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. FCP 214983 (Wis. Div. Hearings and Appeals Jan. 24, 2025) (DHS) ↓ Download PDF ADRCs must determine functional eligibility as soon as practicable, and no later than 30 days after the request for a functional screen. Similarly, IM agencies must generally determine financial and non-financial eligibility within 30 days of the application. […] 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. FCP 216075 (Wis. Div. Hearings and Appeals Feb. 24, 2025) (DHS) ↓ Download PDF When an MCO seeks to reduce services, it has the burden of proof and must justify its action. In this case, an Inclusa representative justified its reduction of Supportive Home Care (SHC) hours from 496 to 446 per […] Read more

DHA Case No. MGE 216109 (Wis. Div. Hearings and Appeals Feb. 14, 2025) (DHS) ↓ Download PDF To be eligible for Community Waivers Medicaid programs, an individual must be elderly, blind, or disabled. In this case, the petitioner was 28 years old and working full time at $15.50 per hour, though he had at some […] Read more

DHA Case No. FCP 216208 (Wis. Div. Hearings and Appeals Feb. 21, 2025) (DHS) ↓ Download PDF In the Family Care program, the MCO must develop an Individual Service Plan that reasonably and effectively addresses all of the client’s long-term needs—but it must also be cost effective, and it can exclude a service the client […] Read more

DHA Case No. MGE 215203 (Wis. Div. Hearings and Appeals Dec. 12, 2024) (DHS) ↓ Download PDF At the first renewal, an individual receiving long-term care Medicaid benefits must have no more than $2,000; there is no limit on a community spouse’s assets. In this case, the petitioner’s renewal was denied because he still owned […] Read more

DHA Case No. FCP 215902 (Wis. Div. Hearings and Appeals Feb. 19, 2025) (DHS) ↓ Download PDF An irrevocable burial trust (as opposed to a life insurance-funded burial contract) is exempt up to $4,500; any amount over that is countable. In this case, the petitioner was disenrolled from Family Care due to his $8,800 irrevocable […] Read more

DHA Case No. MGE 215845 (Wis. Div. Hearings and Appeals Feb. 17, 2025) (DHS) ↓ Download PDF Medicaid denials must be appealed within 45 days. In this case, the petitioner received notices dated April 18, 2023 and August 29, 2023 determining that she was over the asset limit in April, May, and June. But because […] Read more

DHA Case No. FCP 167655 (Wis. Div. Hearings and Appeals Mar. 21, 2016) (DHS) ↓ Download PDF In general, Family Care benefits do not begin until an applicant is determined eligible and signs an enrollment form. In this seminal case, the petitioner applied April 20, signed an enrollment form May 13 (with the date of […] Read more

DHA Case No. MGE 215065 (Wis. Div. Hearings and Appeals Nov. 1, 2024) (DHS) ↓ Download PDF For a single person, up to $1,500 can be exempted as a “burial fund” to the extent other exempt burial assets (burial trusts, life-insurance funded burial contracts, exempt life insurance policies, and burial insurance) do not exceed that […] 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. 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