DHA Case No. MTI 208493 (Wis. Div. of Hearings and Appeals July 14, 2023) (DHS) ↓ Download PDF To be recoverable, an overpayment must be caused by the recipient’s error—overpayments caused by agency error are not recoverable. In this case, the petitioner misread a notice of FoodShare benefits ending, believing all her benefits were ending. In fact, […] Read more
Benjamin S. Wright
DHA Case No. MPA 208352 (Wis. Div. of Hearings and Appeals July 11, 2023) (DHS) ↓ Download PDF DHA Case No. MPA 208353 (Wis. Div. of Hearings and Appeals July 11, 2023) (DHS) ↓ Download PDF To be covered under Medicaid, a service must be medically necessary and cost-effective. In this case, the petitioner requested […] Read more
DHA Case No. CWK 208407 (Wis. Div. of Hearings and Appeals July 10, 2023) (DHS) ↓ Download PDF The Children’s Long-Term Support (CLTS) Waiver Program can cover relocation services for a participant’s “relocation to a safe and accessible community living arrangement.” In this case, the participant’s apartment was not accessible, forcing her to crawl around […] Read more
DHA Case No. FCP 208522 (Wis. Div. of Hearings and Appeals June 28, 2023) (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. CWK 208175 (Wis. Div. of Hearings and Appeals June 13, 2023) (DHS) ↓ Download PDF DHA Case No. CWK 208176 (Wis. Div. of Hearings and Appeals June 13, 2023) (DHS) ↓ Download PDF Two services that may be provided under the Children’s Long-Term Support (CLTS) Waiver Program are respite care and child […] Read more
DHA Case No. MNP 208124 (Wis. Div. of Hearings and Appeals June 6, 2023) (DHS) ↓ Download PDF Emergency Medicaid covers treatment for emergency medical conditions given to non-citizens. An emergency medical condition requires “acute” symptoms severe enough to put the person’s health in “serious” jeopardy. In this case, the petitioner was denied coverage for […] Read more
DHA Case No. CWA 208070 (Wis. Div. of Hearings and Appeals June 6, 2023) (DHS) ↓ Download PDF Home and community-based waiver programs may cover “other services … as cost effective and necessary to avoid institutionalization.” In this case, the IRIS program paid the petitioner’s internet under the “other services” authorization since 2019 but stopped […] Read more
DHA Case No. BCS 207937 (Wis. Div. of Hearings and Appeals June 6, 2023) (DHS) ↓ Download PDF An applicant for BadgerCare Plus must provide his or her Social Security number. In this case, the petitioner applied but failed to provide it. The agency properly issued the request for proof and mailed it to the […] Read more
DHA Case No. HMO 208799 (Wis. Div. of Hearings and Appeals July 7, 2023) (DHS) ↓ Download PDF A Medicaid recipient cannot be held personally liable for a service requiring prior authorization unless he has notice of the prior authorization denial before provision of the service. In this unusual case with no findings of fact, […] Read more
DHA Case No. MGE 208326 (Wis. Div. of Hearings and Appeals July 18, 2023) (DHS) ↓ Download PDF Amember’s patient liability can be reduced to allow payment of medical or remedial expenses that the member “has incurred, is actually paying, and is legally obligated to pay.” In this case, after losing fair hearings on the […] Read more
DHA Case No. FCP 208424 (Wis. Div. of Hearings and Appeals July 10, 2023) (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 him functionally ineligible because […] Read more
DHA Case No. MGE 208349 (Wis. Div. of Hearings and Appeals June 13, 2023) (DHS) ↓ Download PDF In general, applicants are responsible for verification—but agencies cannot deny eligibility when the applicant has no ability to get the required verification. In this case, the petitioner and his wife were both applying for Institutional MA through their […] Read more
DHA Case No. MRA 208459 (Wis. Div. of Hearings and Appeals June 29, 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 income […] Read more
DHA Case No. MDV 208396 (Wis. Div. of Hearings and Appeals June 29, 2023) (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 208783 (Wis. Div. of Hearings and Appeals August 15, 2023) (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