DHA Case No. HMO 206640 (Wis. Div. of Hearings and Appeals January 5, 2023) (DHS) ↓ Download PDF Medicaid HMOs must provide the same services as fee-for-service MA or BadgerCare Plus—they must cover services that are medically necessary. In this case, the petitioner wanted her HMO to cover an out-of-network doctor when in-network doctors either […] Read more
Fair Hearing Decisions
DHA Case No. MGE 211422 (Wis. Div. of Hearings and Appeals February 1, 2024) (DHS) ↓ Download PDF A life-insurance funded burial contract (LIFBC or “burial insurance”) can be funded with more than $4,500 and still be exempt for Medicaid eligibility; but an irrevocable funeral trust can only make up to $4,500 truly irrevocable and […] Read more
DHA Case No. FCP 210973 (Wis. Div. of Hearings and Appeals January 16, 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’s authorized representative failed to complete his renewal: she “apparently left employment with her payee company, […] Read more
DHA Case No. FCP 209929 (Wis. Div. of Hearings and Appeals January 12, 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 ADRC sent the Community Waivers referral to IM on June 16, but “for reasons unclear” IM […] Read more
DHA Case No. MGE 209925 (Wis. Div. of Hearings and Appeals January 12, 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 was eligibile on July 6 but not enrolled until July 21 because the ADRC mistakenly […] Read more
DHA Case No. FCP 209869 (Wis. Div. of Hearings and Appeals January 12, 2024) (DHS) ↓ Download PDF In general, the ADRC has 30 days from the date of request to determine functional eligibility or provide notice of a delay; IM has 30 days from the date of application to determine financial eligibility. In this […] Read more
DHA Case No. FCP 209037 (Wis. Div. of Hearings and Appeals November 14, 2023) (DHS) ↓ Download PDF The Department may backdate Family Care enrollment when there is an agency error that causes an unreasonable delay. In this case, the petitioner was found eligible in December of 2022 and the MCO received her enrollment form […] Read more
DHA Case No. MGE 209328 (Wis. Div. of Hearings and Appeals December 5, 2023) (DHS) ↓ Download PDF An application for Institutional MA can be backdated up to three months before the month of application. The MEH provides that an application faxed and received by the agency after business hours counts as filed on the […] Read more
DHA Case No. MGE 210403 (Wis. Div. of Hearings and Appeals December 8, 2023) (DHS) ↓ Download PDF The assets in an irrevocable trust funded with the petitioner’s property are potentially available if there are any circumstances allowing payment from the trust to the petitioner. In this case, the petitioner established a Hedlund-type trust in 1996 […] Read more
DHA Case No. MGE 209343 (Wis. Div. of Hearings and Appeals October 2, 2023) (DHS) ↓ Download PDF The balance of a land contract is counted as an available asset unless its terms prohibit transfer or no one is willing to purchase it. In this case, the petitioner was selling non-homestead real estate under a […] Read more
DHA Case No. MGE 209372 (Wis. Div. of Hearings and Appeals August 11, 2023) (DHS) ↓ Download PDF In general, a member must have at least ten days to provide required verification during a renewal. In this case, the agency sent a notice on July 3 requesting verification by July 10. Although he should have […] Read more
DHA Case No. CWA 208861 (Wis. Div. of Hearings and Appeals November 10, 2023) (DHS) ↓ Download PDF In general, a service covered by IRIS must be necessary and cost-effective. In this case, the petitioner sought an increase in the rate paid to his AFH from $194.37 per day to $309.20 per day. Thanks largely […] Read more
DHA Case No. CWA 208719 (Wis. Div. of Hearings and Appeals October 23, 2023) (DHS) ↓ Download PDF An IRIS participant may be involuntarily disenrolled for loss of functional eligibility. In this case, the agency attempted to disenroll the petitioner from the IRIS self-directed personal care (SDPC) program only, not IRIS itself, for loss of functional […] Read more
DHA Case No. FCP 207790 (Wis. Div. of Hearings and Appeals May 19, 2023) (DHS) ↓ Download PDF In the Family Care program, the MCO must develop an Individual Service Plan (ISP) that reasonably and effectively addresses long-term care needs and outcomes and is cost-effective. In this case, the petitioner had extreme and violent behaviors […] Read more
DHA Case No. MLL 209268 (Wis. Div. of Hearings and Appeals September 29, 2023) (DHS) ↓ Download PDF An applicant for an estate recovery waiver must file his or her application within 45 days of the Department’s notice. In this case, the petitioner filed it a month after the deadline, then appealed when the waiver […] Read more