DHA Case No. FCP 218386 (Wis. Div. Hearings and Appeals Sep. 23, 2025) (DHS) ↓ Download PDF When an agency error causes delay in an individual’s enrollment in an MCO, the Department may adjust the individual’s enrollment date. In this case, the petitioner switched from the IRIS program to the Family Care program with the […] Read more

DHA Case No. FCP 218679 (Wis. Div. Hearings and Appeals Sep. 2, 2025) (DHS) ↓ Download PDF As stated in the recent DMS Ops Memo 25-07, 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 […] Read more

DHA Case No. MGE 218539 (Wis. Div. Hearings and Appeals Aug. 20, 2025) (DHS) ↓ Download PDF It is well-settled precedent that beneficiaries must be given at least 10 days advance notice prior to an adverse action, such as a reduction or termination in benefits. In this case, the petitioner lost her eligibility for SSI […] Read more

DHA Case No. CWA 216468 (Wis. Div. Hearings and Appeals Aug. 4, 2025) (DHS) ↓ Download PDF Late renewals can cause a gap in Community Waivers enrollment, though the Department has allowed for an expedited re-enrollment process to minimize this. In this case, the petitioner completed a late renewal and would have used the expedited […] Read more

DHA Case No. FCP 218663 (Wis. Div. Hearings and Appeals Jul. 24, 2025) (DHS) ↓ Download PDF As stated in the recent DMS Ops Memo 25-07, 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 […] Read more

DHA Case No. CWA 217265 (Wis. Div. Hearings and Appeals Jul. 22, 2025) (DHS) ↓ Download PDF IRIS benefits may be backdated if agency error causes unreasonable delay. In this case, the petitioner admittedly failed to complete her renewal timely, resulting in a gap in benefits and needing to re-enroll with a new Fiscal Employer […] Read more

DHA Case No. FCP 217755 (Wis. Div. Hearings and Appeals Jul. 11, 2025) (DHS) ↓ Download PDF Family Care MCOs must provide services that reasonably and effectively address all of the member’s long-term needs and outcomes while being cost-effective. In this case, the petitioner’s MCO sought to end his placement in an Adult Family Home, […] Read more

DHA Case No. FCP 217978 (Wis. Div. Hearings and Appeals Jul. 9, 2025) (DHS) ↓ Download PDF Income maintenance agencies have a duty to screen members for other bases of eligibility before disenrolling them. In this case, the petitioner became ineligibile for SSI and was therefore disenrolled from MA, losing her Family Care benefits, even […] Read more

DHA Case No. CWA 217260 (Wis. Div. Hearings and Appeals Jul. 8, 2025) (DHS) ↓ Download PDF IRIS members may be disenrolled if they move to an ineligible living setting. In this case, the petitioner lived in his car for nine months before being disenrolled and did not have a plan to transition to an […] Read more

DHA Case No. FCP 217040 (Wis. Div. Hearings and Appeals Jun. 27, 2025) (DHS) ↓ Download PDF Family Care benefits may be backdated if agency error causes unreasonable delay. In this case, the petitioner was eligible and selected an MCO and enrollment date with the ADRC, but the ADRC worker’s email to the MCO was […] Read more

DHA Case No. CWA 218281 (Wis. Div. Hearings and Appeals Jun. 25, 2025) (DHS) ↓ Download PDF As stated in the recent DMS Ops Memo 25-07, 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 […] Read more

DHA Case No. CWA 216899 (Wis. Div. Hearings and Appeals Jun. 18, 2025) (DHS) ↓ Download PDF IRIS benefits may be backdated if agency error causes unreasonable delay. In this case, the petitioner had a gap in IRIS enrollment due to a late renewal, but it took an additional 77 days after her exedited re-enrollment […] Read more

DHA Case No. CWA 216814 (Wis. Div. Hearings and Appeals Jun. 18, 2025) (DHS) ↓ Download PDF IRIS benefits may be backdated if agency error causes unreasonable delay. In this case, the petitioner mistakenly reported a new life insurance policy during his renewal that was actually owned by his ex-wife. He then had understandable difficulty […] Read more

DHA Case No. FCP 218179 (Wis. Div. Hearings and Appeals Jun. 16, 2025) (DHS) ↓ Download PDF Before disenrolling a member from Family Care, an MCO must give at least ten days’ notice, with the opportunity for the member to request that services be continued pending an appeal. In this case, the petitioner failed to […] Read more