Fair Hearing Decisions

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. CWA 195974 (Wis. Div. of Hearings and Appeals January 6, 2020) (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 refused […] 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. MRA 195793 (Wis. Div. of Hearings and Appeals January 6, 2020) (DHS) ↓ Download PDF In general, it is a divestment if the community spouse transfers assets to anyone other than the institutionalized spouse in the first 5 years of Medicaid eligibility. It can also be a divestment if the institutionalized spouse […] Read more

DHA Case No. MGE 196806 (Wis. Div. of Hearings and Appeals January 9, 2020) (DHS) ↓ Download PDF An applicant must be under the asset limit as of the last day of the month for that month’s eligibility. In this case, the petitioner’s eligibility for August was denied because her bank statement showed a high […] Read more

DHA Case No. MAP 196477 (Wis. Div. of Hearings and Appeals January 13, 2020) (DHS) ↓ Download PDF To be eligible for the MAPP program, the individual’s countable assets must be below $15,000. Assets titled solely in a spouse’s name do not count for MAPP. In this case, the Department disenrolled the petitioner, apparently counting […] Read more

DHA Case No. MGE 196927 (Wis. Div. of Hearings and Appeals January 28, 2020) (DHS) ↓ Download PDF The Department must give applicants adequate notice when requesting verification. In this case, the agency requested verification of a third-party discretionary trust but gave only 9 days to provide it and was not specific about the kind […] Read more

DHA Case No. FCP 197060 (Wis. Div. of Hearings and Appeals February 10, 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. This level of care includes those who cannot safely or appropriately perform […] Read more

DHA Case No. MGE 196854 (Wis. Div. of Hearings and Appeals February 14, 2020) (DHS) ↓ Download PDF For EBD Medicaid programs, a couple’s income is only counted together if they are legally married and living together. In this case, the petitioner lived with his partner, had children with her, had a commitment ceremony, and […] Read more

DHA Case No. MOP 197486 (Wis. Div. of Hearings and Appeals February 27, 2020) (DHS) ↓ Download PDF To establish an overpayment, the Department has the burden of proof by the preponderance of the evidence. In this case, the issue was whether the petitioner’s husband lived with her or not (if so, her household income […] Read more

DHA Case No. MGE 197380 (Wis. Div. of Hearings and Appeals March 2, 2020) (DHS) ↓ Download PDF In general, a Medicaid application must be processed within 30 days (plus 10 days if needed to provide verification) and the applicant has the burden of providing the needed verification. This case, however, was “highly unusual” for […] Read more

DHA Case No. MGE 197359 (Wis. Div. of Hearings and Appeals March 4, 2020) (DHS) ↓ Download PDF A community spouse must sign the Medicaid application and verify his or her assets unless a denial would result in undue hardship. In this case, the petitioner moved to a separate home from his wife in the […] Read more

DHA Case No. FCP 197394 (Wis. Div. of Hearings and Appeals March 9, 2020) (DHS) ↓ Download PDF Benefits cannot be denied for lack of verification unless the member had adequate notice and the ability to produce the required verification. In this case, the petitioner, an incapacitated woman with dementia, moved to a CBRF. The […] Read more

 DHA Case No. 197019 (Wis. Div. of Hearings and Appeals March 17, 2020) (DHS) ↓ Download PDF The Division of Hearings and Appeals must receive notice of a Medicaid appeal within 45 days of the negative decision or the date it went into effect, and DHS must generally receive verification by its due date to […] Read more