4 Program Administration

DHA Case No. MLL 171792 (Wis. Div. of Hearings and Appeals March 21, 2016) (DHS) ↓ Download PDF Estate Recovery must file a claim or lien against the estate of decedents who received long-term care Medicaid benefits. In this case, the petitioner challenged the Department’s intent to file a lien against his mother’s estate, arguing […] Read more

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

DHA Case No. CWK 210573 (Wis. Div. of Hearings and Appeals January 9, 2024) (DHS) ↓ Download PDF The CLTS program can cover respite care to ease “the daily stress and care demands” for the participant’s family “on a short-term basis.” In this case, the petitioner was an 8-year-old with autism. His mother had a […] Read more

DHA Case No. HMO 210862 (Wis. Div. of Hearings and Appeals January 10, 2024) (DHS) ↓ Download PDF Although orthodontia is not usually covered by MA, it must be covered for recipients under age 21 if the Early and Periodic Screening, Diagnosis and Treatment (EPSDT) health assessment and evaluation indicates that it is medically necessary. […] Read more

DHA Case No. FCP 210267 (Wis. Div. of Hearings and Appeals January 25, 2024) (DHS) ↓ Download PDF Supportive Home Care (SHC) can be a benefit provided through Family Care when the member needs assistance with chores. In this case, Inclusa sought to end the petitioner’s SHC, claiming vaguely that “petitioner may be able to […] Read more

DHA Case No. FCP 210269 (Wis. Div. of Hearings and Appeals January 26, 2024) (DHS) ↓ Download PDF Non-medical transportation can be a benefit provided through Family Care when the member needs assistance with transportation. In this case, Inclusa sought to end the petitioner’s non-medical transportation, claiming vaguely that “petitioner may be able to walk […] Read more

DHA Case No. MED 292938 (Wis. Div. of Hearings and Appeals September 3, 2008) (DHS) ↓ Download PDF Gifts received by a Medicaid recipient must be reported within ten days. In this case, the petitioner was disabled with cancer. Her community held a fundraiser and gave her almost $30,000, which she failed to report. Although […] Read more

DHA Case No. FCP 211038 (Wis. Div. of Hearings and Appeals January 31, 2024) (DHS) ↓ Download PDF When an MCO seeks to reduce a member’s supportive home care budget, it has the burden of proof. In this case, the petitioner’s MCO sought to reduce his budget because his son reported some minor improvements. ALJ […] Read more

DHA Case No. MPA 206485 (Wis. Div. of Hearings and Appeals March 1, 2023) (DHS) ↓ Download PDF The number of Personal Care Worker hours approved depends on what activities a member needs help with. In this case, DMS relied solely on a functional screen to conclude the petitioner did not need help with upper-body […] Read more

DHA Case No. MPA 207369 (Wis. Div. of Hearings and Appeals February 28, 2023) (DHS) ↓ Download PDF AMedicaid 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 case, the petitioner’s doctor ordered an MRI and went […] Read more

DHA Case No. MPA 206520 (Wis. Div. of Hearings and Appeals February 7, 2023) (DHS) ↓ Download PDF Personal Care Worker hours can be increased if assistance takes extra time because of the member’s behaviors. In this case, the petitioner was an eight-year-old girl with Down syndrome who was aggressive and resistive during cares, but […] Read more

DHA Case No. FCP 206451 (Wis. Div. of Hearings and Appeals January 30, 2023) (DHS) ↓ Download PDF A medically necessary service must not be duplicative of other services already being provided. In this case, the petitioner had been in a program for 14 years that allowed him to participate in 3 community events every […] Read more

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