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. MGE 216221 (Wis. Div. Hearings and Appeals May 2, 2025) (DHS) ↓ Download PDF Re-enrollment in IRIS can be expedited if a renewal is completed late but within 30 days of disenrollment. In this case, the petitioner was disenrolled October 1 but ready to re-enroll October 7. But because his old fiscal […] 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. CWA 215905 (Wis. Div. Hearings and Appeals Apr. 11, 2025) (DHS) ↓ Download PDF IRIS enrollment and benefits may be backdated if agency error caused unreasonable delay. In this case, the petitioner’s renewal processing was delayed more than a month when a lead worker mistakenly required Letters of the Estate for a […] 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

DHA Case No. CWA 212475 (Wis. Div. Hearings and Appeals Jan. 15, 2025) (DHS) ↓ Download PDF For Community Waivers benefits to be backdated, a delay in enrollment must be caused by agency error. In this case, the petitioner argued notices regarding her renewal were defective for various reasons, making some creative arguments. She also […] Read more

DHA Case No. CWA 215749 (Wis. Div. Hearings and Appeals May 16, 2025) (DHS) ↓ Download PDF Federal regulations require that Medicaid notices of a negative action include an explanation of the right to appeal. In this case, the petitioner received three notices that informed him of a pending disenrollment but said nothing about a […] Read more

DHA Case No. CWA 216742 (Wis. Div. Hearings and Appeals May 14, 2025) (DHS) ↓ Download PDF One service IRIS can provide is Daily Living Skills (DLS), which teaches and improves skills to improve the participant’s independence in daily life. Because it is educational, the service is monitored to ensure progress is being made. In […] Read more

DHA Case No. CWA 215300 (Wis. Div. Hearings and Appeals Dec. 17, 2024) (DHS) ↓ Download PDF IRIS participants are assigned a budget, and their IRIS Consultant Agency (ICA) cannot authorize services exceeding that budget. In this case, the petitioner overbilled her supportive home care budget for many months. Her ICA reduced her authorized supportive […] Read more

DHA Case No. FCP 215954 (Wis. Div. Hearings and Appeals Dec. 13, 2024) (DHS) ↓ Download PDF An individual is functionally eligible for Community Waivers programs if he or she needs a “nursing home” level of care, as determined by the functional screen. In this case, the petitioner’s functional screen found the petitioner functionally ineligible […] Read more