4.2 Benefits

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. 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. FCP 207586 (Wis. Div. of Hearings and Appeals July 20, 2023) (DHS) ↓ Download PDF MCOs in the Family Care program may authorize residential services—such as placement in an Adult Family Home (AFH)—only if they are the most cost-effective option, if they are needed to support the member’s long-term care outcomes, or […] Read more

DHA Case No. HMO 208074 (Wis. Div. of Hearings and Appeals June 12, 2023) (DHS) ↓ Download PDF Medical Assistance does not cover services that DHS deems experimental. In this case, the petitioner was denied coverage of an Intracept spinal procedure to alleviate back pain because it was deemed experimental. ALJ Brian Schneider found no […] Read more

DHA Case No. MPA 207590 (Wis. Div. of Hearings and Appeals April 3, 2023) (DHS) ↓ Download PDF A specialized bed may be provided under the MA program when prescribed by a physician, but it must be cost-effective and not solely for the comfort or convenience of the recipient. In this case, the petitioner was […] Read more

DHA Case No. CWK 207268 (Wis. Div. of Hearings and Appeals March 28, 2023) (DHS) ↓ Download PDF The Children’s Long-Term Support (CLTS) Waiver program can pay for needed home modifications, but they must be cost-effective and solely benefit the participant. In this case, the participant’s mother asked for an interior open-concept remodel, a fence, […] Read more

DHA Case No. FCP 206703 (Wis. Div. of Hearings and Appeals February 16, 2023) (DHS) ↓ Download PDF Family Care can provide supportive home care (SHC) hours to cover services that are necessary, reasonable, appropriate, and cost-effective. In this case, the petitioner’s mother sought an increase in SHC hours so she could be paid to […] Read more

DHA Case No. MPA 206828 (Wis. Div. of Hearings and Appeals January 23, 2023) (DHS) ↓ Download PDF Medicaid can cover durable medical equipment if it is medically necessary, a determination that includes cost-effectiveness. In this case, the petitioner—a 4-year-old with a genetic disorder who was “unable to understand safety, cause and effect, risk, or […] Read more

DHA Case No. CWA 206353 (Wis. Div. of Hearings and Appeals January 17, 2023) (DHS) ↓ Download PDF Services included in an IRIS member’s budget must be cost effective and at the usual and customary rate for the area. In this case, the petitioner’s medical transportation provider increased its rate for transporting him to his […] Read more

DHA Case No. MPA 207077 (Wis. Div. of Hearings and Appeals January 27, 2023) (DHS) ↓ Download PDF Personal care services under Medicaid must be medically necessary and cost-effective. In this case, the petitioner asked for 19.5 Personal Care Worker (PCW) hours per week but was only approved for 10.25. ALJ Brian Schneider upheld the […] Read more

DHA Case No. CWA 206183 (Wis. Div. of Hearings and Appeals January 17, 2023) (DHS) ↓ Download PDF The moving party generally has the burden of proof; when an IRIS participant requests new services, the participant must prove that the requested services meet approval criteria by a preponderance of the evidence. In this case, the […] Read more

DHA Case No. FCP 206264 (Wis. Div. of Hearings and Appeals January 11, 2023) (DHS) ↓ Download PDF In the Family Care program, the MCO must develop an Individual Service Plan with the client that addresses the client’s needs. When the MCO seeks to change that plan and reduce services, it has the burden of […] Read more