DHA Case No. FCP 217860 (Wis. Div. Hearings and Appeals May 28, 2025) (DHS) ↓ Download PDF DHA decisions have recognized for nearly a decade that use of an adaptive aid is equivalent to requiring human assistance and counts as requiring assistance with the related ADL. In this case, the petitioner’s functional screen noted a […] Read more

DHA Case No. CWA 216813 (Wis. Div. Hearings and Appeals May 9, 2025) (DHS) ↓ Download PDF The IRIS waiver requires IRIS Consultant Agencies (ICAs) to monitor participants’ health and safety, address health and safety concerns with the participant, and ultimately disenroll participants when health and safety concerns remain despite remediation efforts. In this case, […] Read more

DHA Case No. CWA 217415 (Wis. Div. Hearings and Appeals May 5, 2025) (DHS) ↓ Download PDF The Department may disenroll IRIS participants if it cannot develop a plan that ensures the participant’s health and safety. In this case, the petitioner’s behavior support plan—staff call 911 and seek refuge in their cars if he gets […] Read more

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. CWA 215899 (Wis. Div. Hearings and Appeals Jan. 30, 2025) (DHS) ↓ Download PDF An appeal of an adverse benefit determination by an MCO must generally be filed within 90 days. Additionally, issues that have been decided in a previous appeal are precluded. In this case, the petitioner faxed her appeal of […] 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. CWA 215921 (Wis. Div. Hearings and Appeals Jan. 22, 2025) (DHS) ↓ Download PDF Providers are generally not allowed to restrain MA participants, but this rule can be waived after an application to the Department. In this case, the petitioner had a waiver that expired June 21, 2024. Although his mother reapplied […] 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. CWA 216742 (Wis. Div. Hearings and Appeals Aug. 4, 2025) (DHS) ↓ Download PDF Under the Wisconsin Equal Access to Justice Act (WEAJA), petitioners who prevail in a fair hearing are entitled to an award of costs unless the agency’s action was “substantially justified.” In this case, the petitioner successfully appealed the […] 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