DHA Case No. FCP 219522 (Wis. Div. Hearings and Appeals Oct. 28, 2025) (DHS) ↓ Download PDF When an MCO reduces a service, it has the burden to prove that the reduction is appropriate. In this case, Inclusa sought to end a lawn care service because it expected the petitioner’s wife to do the yard […] Read more

DHA Case No. MGE 219667 (Wis. Div. Hearings and Appeals Oct. 21, 2025) (DHS) ↓ Download PDF When a person receiving SSI and Medicaid loses SSI eligibility because they start receiving SSDI Disabled Adult Child (DAC) payments, the Medicaid program must treat the person as if they were still receiving SSI. In this case, that […] Read more

DHA Case No. FCP 219433 (Wis. Div. Hearings and Appeals Oct. 16, 2025) (DHS) ↓ Download PDF Family Care MCOs must generally cover services that are needed, but those services must also be cost-effective. In this case, the petitioner was 36 years old, had a corporate guardian, was looking for employment in the community, and […] Read more

DHA Case No. BCS 219426 (Wis. Div. Hearings and Appeals Oct. 15, 2025) (DHS) ↓ Download PDF Medicaid recipients are entitled to at least 10 days’ notice before any adverse action. In this case, the petitioner failed to provide verification due August 4, so on August 5 the agency issued a notice terminating benefits as […] Read more

DHA Case No. FCP 218749 (Wis. Div. Hearings and Appeals Oct. 14, 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 contacted the ADRC October 28 but an options counselor was not assigned […] Read more

DHA Case No. CWA 219315 (Wis. Div. Hearings and Appeals Oct. 9, 2025) (DHS) ↓ Download PDF The IRIS program must generally cover services that are needed and cost-effective. In this case, the petitioner had severe violent behavior that culminated in felony charges after attacking a staff member. After that, only one AFH was both […] Read more

DHA Case No. CWA 219173 (Wis. Div. Hearings and Appeals Oct. 1, 2025) (DHS) ↓ Download PDF When a person’s eligibility for SSI ends, agency policy is to automatically run Medicaid eligibility under other criteria. In this case, the petitioner’s SSI ended and she even received a notice saying she didn’t need to do anything […] Read more

DHA Case No. FCP 219735 (Wis. Div. Hearings and Appeals Nov. 24, 2025) (DHS) ↓ Download PDF The Family Care program must generally provide services that reasonably and effectively address the participant’s long-term needs but are also cost-effective. In this case, the petitioner requested community-based day habilitation services to “remain active and busy in order […] Read more

DHA Case No. CWK 219831 (Wis. Div. Hearings and Appeals Nov. 20, 2025) (DHS) ↓ Download PDF CLTS policy requires advance notice of any adverse action at least 15 days before the effective date. In this case, the petitioner was found functionally ineligible and the notice was sent by the county only six days before […] Read more

DHA Case No. MAP 219598 (Wis. Div. Hearings and Appeals Nov. 10, 2025) (DHS) ↓ Download PDF Payment of a monthly premium is a condition of eligibility for MAPP, though a member may ask for a temporary hardship waiver that cannot exceed 12 months “for the same hardship reason.” In this case, the petitioner received […] Read more

DHA Case No. FCP 219488 (Wis. Div. Hearings and Appeals Nov. 4, 2025) (DHS) ↓ Download PDF To be covered under Family Care, a service must be cost-effective. In this case, the MCO denied the petitioner’s request for 24/7 supportive home care (SHC), claiming it would be more cost-effective for him to move to a […] Read more

DHA Case No. CWA 219979 (Wis. Div. Hearings and Appeals Oct. 27, 2025) (DHS) ↓ Download PDF To be eligible for Community Waivers programs, a person must be in one of the target groups—physical disability, frail elder, or developmental disability—in addition to needing a nursing home level of care. In this case, the 21-year-old petitioner […] Read more

DHA Case No. MDD 219938 (Wis. Div. Hearings and Appeals Oct. 23, 2025) (DHS) ↓ Download PDF The MAPP program allows disabled individuals to work but to retain eligibility for MA. In this case, the petitioner lost his SSI and “regular” MA when a new job put him over the substantial gainful activity limit, but […] Read more

DHA Case No. CWA 219333 (Wis. Div. Hearings and Appeals Oct. 15, 2025) (DHS) ↓ Download PDF Aperson enrolled in IRIS is required to pay a cost share as a condition of eligibility. In this case, the petitioner had more than $4,000 in overdue cost share and had previously entered a repayment agreement, but failed […] Read more