DHA Case No. BCS 210493 (Wis. Div. of Hearings and Appeals January 9, 2024) (DHS) ↓ Download PDF BadgerCare Plus eligibility is based on income and, unlike EBD Medicaid programs, taxable withdrawals from IRAs are counted as income. In this case, the petitioner was 63 and his only income was monthly withdrawals of $3,200 from […] Read more

DHA Case No. MED 53/97033 (Wis. Div. of Hearings and Appeals December 8, 2008) (DHS) ↓ Download PDF Home maintenance expenses only reduce the patient liability of an institutionalized recipient if a physician certifies the recipient is likely to return home within six months. In this case, the physician certified that the petitioner was not […] Read more

DHA Case No. HMO 210862 (Wis. Div. of Hearings and Appeals January 10, 2024) (DHS) ↓ Download PDF Although orthodontia is not usually covered by MA, it must be covered for recipients under age 21 if the Early and Periodic Screening, Diagnosis and Treatment (EPSDT) health assessment and evaluation indicates that it is medically necessary. […] Read more

DHA Case No. CWA 210997 (Wis. Div. of Hearings and Appeals January 17, 2024) (DHS) ↓ Download PDF It is the guardian’s responsibility to complete a Medicaid renewal and to keep DHS informed when circumstances change. In this case, the petitioner changed guardians but neither guardian informed the agency, which then sent the renewal notices […] Read more

DHA Case No. MRA 70/105086 (Wis. Div. of Hearings and Appeals July 30, 2009) (DHS) ↓ Download PDF In general, an asset is counted if it is available—if the owner can access it and use it for support and maintenance. In this case, the agency counted as available a $7,233 check paid to and cashed […] Read more

DHA Case No. FCP 211106 (Wis. Div. of Hearings and Appeals January 23, 2024) (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—but occasionally the screening program is wrong. In this case, the petitioner used […] Read more

DHA Case No. FCP 210267 (Wis. Div. of Hearings and Appeals January 25, 2024) (DHS) ↓ Download PDF Supportive Home Care (SHC) can be a benefit provided through Family Care when the member needs assistance with chores. In this case, Inclusa sought to end the petitioner’s SHC, claiming vaguely that “petitioner may be able to […] Read more

DHA Case No. FCP 210269 (Wis. Div. of Hearings and Appeals January 26, 2024) (DHS) ↓ Download PDF Non-medical transportation can be a benefit provided through Family Care when the member needs assistance with transportation. In this case, Inclusa sought to end the petitioner’s non-medical transportation, claiming vaguely that “petitioner may be able to walk […] Read more

DHA Case No. FCP 211038 (Wis. Div. of Hearings and Appeals January 31, 2024) (DHS) ↓ Download PDF When an MCO seeks to reduce a member’s supportive home care budget, it has the burden of proof. In this case, the petitioner’s MCO sought to reduce his budget because his son reported some minor improvements. ALJ […] Read more

DHA Case No. FCP 206451 (Wis. Div. of Hearings and Appeals January 30, 2023) (DHS) ↓ Download PDF A medically necessary service must not be duplicative of other services already being provided. In this case, the petitioner had been in a program for 14 years that allowed him to participate in 3 community events every […] Read more

DHA Case No. FCP 206397 (Wis. Div. of Hearings and Appeals January 17, 2023) (DHS) ↓ Download PDF Family Care generally does not cover household repairs or improvements that are not directly related to the member’s care. In this case, the petitioner’s carpet was fouled and beyond cleaning, so she asked her MCO to replace […] Read more

DHA Case No. MGE 211422 (Wis. Div. of Hearings and Appeals February 1, 2024) (DHS) ↓ Download PDF A life-insurance funded burial contract (LIFBC or “burial insurance”) can be funded with more than $4,500 and still be exempt for Medicaid eligibility; but an irrevocable funeral trust can only make up to $4,500 truly irrevocable and […] Read more

DHA Case No. FCP 210973 (Wis. Div. of Hearings and Appeals January 16, 2024) (DHS) ↓ Download PDF Family Care enrollment can be backdated if agency error by the ADRC or IM causes unreasonable delay. In this case, the petitioner’s authorized representative failed to complete his renewal: she “apparently left employment with her payee company, […] Read more

DHA Case No. FCP 209929 (Wis. Div. of Hearings and Appeals January 12, 2024) (DHS) ↓ Download PDF Family Care enrollment can be backdated if agency error by the ADRC or IM causes unreasonable delay. In this case, the ADRC sent the Community Waivers referral to IM on June 16, but “for reasons unclear” IM […] Read more