DHA Case No. MGE 216109 (Wis. Div. Hearings and Appeals Feb. 14, 2025) (DHS) ↓ Download PDF To be eligible for Community Waivers Medicaid programs, an individual must be elderly, blind, or disabled. In this case, the petitioner was 28 years old and working full time at $15.50 per hour, though he had at some […] Read more

DHA Case No. CWA 216242 (Wis. Div. Hearings and Appeals Feb. 14, 2025) (DHS) ↓ Download PDF Before taking any negative action, the Medicaid agency must give adequate notice. In this case, TMG mailed notice of IRIS disenrollment due to a missed renewal to the wrong address. ALJ Brian Schneider concluded the petitioner did not […] Read more

DHA Case No. BCS 216058 (Wis. Div. Hearings and Appeals Feb. 14, 2025) (DHS) ↓ Download PDF When verifying income with BadgerCare Plus, the agency must “advise the applicant of the specific verification required.” If the applicant “is able to produce required verifications but refuses or fails to do so,” the benefits will be denied […] Read more

DHA Case No. FCP 216208 (Wis. Div. Hearings and Appeals Feb. 21, 2025) (DHS) ↓ Download PDF In the Family Care program, the MCO must develop an Individual Service Plan that reasonably and effectively addresses all of the client’s long-term needs—but it must also be cost effective, and it can exclude a service the client […] Read more

DHA Case No. BCS 215656 (Wis. Div. Hearings and Appeals Dec. 27, 2024) (DHS) ↓ Download PDF A notice requesting verification must be in writing, specific as to the verification required, and allow a minimum of 20 days to provide it. A notice of adverse action must be mailed at least 10 calendar days before […] Read more

DHA Case No. MRA 215653 (Wis. Div. Hearings and Appeals Dec. 20, 2024) (DHS) ↓ Download PDF An ALJ may increase the community spouse income allocation (CSIA) if the community spouse does not have enough income to pay his or her “necessary and basic maintenance needs.” In this case, ALJ Kelly Cochrane summarily ordered the […] Read more

DHA Case No. BCS 215161 (Wis. Div. Hearings and Appeals Dec. 18, 2024) (DHS) ↓ Download PDF To be eligible for BadgerCare Plus, a person must meet certain financial and non-financial requirements, including verification of income for self-employment. In this case, the petitioner verified her self-employment income with a partial, unsigned copy of her tax […] Read more

DHA Case No. MGE 215203 (Wis. Div. Hearings and Appeals Dec. 12, 2024) (DHS) ↓ Download PDF At the first renewal, an individual receiving long-term care Medicaid benefits must have no more than $2,000; there is no limit on a community spouse’s assets. In this case, the petitioner’s renewal was denied because he still owned […] Read more

DHA Case No. CWA 215956 (Wis. Div. Hearings and Appeals Feb. 28, 2025) (DHS) ↓ Download PDF To be approved as part of an IRIS budget, services must generally be cost-effective. In this case, the petitioner requested a budget amendment to pay $30 and $35 per hour for Supportive Home Care (SHC) services. The agency […] Read more

DHA Case No. FCP 215902 (Wis. Div. Hearings and Appeals Feb. 19, 2025) (DHS) ↓ Download PDF An irrevocable burial trust (as opposed to a life insurance-funded burial contract) is exempt up to $4,500; any amount over that is countable. In this case, the petitioner was disenrolled from Family Care due to his $8,800 irrevocable […] Read more

DHA Case No. CWA 215403 (Wis. Div. Hearings and Appeals Feb. 5, 2025) (DHS) ↓ Download PDF The IRIS program can pay for residential services, such as those provided in an adult family home (AFH), but “residential services” does not include the cost of room and board. In this case, the petitioner asked to increase […] Read more

DHA Case No. MGE 215845 (Wis. Div. Hearings and Appeals Feb. 17, 2025) (DHS) ↓ Download PDF Medicaid denials must be appealed within 45 days. In this case, the petitioner received notices dated April 18, 2023 and August 29, 2023 determining that she was over the asset limit in April, May, and June. But because […] Read more

DHA Case No. MSC 215557 (Wis. Div. Hearings and Appeals Feb. 24, 2025) (DHS) ↓ Download PDF SeniorCare members with income under 200% of the Federal Poverty Level have a $500 deductible; members under 240% have a $850 deductible. In this case, the petitioner had a $850 deductible after his renewal, based on his expected […] Read more

DHA Case No. FCP 167655 (Wis. Div. Hearings and Appeals Mar. 21, 2016) (DHS) ↓ Download PDF In general, Family Care benefits do not begin until an applicant is determined eligible and signs an enrollment form. In this seminal case, the petitioner applied April 20, signed an enrollment form May 13 (with the date of […] Read more