DHA Case No. MDV 214223 (Wis. Div. Hearings and Appeals Nov. 27, 2024) (DHS) ↓ Download PDF A divestment penalty is generally imposed when an applicant reports a divestment and would be otherwise eligible. In this case, the petitioner originally applied in 2020 after creating an irrevocable trust, but no divestment penalty was imposed because […] Read more

DHA Case No. MDV 214942 (Wis. Div. Hearings and Appeals Nov. 20, 2024) (DHS) ↓ Download PDF The deadline to file an appeal of a denied Medicaid application is 45 days from the notice. If a separate undue harship waiver is requested, the petitioner has 20 days from the request to provide any additional proof […] Read more

DHA Case No. MGE 214870 (Wis. Div. Hearings and Appeals Nov. 19, 2024) (DHS) ↓ Download PDF One exception to the usual divestment rule is if the individual intended to dispose of the resource at fair market value. In this case, the petitioner’s husband had “invested” $275,000 in an online scam, for which the county […] Read more

DHA Case No. MGE 214773 (Wis. Div. Hearings and Appeals Nov. 1, 2024) (DHS) ↓ Download PDF The county agency is required to verify a Medicaid applicant’s income and assets, including potential divestments. In this case, the petitioner reported a $5,000 transfer to his sister for “paid bills” and his bank statements showed withdrawals of […] Read more

DHA Case No. FCP 212977 (Wis. Div. Hearings and Appeals May 13, 2024) (DHS) ↓ Download PDF When an MCO seeks to reduce services, it has the burden of proof to show the need for the change. In this case, Inclusa sought to restrict the petitioner’s non-medical transportation to see movies in the community to […] Read more

DHA Case No. FCP 212237 (Wis. Div. Hearings and Appeals May 9, 2024) (DHS) ↓ Download PDF Family Care may cover home modifications such as ramps and lifts to provide safe access to the home, reduce risk of injury, and facilitate independence and self-reliance. In this case, the petitioner was an 81-year-old woman unable to […] Read more

DHA Case No. SSO 211439 (Wis. Div. Hearings and Appeals Apr. 2, 2024) (DHS) ↓ Download PDF When recovering a state SSI overpayment, DHS is limited to recovering benefits paid during the twelve months before the overpayment discovery date. Neither the administrative code nor DHS’s SSI policies define “date of discovery.” In the absence of […] Read more

DHA Case No. CWA 211701 (Wis. Div. Hearings and Appeals Mar. 5, 2024) (DHS) ↓ Download PDF Services provided through the IRIS program must generally be cost-effective and necessary to achieve a long-term care outcome. In this case, the petitioner’s request for twice-weekly mowing was denied. Although she claimed this was necessary to maintain a […] Read more

DHA Case No. FCP 211227 (Wis. Div. Hearings and Appeals Feb. 15, 2024) (DHS) ↓ Download PDF In the Family Care program, MCOs must provide medically necessary services that reasonably and effectively address the participant’s long-term care outcomes. In this case, the petitioner wanted to attend a summer camp that cost $2,970. His MCO denied […] Read more

DHA Case No. CWK 210876 (Wis. Div. Hearings and Appeals Feb. 2, 2024) (DHS) ↓ Download PDF Relocation services under the CLTS program include “supports and essential items needed to establish a community living arrangement.” In this case, the petitioner asked for reimbursement for significant time spent by several people in packing, moving, and unpacking […] Read more

DHA Case No. CWA 211040 (Wis. Div. Hearings and Appeals Feb. 2, 2024) (DHS) ↓ Download PDF A budget amendment may be denied if it requests services that are duplicative of services already provided. In this case, the petitioner, an 18-year-old with Down Syndrome, requested a budget amendment to allow her to attend a 9-month […] Read more

DHA Case No. CWA 211308 (Wis. Div. Hearings and Appeals Jan. 25, 2024) (DHS) ↓ Download PDF IRIS participants choose needed supports and services to meet long-term care outcomes as identified in an Individual Support and Services Plan. In this case, the petitioner (a 29-year-old with autism) sought a budget amendment to pay for therapeutic […] Read more

DHA Case No. HMO 209818 (Wis. Div. Hearings and Appeals Jan. 11, 2024) (DHS) ↓ Download PDF An experimental or unproven treatment is not covered by MA as medically necessary. In this case, the petitioner’s request for a peripheral nerve stimulator was denied by her Medicaid HMO because it considered the treatment “unproven and not […] Read more

DHA Case No. CWK 210810 (Wis. Div. Hearings and Appeals Jan. 9, 2024) (DHS) ↓ Download PDF The CLTS program can pay for home modifications that “maximize a participant’s independent functioning in their home,” but not those that are merely “of general utility and not of direct medical or remedial benefit to them and in […] Read more