DHA Case No. BCS 207937 (Wis. Div. of Hearings and Appeals June 6, 2023) (DHS) ↓ Download PDF An applicant for BadgerCare Plus must provide his or her Social Security number. In this case, the petitioner applied but failed to provide it. The agency properly issued the request for proof and mailed it to the […] Read more

DHA Case No. MGE 208326 (Wis. Div. of Hearings and Appeals July 18, 2023) (DHS) ↓ Download PDF Amember’s patient liability can be reduced to allow payment of medical or remedial expenses that the member “has incurred, is actually paying, and is legally obligated to pay.” In this case, after losing fair hearings on the […] Read more

DHA Case No. FCP 208424 (Wis. Div. of Hearings and Appeals July 10, 2023) (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. In this case, the petitioner’s functional screen found him functionally ineligible because […] Read more

DHA Case No. MGE 208349 (Wis. Div. of Hearings and Appeals June 13, 2023) (DHS) ↓ Download PDF In general, applicants are responsible for verification—but agencies cannot deny eligibility when the applicant has no ability to get the required verification. In this case, the petitioner and his wife were both applying for Institutional MA through their […] Read more

DHA Case No. MRA 208459 (Wis. Div. of Hearings and Appeals June 29, 2023) (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, the community spouse had income […] Read more

DHA Case No. MDV 208396 (Wis. Div. of Hearings and Appeals June 29, 2023) (DHS) ↓ Download PDF Any transfer of resources for less than fair market value is generally a divestment, but there is an exception if the resource was transferred “exclusively for some other purpose than to become eligible for MA.” In this […] Read more

DHA Case No. CWA 208804 (Wis. Div. of Hearings and Appeals September 8, 2023) (DHS) ↓ Download PDF The Medicaid Eligibility Handbook counts some income even though it is unavailable—garnishments, for example. In this case, the petitioner had $300 garnished monthly for a tax debt but his patient liability was not reduced to compensate. ALJ John Tedesco […] Read more

DHA Case No. FCP 207586 (Wis. Div. of Hearings and Appeals July 20, 2023) (DHS) ↓ Download PDF MCOs in the Family Care program may authorize residential services—such as placement in an Adult Family Home (AFH)—only if they are the most cost-effective option, if they are needed to support the member’s long-term care outcomes, or […] Read more

DHA Case No. FCP 208218 (Wis. Div. of Hearings and Appeals June 12, 2023) (DHS) ↓ Download PDF Cost share reductions are effective the month of the change report, even if the actual change in income or expense was earlier. In this case, the petitioner enrolled in Family Care with a cost share effective November […] Read more

DHA Case No. CWA 208193 (Wis. Div. of Hearings and Appeals October 2, 2023) (DHS) ↓ Download PDF When DHS increases a member’s cost share, it has the burden of proof on appeal. In this rather messy case, it was clear that the cost share should have been lower but it was not clear whose […] Read more

DHA Case No. FCP 208068 (Wis. Div. of Hearings and Appeals August 9, 2023) (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’s primary diagnosis was schizophrenia […] Read more

DHA Case No. MGE 207353 (Wis. Div. of Hearings and Appeals June 21, 2023) (Decision on Remand) (DHS) ↓ Download PDF Amember’s patient liability can be reduced to allow payment of medical or remedial expenses that the member “has incurred, is actually paying, and is legally obligated to pay.” In this case, the petitioner verified […] Read more

DHA Case No. MQB 207807 (Wis. Div. of Hearings and Appeals July 7, 2023) (DHS) ↓ Download PDF QMB benefits cannot normally be backdated (compare MQB 207494), but an ALJ can order backdating following a fair hearing. In this case, the Social Security Administration conceded that its own error caused a 3-month delay in verification […] Read more

DHA Case No. FCP 173457 (Wis. Div. of Hearings and Appeals September 15, 2016) (DHS) ↓ Download PDF The Medicaid Eligibility Handbook used to direct that the snapshot date for a spousal asset assessment was the “date of the first request for Community Waivers.” In this case, the petitioner was determined functionally eligible on August […] Read more