ALJ Jason M. Grace

DHA Case No. CWA 206353 (Wis. Div. of Hearings and Appeals January 17, 2023) (DHS) ↓ Download PDF Services included in an IRIS member’s budget must be cost effective and at the usual and customary rate for the area. In this case, the petitioner’s medical transportation provider increased its rate for transporting him to his […] Read more

DHA Case No. MGE 207580 (Wis. Div. of Hearings and Appeals April 14, 2023) (DHS) ↓ Download PDF An institutionalized spouse may allocate income to the community spouse up to a certain amount, and an ALJ may increase that if the petitioner shows “exceptional circumstances resulting in financial duress.” In this case, the petitioner appealed […] Read more

DHA Case No. BCS 207530 (Wis. Div. of Hearings and Appeals April 6, 2023) (DHS) ↓ Download PDF Wisconsin law provides that able-bodied adults who refused to cooperate in establishing the paternity of a child without good cause are ineligible for MA. In this case, the petitioner refused to identify the father of her child […] Read more

DHA Case No. CWA 207474 (Wis. Div. of Hearings and Appeals April 3, 2023) (DHS) ↓ Download PDF An IRIS participant may request a budget amendment to pay for an ongoing need not met within the current budget. In this case, the petitioner asked for a budget increase from $15.75 to $17/hr to pay for […] Read more

DHA Case No. MGE 207300 (Wis. Div. of Hearings and Appeals February 28, 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 earned […] Read more

DHA Case No. MRA 207266 (Wis. Div. of Hearings and Appeals April 27, 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, ALJ Jason Grace increased the […] Read more

DHA Case No. MAC 207150 (Wis. Div. of Hearings and Appeals January 31, 2023) (DHS) ↓ Download PDF To justify an Order to Compel Payment of Liability on appeal, the agency must at least show: (1) that it sent proper notice of the initial overpayment, (2) that it provided instructions for how to make payment […] Read more

DHA Case No. CWA 207083 (Wis. Div. of Hearings and Appeals April 5, 2023) (DHS) ↓ Download PDF When the agency reduces supportive home care (SHC) hours and the member appeals, the burden of proof is on the agency to justify the reduction. In this case, the agency reduced SHC hours after a supplemental functional […] Read more

DHA Case No. MAC 206795 (Wis. Div. of Hearings and Appeals February 8, 2023) (DHS) ↓ Download PDF To prevail at an appeal regarding an Order to Compel Payment of MA/BCP Liability, the agency must show, to begin with, that it provided proper notice of the underlying overpayment. Proper notice must include both the right […] Read more

DHA Case No. CWA 202841 (Wis. Div. of Hearings and Appeals January 5, 2022) (DHS) ↓ Download PDF An IRIS participant may request a budget amendment to pay for an ongoing need not met within the current budget. In this case, the petitioner asked for a budget increase from $15 to $17/hr to pay for […] Read more

DHA Case No. MGE 208717 (Wis. Div. of Hearings and Appeals July 20, 2023) (DHS) ↓ Download PDF The Medicaid Eligibility Handbook contains two competing rules: revocable annuities are countable and available assets, but IRAs belonging to a community spouse are disregarded. In this case, the community spouse owned two Individual Retirement Annuities. The agency argued these […] Read more

DHA Case No. MDV 198612 (Wis. Div. of Hearings and Appeals June 24, 2020) (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. MDD 200680 (Wis. Div. of Hearings and Appeals February 10, 2021) (DHS) ↓ Download PDF In making a disability determination, the Disability Determination Bureau (DDB) applies a 5-step test. Step 5 considers whether the individual can adjust to types of work the individual has not performed in the past, considering his or […] Read more

DHA Case No. MGE 201671 (Wis. Div. of Hearings and Appeals June 15, 2021) (DHS) ↓ Download PDF A Medicaid member must have adequate notice of any change in his or her patient liability. In this case, the petitioner elected online notices and a notice of patient liability was posted to her ACCESS account. Her […] Read more