DHA Case No. MGE 211748 (Wis. Div. of Hearings and Appeals April 3, 2024) (DHS) ↓ Download PDF A person must be a U.S. citizen or qualifying lawful immigrant to be eligible for Medicaid. In this case, the petitioner was an immigrant with “temporary protected status.” Her Medicaid application was mistakenly approved in 2022 and the […] Read more

DHA Case No. MGE 211383 (Wis. Div. of Hearings and Appeals March 28, 2024) (DHS) ↓ Download PDF The patient liability for an institutionalized person generally leaves only a small amount of money for personal needs ($45 at the time of this case, now $55). In this case, the petitioner complained that her $45 per […] Read more

DHA Case No. FCP 211142 (Wis. Div. of Hearings and Appeals March 19, 2024) (DHS) ↓ Download PDF Family Care enrollment can be backdated if agency error by the ADRC or IM causes unreasonable delay. In this case, the petitioner filed an application October 10, but the agency never told his authorized representative of the […] Read more

DHA Case No. CWK 211595 (Wis. Div. of Hearings and Appeals March 22, 2024) (DHS) ↓ Download PDF The legal standards of functional eligibility for the Children’s Long-Term Support (CLTS) Waiver program and for the Katie Beckett program are identical. In this odd case, the petitioner was determined functionally ineligible for her CLTS renewal by […] Read more

DHA Case No. MGE 211311 (Wis. Div. of Hearings and Appeals March 19, 2024) (DHS) ↓ Download PDF Tribal General Welfare Assistance (GWA) is exempt income only if it is based on the individual’s demonstration of need. In this case, the petitioner received GWA that was apparently not based on need. ALJ Teresa Perez concluded […] Read more

DHA Case No. MGE 211566 (Wis. Div. of Hearings and Appeals March 15, 2024) (DHS) ↓ Download PDF Countable assets do not include income received that month and money that is not available. In this case, the petitioner’s eligibility for July was denied because the agency counted $1,599 in Social Security (deposited July 3) and […] Read more

DHA Case No. MNP 211393 (Wis. Div. of Hearings and Appeals March 8, 2024) (DHS) ↓ Download PDF Wisconsin Medicaid covers emergency out-of-state services, even if the provider is not certified with Wisconsin Medicaid. In this case, the petitioner had a seizure while in Florida with her family and was transported by ambulance. The ambulance […] Read more

DHA Case No. FCP 211094 (Wis. Div. of Hearings and Appeals February 12, 2024) (DHS) ↓ Download PDF An MCO must develop an individual service plan that reasonably and effectively addresses the enrollee’s long-term care needs and outcomes, including needs for socialization and activities. In this case, the petitioner’s MCO stopped paying for adult day […] Read more

DHA Case No. CWA 209367 (Wis. Div. of Hearings and Appeals January 4, 2024) (DHS) ↓ Download PDF Community Waivers enrollment can be backdated if agency error causes unreasonable delay. In this complicated case, the petitioner was first enrolled in IRIS during the pandemic as a 17- or 18-year-old under his mother’s name. His mother […] Read more

DHA Case No. BCS 210493 (Wis. Div. of Hearings and Appeals January 9, 2024) (DHS) ↓ Download PDF BadgerCare Plus eligibility is based on income and, unlike EBD Medicaid programs, taxable withdrawals from IRAs are counted as income. In this case, the petitioner was 63 and his only income was monthly withdrawals of $3,200 from […] Read more

DHA Case No. HMO 210862 (Wis. Div. of Hearings and Appeals January 10, 2024) (DHS) ↓ Download PDF Although orthodontia is not usually covered by MA, it must be covered for recipients under age 21 if the Early and Periodic Screening, Diagnosis and Treatment (EPSDT) health assessment and evaluation indicates that it is medically necessary. […] Read more

DHA Case No. FCP 211038 (Wis. Div. of Hearings and Appeals January 31, 2024) (DHS) ↓ Download PDF When an MCO seeks to reduce a member’s supportive home care budget, it has the burden of proof. In this case, the petitioner’s MCO sought to reduce his budget because his son reported some minor improvements. ALJ […] Read more

DHA Case No. SSO 206537 (Wis. Div. of Hearings and Appeals January 18, 2023) (DHS) ↓ Download PDF In a fair hearing on an overpayment determination, the agency has the burden of proof. In this case, the petitioner lived in her car and drove to Arizona for the winter. She continued to receive federal SSI […] Read more

DHA Case No. MGE 210257 (Wis. Div. of Hearings and Appeals December 7, 2023) (DHS) ↓ Download PDF An appeal must be filed within 45 days of a Medicaid application denial for the Division of Hearings and Appeals to have jurisdiction. In this case, the deadline to appeal the initial denial of the Medicaid application […] Read more