DHA Case No. FCP 207851 (Wis. Div. of Hearings and Appeals August 31, 2023) (DHS) ↓ Download PDF An MCO must determine whether a requested service is medically necessary and cost-effective. But in this case, the petitioner’s mother and guardian refused to cooperate with the MCO’s attempts to get the information it needed to make […] Read more

DHA Case No. CWA 208804 (Wis. Div. of Hearings and Appeals September 8, 2023) (DHS) ↓ Download PDF The Medicaid Eligibility Handbook counts some income even though it is unavailable—garnishments, for example. In this case, the petitioner had $300 garnished monthly for a tax debt but his patient liability was not reduced to compensate. ALJ John Tedesco […] Read more

DHA Case No. CWA 208193 (Wis. Div. of Hearings and Appeals October 2, 2023) (DHS) ↓ Download PDF When DHS increases a member’s cost share, it has the burden of proof on appeal. In this rather messy case, it was clear that the cost share should have been lower but it was not clear whose […] Read more

DHA Case No. MDD 207614 (Wis. Div. of Hearings and Appeals April 24, 2023) (DHS) ↓ Download PDF To be eligible for the MAPP program, the applicant must meet the SSI definition of disability. This disability determination considers the applicant’s functional capacity to do various kinds of work. In this case, the applicant was 30 […] 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. MQB 207494 (Wis. Div. of Hearings and Appeals May 1, 2023) (DHS) ↓ Download PDF For the Qualified Medicare Beneficiary (QMB) program, benefits cannot begin until the month after the application is processed. In this straightforward case, the petitioner applied but did not complete verification until November 14. ALJ John Tedesco concluded […] Read more

DHA Case No. MDD 206834 (Wis. Div. of Hearings and Appeals March 28, 2023) (DHS) ↓ Download PDF To be eligible for MAPP, an applicant must meet the SSI definition of disability. In this case, the petitioner was a 64-year-old woman with a high school diploma; diagnoses including Bipolar Disorder, ADHD, PTSD, torn rotator cuff, […] Read more

DHA Case No. MGE 166562 (Wis. Div. of Hearings and Appeals August 21, 2015) (DHS) ↓ Download PDF In general, an irrevocable trust established by either spouse is a countable, available asset if there are any circumstances under which the applicant could receive money from the trust. But this policy does not apply to a […] Read more

DHA Case No. MGE 197217 (Wis. Div. of Hearings and Appeals May 21, 2020) (DHS) ↓ Download PDF The usual maximum for the Community Spouse Income Allocation (CSIA) can be increased by an ALJ if needed to pay for “necessary and basic” expenses. In this case, ALJ John Tedesco increased the CSIA to $4,078, largely […] Read more

DHA Case No. CWA 198273 (Wis. Div. of Hearings and Appeals August 3, 2020) (DHS) ↓ Download PDF This brief decision is a straightforward application of the name-on-the-check rule. A Medicaid-compliant annuity that pays only to the community spouse is not income available to the insititutionalized spouse. Preliminary Recitals Pursuant to a petition filed on […] Read more

DHA Case No. MDV 183502 (Wis. Div. of Hearings and Appeals December 6, 2017) (DHS) ↓ Download PDF Adivestment occurs upon the transfer of a non-exempt resource for less than fair market value. In this simple case, the petitioner sold the home in which she had a life estate and paid a prorated portion of […] Read more

DHA Case No. MOP 204371 (Wis. Div. of Hearings and Appeals May 2, 2022) (DHS) ↓ Download PDF A person must be a resident of Wisconsin to receive Medicaid benefits, and residency ends if another state determines the person to be a resident for its own Medicaid programs. In this case, the petitioner applied for […] Read more

DHA Case No. MGE 185074 (Wis. Div. Hearings and Appeals March 14, 2018) (DHS)  ↓ Download PDF In this straightforward decision, the petitioner owned home property in Michigan but was admitted to a Wisconsin nursing home. Her Medicaid application was denied because the agency “did not receive timely verification of any circumstance that would exempt […] Read more