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 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. MRA 208459 (Wis. Div. of Hearings and Appeals June 29, 2023) (DHS) ↓ Download PDF An ALJ may increase the community spouse income allocation (CSIA) if the community spouse does not have enough income to pay his or her “necessary and basic maintenance needs.” In this case, the community spouse had income […] 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 203793 (Wis. Div. of Hearings and Appeals December 23, 2021) (DHS) ↓ Download PDF Income is not counted as a resource in the month it is received. In this case, the petitioner had income of $3,660.10, but his checking account balance at the end of the month was only $983.80. The […] 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. MPA 207077 (Wis. Div. of Hearings and Appeals January 27, 2023) (DHS) ↓ Download PDF Personal care services under Medicaid must be medically necessary and cost-effective. In this case, the petitioner asked for 19.5 Personal Care Worker (PCW) hours per week but was only approved for 10.25. ALJ Brian Schneider upheld the […] Read more

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. 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 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. 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. BCS 207290 (Wis. Div. of Hearings and Appeals February 10, 2023) (DHS) ↓ Download PDF An applicant must be a U.S. citizen or qualifying lawful immigrant to be eligible for Medicaid. In this case, the petitioner applied for MA and was initially approved, but Homeland Security soon notified the agency that the […] Read more

DHA Case No. MDV 207202 (Wis. Div. of Hearings and Appeals February 23, 2023) (DHS) ↓ Download PDF A transfer for less than fair market value is a divestment, and payments to relatives often also need a notarized contract or lease. In this case, the petitioner’s son and POA used the proceeds from selling her […] Read more