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

DHA Case No. MGE 216329 (Wis. Div. Hearings and Appeals May 9, 2025) (DHS) ↓ Download PDF When an agency error causes a delay in an individual’s enrollment in Family Care, the enrollment date may be adjusted. In this case, the petitioner submitted his 183-page Medicaid application in three faxes on October 29 and received […] Read more

DHA Case No. FCP 216239 (Wis. Div. Hearings and Appeals May 2, 2025) (DHS) ↓ Download PDF ADRCs and IM agencies must generally determine functional and financial eligibility as soon as practical and within 30 days, and Family Care benefits may be backdated if agency error causes a delay in enrollment. In this case, the […] Read more

DHA Case No. FCP 216187 (Wis. Div. Hearings and Appeals Apr. 25, 2025) (DHS) ↓ Download PDF In the Family Care program, the MCO may not deny a service that is reasonable and necessary to support the member’s long-term care outcomes—but it must also be cost-effective, and it can exclude a service the client wants […] Read more

DHA Case No. FCP 215775 (Wis. Div. Hearings and Appeals May 2, 2025) (DHS) ↓ Download PDF Family Care benefits may be backdated if agency error causes a delay in enrollment. In this case, the petitioner resided in a CBRF that Income Maintenance misidentified as a nursing home. She applied August 22, the ADRC sent […] Read more

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