5.05 Home and Community-Based Waivers Long-Term Care

DHA Case No. MDV 199858 (Wis. Div. of Hearings and Appeals December 4, 2020) (DHS) ↓ Download PDF Divestment is a transfer of non-exempt resources for less than fair market value. This case involved two potential divestments when the petitioner’s house was sold to her daughter and daughter’s boyfriend: (1) the boyfriend was paid $40,534.37 […] Read more

DHA Case No. MDV 200210 (Wis. Div. of Hearings and Appeals January 21, 2021) (DHS) ↓ Download PDF An appeal must be filed within 45 days of an agency action for the ALJ to have jurisdiction to review it. In this case, the petitioner established an irrevocable trust, divested, and applied for Medicaid in May […] Read more

DHA Case No. MDV 201093 (Wis. Div. of Hearings and Appeals March 8, 2021) (DHS) ↓ Download PDF Using an inheritance to buy personal property for fair market value is not a divestment, but the purchases must be verified. In this case, the petitioner inherited $9,633 and claimed to have spent it on a desk, […] 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 203537 (Wis. Div. of Hearings and Appeals January 28, 2022) (DHS) ↓ Download PDF Dental implants are listed as a non-covered service under Wis. Admin. Code § DHS 107.07(4)(i). In this case, the petitioner had strong evidence that dental implant-retained dentures were medically necessary and would support her long-term care outcomes. […] Read more

DHA Case No. MDV 204093 (Wis. Div. of Hearings and Appeals March 24, 2022) (DHS) ↓ Download PDF A divestment penalty does not start until the date a Community Waivers applicant requests a waiver program, meets the functional screen criteria, and meets all other Medicaid eligibility requirements. In this case, the petitioner—represented by a lawyer—divested […] 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. MRA 205971 (Wis. Div. of Hearings and Appeals October 17, 2022) (DHS) ↓ Download PDF An ALJ may increase the Community Spouse Income Allowance (CSIA) if either spouse proves exceptional circumstances resulting in financial duress. In this case, although the community spouse had $3,858.22 of her own income, she also had monthly […] 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 206149 (Wis. Div. of Hearings and Appeals January 12, 2023) (DHS) ↓ Download PDF The Department must ensure the health and safety of IRIS participants, which it does in part by conducting in-home visits. The IRIS policy manual allows involuntary disenrollment for “health and safety risks that participants are unable or […] 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

DHA Case No. FCP 181279 (Wis. Div. of Hearings and Appeals January 22, 2018) (DHS) ↓ Download PDF The Medicaid Eligibility Handbook allows business property to be exempted—regardless of value or rate of return—if the individual is “actively involved in the business operation on a day-to-day basis.” In this case, the petitioner had a history of renting […] Read more