DHA Case No. MDD 203616 (Wis. Div. of Hearings and Appeals January 19, 2022) (DHS) ↓ Download PDF Even if a person cannot engage in any substantial gainful activity, he must still pass a 5-step test to be determined disabled. If he can perform work he has done in the past, Step 4 requires a […] Read more

DHA Case No. FCP 203537 (Wis. Div. of Hearings and Appeals January 28, 2022) (DHS) ↓ Download PDF Dental implants are listed as a non-covered service under Wis. Admin. Code § DHS 107.07(4)(i). In this case, the petitioner had strong evidence that dental implant-retained dentures were medically necessary and would support her long-term care outcomes. […] Read more

DHA Case No. MDV 204093 (Wis. Div. of Hearings and Appeals March 24, 2022) (DHS) ↓ Download PDF A divestment penalty does not start until the date a Community Waivers applicant requests a waiver program, meets the functional screen criteria, and meets all other Medicaid eligibility requirements. In this case, the petitioner—represented by a lawyer—divested […] Read more

DHA Case No. FCP 205395 (Wis. Div. of Hearings and Appeals August 16, 2022) (DHS) ↓ Download PDF If agency error causes an unreasonable delay in an individual’s enrollment in Family Care, DHS may backdate enrollment. In this case, the petitioner applied for Community Waivers for both spouses on April 20, but enrollment did not […] Read more

DHA Case No. MRA 205971 (Wis. Div. of Hearings and Appeals Oct. 17, 2022) (DHS) ↓ Download PDF An ALJ may increase the Community Spouse Income Allowance (CSIA) if either spouse proves exceptional circumstances resulting in financial duress. In this case, although the community spouse had $3,858.22 of her own income, she also had monthly […] Read more

DHA Case No. FCP 206406 (Wis. Div. of Hearings and Appeals November 22, 2022) (DHS) ↓ Download PDF The Family Care Contract prohibits an MCO from denying services that are “reasonable and necessary to cost-effectively support the member’s long term care outcomes …”. In this case, the petitioner asked for a home modification: stairs to […] Read more

DHA Case No. FCP 206000 (Wis. Div. of Hearings and Appeals October 28, 2022) (DHS) ↓ Download PDF To be functionally eligible for Family Care, a person must fall into one of the program’s target groups in addition to needing a nursing home level of care. In this case, the petitioner was 44 and diagnosed […] Read more

DHA Case No. CWA 206149 (Wis. Div. of Hearings and Appeals January 12, 2023) (DHS) ↓ Download PDF The Department must ensure the health and safety of IRIS participants, which it does in part by conducting in-home visits. The IRIS policy manual allows involuntary disenrollment for “health and safety risks that participants are unable or […] Read more

DHA Case No. CWA 206378 (Wis. Div. of Hearings and Appeals December 5, 2022) (DHS) ↓ Download PDF An individual is functionally eligible for Family Care if he or she needs a “nursing home” level of care, as determined by the functional screen. This level of care includes those who cannot safely or appropriately perform […] Read more

DHA Case No. FCP 181279 (Wis. Div. of Hearings and Appeals January 22, 2018) (DHS) ↓ Download PDF The Medicaid Eligibility Handbook allows business property to be exempted—regardless of value or rate of return—if the individual is “actively involved in the business operation on a day-to-day basis.” In this case, the petitioner had a history of renting […] Read more

DHA Case No. MPC-13/78330 (Wis. Div. of Hearings and Appeals November 1, 2006) (DHS)  ↓ Download PDF In Community Waivers cases, countable income is first used in eligibility determinations to place an applicant into a group; then the post-eligibility cost share is calculated based on the formula for that group. In this case, the petitioner’s […] Read more

DHA Case No. MGE 143573 (Wis. Div. of Hearings and Appeals March 13, 2013) (DHS)  ↓ Download PDF This unusual case is fact-specific, involving the interplay of Community Waiver benefits, the community spouse asset share, and the timing of getting a functional screen from the Aging and Disability Resource Center (ADRC). The issue was that […] Read more

DHA Case No. FCP 155113 (Wis. Div. of Hearings and Appeals May 14, 2014) (DHS)  ↓ Download PDF The issue in this case was whether overnight caregiver costs counted as a remedial expense, which could be deducted from income before determining the cost share. The agency argued these could not be a remedial expense, relying […] Read more

DHA Case No. FCP 193270 (Wis. Div. Hearings and Appeals June 14, 2019) (DHS)  ↓ Download PDF In this case, the petitioner was receiving Family Care and owed monthly room and board to an assisted living facility. Due to an anomaly, the check for December was never delivered, resulting in it being reissued and mailed […] Read more