DHA Case No. FCP 208209 (Wis. Div. of Hearings and Appeals May 31, 2023) (DHS) ↓ Download PDF In the Family Care program, the MCO must develop an Individual Service Plan with the client that addresses the client’s needs while being cost-effective. The MCO does not have to provide a service if there are less […] Read more

DHA Case No. CWA 207516 (Wis. Div. of Hearings and Appeals May 18, 2023) (DHS) ↓ Download PDF An IRIS participant may request a budget amendment to pay for an ongoing need not met within the current budget. In this case, the petitioner asked for a budget increase when her home health agency ended her […] Read more

DHA Case No. FCP 207491 (Wis. Div. of Hearings and Appeals May 9, 2023) (DHS) ↓ Download PDF A Family Care MCO’s member-centered plan must assess and identify “long-term care outcomes that are consistent with the values and preference of the enrollee” in the areas of both “self-determination of daily routine, services, activities and living […] Read more

DHA Case No. FCP 207518 (Wis. Div. of Hearings and Appeals April 19, 2023) (DHS) ↓ Download PDF Assisted living is a possible residential choice in the Family Care program, but it generally must be cost-effective in addressing the member’s individual service plan. In this case, the petitioner—a 61-year-old woman with autism, anxiety, PTSD, vertigo, […] Read more

DHA Case No. CWA 207522 (Wis. Div. of Hearings and Appeals April 18, 2023) (DHS) ↓ Download PDF An IRIS participant may request a budget amendment to pay for an ongoing need not met within the current budget. In this case, the petitioner asked for a budget increase when her home health agency ended her […] Read more

DHA Case No. CWA 207408 (Wis. Div. of Hearings and Appeals April 17, 2023) (DHS) ↓ Download PDF To cover a service dog, IRIS policy requires that it be “individually trained by a reputable provider experienced in providing structured training for service dogs to do work or perform tasks for the participant that are directly […] Read more

DHA Case No. MGE 207580 (Wis. Div. of Hearings and Appeals April 14, 2023) (DHS) ↓ Download PDF An institutionalized spouse may allocate income to the community spouse up to a certain amount, and an ALJ may increase that if the petitioner shows “exceptional circumstances resulting in financial duress.” In this case, the petitioner appealed […] Read more

DHA Case No. MGE 207488 (Wis. Div. of Hearings and Appeals April 7, 2023) (DHS) ↓ Download PDF An appeal must be filed within 45 days of a Medicaid application denial for the Division of Hearings and Appeals to have jurisdiction. In this case, the petitioner’s denial notice was dated December 7, 2022 and identified […] Read more

DHA Case No. CWA 207563 (Wis. Div. of Hearings and Appeals April 3, 2023) (DHS) ↓ Download PDF An IRIS participant may request a budget amendment to pay for an ongoing need not met within the current budget. In this case, the petitioner asked for a budget increase when her home health agency ended her […] Read more

DHA Case No. CWA 207474 (Wis. Div. of Hearings and Appeals April 3, 2023) (DHS) ↓ Download PDF An IRIS participant may request a budget amendment to pay for an ongoing need not met within the current budget. In this case, the petitioner asked for a budget increase from $15.75 to $17/hr to pay for […] Read more

DHA Case No. MGE 207353 (Wis. Div. of Hearings and Appeals March 28, 2023) (DHS) ↓ Download PDF A member’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 that he […] Read more

DHA Case No. BCS 207395 (Wis. Div. of Hearings and Appeals March 28, 2023) (DHS) ↓ Download PDF A Notice of Proof Needed must advise the applicant of the specific verification required. In this case, the petitioner received a notice requesting proof of “TUITION: Amount of student loan or grant funds and how they are […] Read more

DHA Case No. MPA 207225 (Wis. Div. of Hearings and Appeals March 6, 2023) (DHS) ↓ Download PDF Orthodontia is normally not a covered service under Wisconsin Medicaid, but if needed by a member under age 21 it can be covered (with a prior authorization) if shown to be medically necessary. It is medically necessary if […] Read more

DHA Case No. MAC 207150 (Wis. Div. of Hearings and Appeals January 31, 2023) (DHS) ↓ Download PDF To justify an Order to Compel Payment of Liability on appeal, the agency must at least show: (1) that it sent proper notice of the initial overpayment, (2) that it provided instructions for how to make payment […] Read more