not count the prorated income until it is received.” In this case, the petitioner received a yearly annuity payment in January and […] Read more

DHA Case No. FCP 219522 (Wis. Div. Hearings and Appeals Oct. 28, 2025) (DHS) ↓ Download PDF When an MCO reduces a service, it has the burden to prove that the reduction is appropriate. In this case, Inclusa sought to end a lawn care service because it expected the petitioner’s wife to do the yard […] Read more

DHA Case No. FCP 219433 (Wis. Div. Hearings and Appeals Oct. 16, 2025) (DHS) ↓ Download PDF Family Care MCOs must generally cover services that are needed, but those services must also be cost-effective. In this case, the petitioner was 36 years old, had a corporate guardian, was looking for employment in the community, and […] Read more