DHA Case No. MLL 211983 (Wis. Div. of Hearings and Appeals March 18, 2024) (DHS) ↓ Download PDF A hardship waiver for estate recovery must be mailed within 45 days of the notice from DHS. In this tragic case, the waiver was due December 25. The petitioner called Estate Recovery on December 18 to ask […] Read more

DHA Case No. CWK 210726 (Wis. Div. of Hearings and Appeals March 15, 2024) (DHS) ↓ Download PDF Individual choice of provider is a main tenant of the CLTS program. Even when a background check on a proposed provider reveals negative—but not disqualifying—findings, the County Waiver Agency must respect the participant’s choice “unless there is […] Read more

DHA Case No. MNP 211393 (Wis. Div. of Hearings and Appeals March 8, 2024) (DHS) ↓ Download PDF Wisconsin Medicaid covers emergency out-of-state services, even if the provider is not certified with Wisconsin Medicaid. In this case, the petitioner had a seizure while in Florida with her family and was transported by ambulance. The ambulance […] Read more

DHA Case No. MAP 211494 (Wis. Div. of Hearings and Appeals March 6, 2024) (DHS) ↓ Download PDF To be exempt homestead property, the property must serve as the individual’s primary place of residence. In this case, the petitioner owned real estate worth $25,000 and claimed he lived there in a tent, providing documents and […] Read more

DHA Case No. MPP 211770 (Wis. Div. of Hearings and Appeals February 21, 2024) (DHS) ↓ Download PDF If a Medicaid recipient knowingly obtains health care that exceeds program limits or is not medically necessary, the Department may enroll the recipient in the “lock-in program,” which limits the recipient to one prescriber and one pharmacy […] Read more

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