DHA Case No. FCP 163632 (Wis. Div. of Hearings and Appeals April 13, 2015) (DHS) ↓ Download PDF Family Care benefits generally cannot be backdated, except that retroactive enrollment can be ordered by an ALJ to correct delay caused by agency error. This is an early case where the agency delayed sending a request for […] Read more

DHA Case No. FCP 176566 (Wis. Div. of Hearings and Appeals December 28, 2016) (DHS) ↓ Download PDF Family Care eligibility generally cannot be backdated, but retroactive enrollment can be ordered by an ALJ to correct delay caused by agency error. In this case, the petitioner’s enrollment in Family Care was delayed because the ADRC took […] Read more

DHA Case No. FCP 196128 (Wis. Div. of Hearings and Appeals January 2, 2020) (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’s functional screen found her functionally ineligible because […] Read more

DHA Case No. MGE 197359 (Wis. Div. of Hearings and Appeals March 4, 2020) (DHS) ↓ Download PDF A community spouse must sign the Medicaid application and verify his or her assets unless a denial would result in undue hardship. In this case, the petitioner moved to a separate home from his wife in the […] Read more

DHA Case No. FCP 197394 (Wis. Div. of Hearings and Appeals March 9, 2020) (DHS) ↓ Download PDF Benefits cannot be denied for lack of verification unless the member had adequate notice and the ability to produce the required verification. In this case, the petitioner, an incapacitated woman with dementia, moved to a CBRF. The […] Read more

DHA Case No. MGE 198010 (Wis. Div. of Hearings and Appeals March 27, 2020) (DHS) ↓ Download PDF When a member disenrolls from a managed long-term care program, DHS’s policy is to automatically test for eligibility for non-waivers programs. In this case, the petitioner voluntarily disenrolled from Family Care after moving to a nursing home […] Read more

DHA Case No. MDV 198638 (Wis. Div. of Hearings and Appeals June 29, 2020) (DHS) ↓ Download PDF A divestment penalty for a Medicaid applicant begins on the date the person applies and is “otherwise eligible” but for the divestment; it begins for a member the first of the month after the member receives timely notice. In this case, […] Read more

DHA Case No. FCP 177944 (Wis. Div. of Hearings and Appeals December 13, 2016) (DHS) ↓ Download PDF It is a divestment when a life estate is terminated and the life estate holder is not paid her proportional share. In this case, the petitioner’s life estate was divested when she sold her home and her […] Read more

DHA Case No. MGE 202884 (Wis. Div. of Hearings and Appeals November 2, 2021) (DHS) ↓ Download PDF In a spousal impoverishment case, the most valuable vehicle is exempted and all others are counted. In this case, the petitioner’s attorney argued (among other things) that he could elect to exempt the least valuable vehicle for the asset […] Read more

DHA Case No. MDD 203616 (Wis. Div. of Hearings and Appeals January 19, 2022) (DHS) ↓ Download PDF Even if a person cannot engage in any substantial gainful activity, he must still pass a 5-step test to be determined disabled. If he can perform work he has done in the past, Step 4 requires a […] Read more

DHA Case No. FCP 205395 (Wis. Div. of Hearings and Appeals August 16, 2022) (DHS) ↓ Download PDF If agency error causes an unreasonable delay in an individual’s enrollment in Family Care, DHS may backdate enrollment. In this case, the petitioner applied for Community Waivers for both spouses on April 20, but enrollment did not […] Read more

DHA Case No. FCP 206406 (Wis. Div. of Hearings and Appeals November 22, 2022) (DHS) ↓ Download PDF The Family Care Contract prohibits an MCO from denying services that are “reasonable and necessary to cost-effectively support the member’s long term care outcomes …”. In this case, the petitioner asked for a home modification: stairs to […] Read more

DHA Case No. FCP 206000 (Wis. Div. of Hearings and Appeals October 28, 2022) (DHS) ↓ Download PDF To be functionally eligible for Family Care, a person must fall into one of the program’s target groups in addition to needing a nursing home level of care. In this case, the petitioner was 44 and diagnosed […] Read more

DHA Case No. CWA 206378 (Wis. Div. of Hearings and Appeals December 5, 2022) (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. This level of care includes those who cannot safely or appropriately perform […] Read more