DHA Case No. FCP 189662 (Wis. Div. of Hearings and Appeals January 14, 2019) (DHS) ↓ Download PDF An individual is functionally eligible for Family Care if he or she needs a “nursing home” level of care, as determined by the functional screen. In this case, the petitioner was enrolled in Family Care and receiving […] Read more
4 Program Administration
DHA Case No. CWA 189467 (Wis. Div. of Hearings and Appeals January 3, 2019) (DHS) ↓ Download PDF The IRIS program cannot cover nursing services that are already covered by the state Medicaid plan. In this case, the petitioner’s IRIS supportive home care (SHC) hours were reduced from 96 hours per week to 40 hours […] Read more
DHA Case No. MOP 190168 (Wis. Div. of Hearings and Appeals January 11, 2019) (DHS) ↓ Download PDF When a Medicaid recipient fails to report a change in income or assets that would affect eligibility, an overpayment results. In this case, the petitioner was a 92-year-old woman receiving community waivers and healthcare benefits, and it […] Read more
DHA Case No. MGE 190017 (Wis. Div. of Hearings and Appeals March 11, 2019) (DHS) ↓ Download PDF When an irrevocable trust is involved, the Department may require documentation needed to determine when assets were added, what distributions have been made, and whether a divestment occurred. In this case, the petitioner applied and disclosed an […] Read more
DHA Case No. MDV 193440 (Wis. Div. of Hearings and Appeals June 11, 2019) (DHS) ↓ Download PDF A land contract must have a term within the lender’s life expectancy, provide for equal payments, and not allow cancellation on the death of the lender to avoid being considered a divestment. If it does not meet […] Read more
CWA 208405 (10/16/2023)
Community transportation budget ended when petitioner found to drive himself
DHA Case No. CWA 208405 (Wis. Div. of Hearings and Appeals October 16, 2023) (DHS) ↓ Download PDF Community transportation can be covered by IRIS, but the service assumes that someone besides the participant is doing the driving. In this case, the petitioner had a community transportation budget with his wife as the “participant-hired worker” […] Read more
DHA Case No. CWA 208350 (Wis. Div. of Hearings and Appeals September 19, 2023) (DHS) ↓ Download PDF The IRIS program can cover “individual directed goods and services” that are not covered under another service category and not obtainable from another source. In this case, the petitioner somehow had IRIS paying for food from vendors […] Read more
DHA Case No. FCP 207851 (Wis. Div. of Hearings and Appeals August 31, 2023) (DHS) ↓ Download PDF An MCO must determine whether a requested service is medically necessary and cost-effective. But in this case, the petitioner’s mother and guardian refused to cooperate with the MCO’s attempts to get the information it needed to make […] 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
DHA Case No. MPA 208352 (Wis. Div. of Hearings and Appeals July 11, 2023) (DHS) ↓ Download PDF DHA Case No. MPA 208353 (Wis. Div. of Hearings and Appeals July 11, 2023) (DHS) ↓ Download PDF To be covered under Medicaid, a service must be medically necessary and cost-effective. In this case, the petitioner requested […] Read more
DHA Case No. CWK 208407 (Wis. Div. of Hearings and Appeals July 10, 2023) (DHS) ↓ Download PDF The Children’s Long-Term Support (CLTS) Waiver Program can cover relocation services for a participant’s “relocation to a safe and accessible community living arrangement.” In this case, the participant’s apartment was not accessible, forcing her to crawl around […] Read more
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