ALJ Debra Bursinger

DHA Case No. CWK 207740 (Wis. Div. of Hearings and Appeals June 9, 2023) (DHS) ↓ Download PDF One of the benefits of the Children’s Long-Term Support program is access to a Support and Service Coordinator (SSC); DHS’s Participant Rights and Responsibilities notice even says, “You have a right to meet with this person as […] Read more

DHA Case No. FCP 206978 (Wis. Div. of Hearings and Appeals April 7, 2023) (DHS) ↓ Download PDF In the Family Care program, the MCO must develop an Individual Service Plan (ISP) that reasonably and effectively addresses the enrollee’s long-term care needs and outcomes and is cost-effective. In this case, Community Care ended the petitioner’s […] Read more

DHA Case No. CWA 207243 (Wis. Div. of Hearings and Appeals May 19, 2023) (DHS) ↓ Download PDF The Department must ensure the health and safety of IRIS participants. The IRIS policy manual allows involuntary disenrollment for “health and safety risks that participants are unable or unwilling to resolve.” In this case, the petitioner’s mother […] Read more

DHA Case No. FCP 206782 (Wis. Div. of Hearings and Appeals January 11, 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 needed help with one […] 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

DHA Case No. FCP 176566 (Wis. Div. of Hearings and Appeals December 28, 2016) (DHS) ↓ Download PDF Family Care eligibility generally cannot be backdated, but retroactive enrollment can be ordered by an ALJ to correct delay caused by agency error. In this case, the petitioner’s enrollment in Family Care was delayed because the ADRC took […] Read more

DHA Case No. FCP 196128 (Wis. Div. of Hearings and Appeals January 2, 2020) (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 her functionally ineligible because […] Read more

DHA Case No. MGE 194293 (Wis. Div. of Hearings and Appeals January 6, 2020) (DHS) ↓ Download PDF The amount a community spouse can keep depends on the couple’s total resources on the date of the asset assessment, which is often the date a functional screen was completed and the person was determined functionally eligible. […] Read more

DHA Case No. MDV 198638 (Wis. Div. of Hearings and Appeals June 29, 2020) (DHS) ↓ Download PDF A divestment penalty for a Medicaid applicant begins on the date the person applies and is “otherwise eligible” but for the divestment; it begins for a member the first of the month after the member receives timely notice. In this case, […] Read more

DHA Case No. MDV 199054 (Wis. Div. of Hearings and Appeals August 25, 2020) (DHS) ↓ Download PDF A divestment occurs upon the transfer of a non-exempt resource for less than fair market value. In this case, the petitioner sold the home in which she had a life estate for $3,200 less than the tax […] Read more

DHA Case No. MDV 199858 (Wis. Div. of Hearings and Appeals December 4, 2020) (DHS) ↓ Download PDF Divestment is a transfer of non-exempt resources for less than fair market value. This case involved two potential divestments when the petitioner’s house was sold to her daughter and daughter’s boyfriend: (1) the boyfriend was paid $40,534.37 […] Read more

DHA Case No. MAP 199545 (Wis. Div. of Hearings and Appeals December 17, 2020) (DHS) ↓ Download PDF Medicaid applicants must have adequate notice of the proof needed to verify their assets. In this case, the agency issued a Notice of Proof Needed after finding additional accounts in the Asset Verification System (AVS), but the […] Read more

DHA Case No. MDV 200210 (Wis. Div. of Hearings and Appeals January 21, 2021) (DHS) ↓ Download PDF An appeal must be filed within 45 days of an agency action for the ALJ to have jurisdiction to review it. In this case, the petitioner established an irrevocable trust, divested, and applied for Medicaid in May […] Read more

DHA Case No. MDV 201093 (Wis. Div. of Hearings and Appeals March 8, 2021) (DHS) ↓ Download PDF Using an inheritance to buy personal property for fair market value is not a divestment, but the purchases must be verified. In this case, the petitioner inherited $9,633 and claimed to have spent it on a desk, […] Read more

DHA Case No. FCP 205395 (Wis. Div. of Hearings and Appeals August 16, 2022) (DHS) ↓ Download PDF If agency error causes an unreasonable delay in an individual’s enrollment in Family Care, DHS may backdate enrollment. In this case, the petitioner applied for Community Waivers for both spouses on April 20, but enrollment did not […] Read more