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
4.7 Notices & fair hearings
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. FCP 206397 (Wis. Div. of Hearings and Appeals January 17, 2023) (DHS) ↓ Download PDF Family Care generally does not cover household repairs or improvements that are not directly related to the member’s care. In this case, the petitioner’s carpet was fouled and beyond cleaning, so she asked her MCO to replace […] 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. 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
DHA Case No. FCP 209188 (Wis. Div. of Hearings and Appeals September 5, 2023) (DHS) ↓ Download PDF An appeal of a negative MA decision must be filed, at most, within 90 days (for most decisions it’s 45 days). In this case, the petitioner’s cost share was increased by notices effective September 1, 2022 and […] Read more
DHA Case No. HMO 209172 (Wis. Div. of Hearings and Appeals July 27, 2023) (DHS) ↓ Download PDF When a member disagrees with a Medicaid HMO’s decision, the member must first appeal to the HMO. The Division of Hearings and Appeals does not have jurisdiction until there is a final determination by the HMO’s internal […] Read more
DHA Case No. MDV 209022 (Wis. Div. of Hearings and Appeals August 25, 2023) (DHS) ↓ Download PDF An appeal of a divestment penalty must be filed within 45 days; an appeal of a hardship waiver denial must also be filed within 45 days. In this case, the agency imposed a divestment penalty when the […] Read more
DHA Case No. MGE 207999 (Wis. Div. of Hearings and Appeals May 10, 2023) (DHS) ↓ Download PDF When a consumer is discharged from the Comprehensive Community Services (CCS) program and receives MA, they must first exhaust the grievance procedure at the local level before appealing to a fair hearing. The notice of discharge, however, […] Read more
DHA Case No. FCP 210574 (Wis. Div. of Hearings and Appeals November 30, 2023) (DHS) ↓ Download PDF An MCO must give ten days’ notice of any adverse benefit determination. In this case, the petitioner’s MCO issued a notice on September 29 disenrolling her retroactive to August 21. ALJ Brian Schneider concluded the MCO had not […] Read more
DHA Case No. SSO 209011 (Wis. Div. of Hearings and Appeals September 18, 2023) (DHS) ↓ Download PDF DHS cannot recover state SSI benefits that were incorrectly paid more than 12 months before the “date of discovery” of the overpayment. In this case, the Social Security Administration retroactively terminated the petitioner’s SSI eligibility for January […] 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
DHA Case No. CWA 208908 (Wis. Div. of Hearings and Appeals October 27, 2023) (DHS) ↓ Download PDF In this brief case, the petitioner appealed the termination of her IRIS benefits due to losing functional eligibility. Because she did not appear at the hearing, ALJ John Tedesco dismissed the case and the IRIS termination was […] Read more
DHA Case No. MAC 208599 (Wis. Div. of Hearings and Appeals July 19, 2023) (DHS) ↓ Download PDF A Medicaid appeal must be filed with the Division of Hearings and Appeals, not a different agency, by the deadline. In this case, the petitioner apparently mailed his appeal to the county agency (i.e., DHS) rather than […] Read more
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