DHA Case No. MLL 211310 (Wis. Div. of Hearings and Appeals February 19, 2024) (DHS) ↓ Download PDF When an heir applies for a hardship waiver of an estate recovery claim, the heir  must include documents establishing his or her relationship to the decedent. In this case, the heir failed to document her relationship, though […] Read more

DHA Case No. FCP 211094 (Wis. Div. of Hearings and Appeals February 12, 2024) (DHS) ↓ Download PDF An MCO must develop an individual service plan that reasonably and effectively addresses the enrollee’s long-term care needs and outcomes, including needs for socialization and activities. In this case, the petitioner’s MCO stopped paying for adult day […] Read more

DHA Case No. BCS 211320 (Wis. Div. of Hearings and Appeals January 18, 2024) (DHS) ↓ Download PDF To be eligible for Medicaid, an applicant must verify his or her income. In this case, the petitioner tried to fax the verification from a public library to two different fax numbers, but the agency never received […] Read more

DHA Case No. MGE 209717 (Wis. Div. of Hearings and Appeals January 5, 2024) (DHS) ↓ Download PDF To be eligible for SSI-related Medicaid, an unmarried individual’s countable assets must be less than $2,000. The individual must also provide the necessary verification. In this case, the petitioner received a VA lump sum payment and was […] Read more

DHA Case No. MGE 169735 (Wis. Div. of Hearings and Appeals May 3, 2016) (DHS) ↓ Download PDF Applicants for Medicaid must verify their assets, but workers cannot deny eligibility if the applicant lacks the ability to produce verification. In this case, the petitioner was incompetent and her representatives—her son and lawyer—were unable to verify […] Read more

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