DHA Case No. MDV 214370 (Wis. Div. Hearings and Appeals Oct. 22, 2024) (DHS) ↓ Download PDF The transfer of an exempt asset (except a homestead) is not a divestment. In this case, the petitioner bought a car—though she could not drive herself—that her son used to transport her to medical appointments. About seven months […] Read more

DHA Case No. CWA 213537 (Wis. Div. Hearings and Appeals Oct. 18, 2024) (DHS) ↓ Download PDF The IRIS Policy Manual requires a notice of action and provides a right to appeal when services are reduced, terminated, or denied. In this case, the petitioner’s care worker failed to timely submit the required documentation to become […] Read more

DHA Case No. MRA 213346 (Wis. Div. Hearings and Appeals Aug. 30, 2024) (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 Nicole Bjork increased the CSIA […] Read more

DHA Case No. FCP 213736 (Wis. Div. Hearings and Appeals Aug. 28, 2024) (DHS) ↓ Download PDF A participant in Family Care can be involuntarily disenrolled if they are determined ineligible for MA. In this case, the petitioner submitted his renewal timely and was eligible, but his MCO disenrolled him in error and could not […] Read more

DHA Case No. FCP 213572 (Wis. Div. Hearings and Appeals Sep. 24, 2024) (DHS) ↓ Download PDF A service that is “duplicative with respect to other services being provided” is not medically necessary. In this case, the petitioner attended after-hours recreational activities in the community while living with her mother for many years. But when […] Read more

DHA Case No. BCS 213610 (Wis. Div. Hearings and Appeals Sep. 23, 2024) (DHS) ↓ Download PDF To determine self-employment income, Wisconsin Medicaid programs generally use the previous year’s federal tax return; but if the business had a “significant change in circumstances,” the agency must use anticipated earnings instead. In this case, the petitioner was […] Read more

DHA Case No. FCP 213852 (Wis. Div. Hearings and Appeals Sep. 12, 2024) (DHS) ↓ Download PDF Family Care enrollment may only be backdated when the agency has caused a delay after the application date. In this case, the petitioner mistakenly applied for Institutional MA in March and was found eligible before discovering that she […] Read more

DHA Case No. CWA 213191 (Wis. Div. Hearings and Appeals Jul. 15, 2024) (DHS) ↓ Download PDF Community Waivers members in Groups B and B Plus may use spousal improverishment rules to give income to their spouses, but Group A members may not. In this case, the petitioner was enrolled in Group B in 2019 […] Read more

DHA Case No. CWA 213089 (Wis. Div. Hearings and Appeals Jul. 2, 2024) (DHS) ↓ Download PDF The agency may deny an application for IRIS during the referral stage if the applicant committed substantiated fraud during a previous enrollment. In this case, the petitioner was previously enrolled in IRIS and the agency had issued a […] Read more

DHA Case No. MDV 190237 (Wis. Div. Hearings and Appeals Dec. 13, 2018) (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 case, […] Read more

DHA Case No. CWA 210975 (Wis. Div. of Hearings and Appeals January 24, 2024) (DHS) ↓ Download PDF One way to be functionally eligible for the IRIS program is to need help with one activity of daily living (ADL) and three instrumental activities of daily living (IADLs) and have a cognitive impairment. In this case, […] Read more

DHA Case No. MGE 209717 (Wis. Div. of Hearings and Appeals January 5, 2024) (DHS) ↓ Download PDF To be eligible for SSI-related Medicaid, an unmarried individual’s countable assets must be less than $2,000. The individual must also provide the necessary verification. In this case, the petitioner received a VA lump sum payment and was […] Read more

DHA Case No. MPA 206485 (Wis. Div. of Hearings and Appeals March 1, 2023) (DHS) ↓ Download PDF The number of Personal Care Worker hours approved depends on what activities a member needs help with. In this case, DMS relied solely on a functional screen to conclude the petitioner did not need help with upper-body […] 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