4 Program Administration

DHA Case No. HMO 208799 (Wis. Div. of Hearings and Appeals July 7, 2023) (DHS) ↓ Download PDF A Medicaid 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 unusual case with no findings of fact, […] Read more

DHA Case No. MGE 208326 (Wis. Div. of Hearings and Appeals July 18, 2023) (DHS) ↓ Download PDF Amember’s patient liability can be reduced to allow payment of medical or remedial expenses that the member “has incurred, is actually paying, and is legally obligated to pay.” In this case, after losing fair hearings on the […] Read more

DHA Case No. MGE 208349 (Wis. Div. of Hearings and Appeals June 13, 2023) (DHS) ↓ Download PDF In general, applicants are responsible for verification—but agencies cannot deny eligibility when the applicant has no ability to get the required verification. In this case, the petitioner and his wife were both applying for Institutional MA through their […] Read more

DHA Case No. MDV 208757 (Wis. Div. of Hearings and Appeals July 27, 2023) (DHS) ↓ Download PDF To waive the entire divestment penalty, an undue hardship waiver request must be filed within 20 days of the undue hardship notice letter mailed by the agency. If filed later, the earliest effective date is the date […] Read more

DHA Case No. FCP 207586 (Wis. Div. of Hearings and Appeals July 20, 2023) (DHS) ↓ Download PDF MCOs in the Family Care program may authorize residential services—such as placement in an Adult Family Home (AFH)—only if they are the most cost-effective option, if they are needed to support the member’s long-term care outcomes, or […] Read more

DHA Case No. SSO 208238 (Wis. Div. of Hearings and Appeals June 22, 2023) (DHS) ↓ Download PDF Wisconsin pays a state supplement to SSI recipients who are Wisconsin residents. In this case, the state SSI office claimed an overpayment because the Social Security Administration coded the petitioner as a California resident from December 2021 […] Read more

DHA Case No. HMO 208074 (Wis. Div. of Hearings and Appeals June 12, 2023) (DHS) ↓ Download PDF Medical Assistance does not cover services that DHS deems experimental. In this case, the petitioner was denied coverage of an Intracept spinal procedure to alleviate back pain because it was deemed experimental. ALJ Brian Schneider found no […] Read more

DHA Case No. MGE 207353 (Wis. Div. of Hearings and Appeals June 21, 2023) (Decision on Remand) (DHS) ↓ Download PDF Amember’s patient liability can be reduced to allow payment of medical or remedial expenses that the member “has incurred, is actually paying, and is legally obligated to pay.” In this case, the petitioner verified […] Read more

DHA Case No. MTI 207782 (Wis. Div. of Hearings and Appeals April 12, 2023) (DHS) ↓ Download PDF A party has 30 days from the date of a tax intercept notice to file an appeal; the filing date is the postmark date or the date of actual receipt by DHA, whichever is earlier. In this […] Read more

DHA Case No. MPA 207590 (Wis. Div. of Hearings and Appeals April 3, 2023) (DHS) ↓ Download PDF A specialized bed may be provided under the MA program when prescribed by a physician, but it must be cost-effective and not solely for the comfort or convenience of the recipient. In this case, the petitioner was […] Read more

DHA Case No. CWK 207268 (Wis. Div. of Hearings and Appeals March 28, 2023) (DHS) ↓ Download PDF The Children’s Long-Term Support (CLTS) Waiver program can pay for needed home modifications, but they must be cost-effective and solely benefit the participant. In this case, the participant’s mother asked for an interior open-concept remodel, a fence, […] Read more

DHA Case No. FCP 206703 (Wis. Div. of Hearings and Appeals February 16, 2023) (DHS) ↓ Download PDF Family Care can provide supportive home care (SHC) hours to cover services that are necessary, reasonable, appropriate, and cost-effective. In this case, the petitioner’s mother sought an increase in SHC hours so she could be paid to […] Read more

DHA Case No. MPA 206828 (Wis. Div. of Hearings and Appeals January 23, 2023) (DHS) ↓ Download PDF Medicaid can cover durable medical equipment if it is medically necessary, a determination that includes cost-effectiveness. In this case, the petitioner—a 4-year-old with a genetic disorder who was “unable to understand safety, cause and effect, risk, or […] Read more

DHA Case No. CWA 206353 (Wis. Div. of Hearings and Appeals January 17, 2023) (DHS) ↓ Download PDF Services included in an IRIS member’s budget must be cost effective and at the usual and customary rate for the area. In this case, the petitioner’s medical transportation provider increased its rate for transporting him to his […] Read more