DHA Case No. FCP 189985 (Wis. Div. of Hearings and Appeals January 14, 2019) (DHS) ↓ Download PDF MCOs must consider an MA recipient’s income when determining benefits. In this case, the petitioner’s MCO reduced his out-of-benefit food budget when he started working, reasoning he could contribute that towards the cost of his food. ALJ […] Read more

DHA Case No. FCP 189984 (Wis. Div. of Hearings and Appeals January 14, 2019) (DHS) ↓ Download PDF MCOs must consider an MA recipient’s income when determining benefits. In this case, the petitioner’s MCO reduced his out-of-benefit food budget when he started receiving the state supplemental SSI payment, reasoning he could contribute that towards the […] Read more

DHA Case No. MPA 208352 (Wis. Div. of Hearings and Appeals July 11, 2023) (DHS) ↓ Download PDF DHA Case No. MPA 208353 (Wis. Div. of Hearings and Appeals July 11, 2023) (DHS) ↓ Download PDF To be covered under Medicaid, a service must be medically necessary and cost-effective. In this case, the petitioner requested […] Read more

DHA Case No. CWK 208407 (Wis. Div. of Hearings and Appeals July 10, 2023) (DHS) ↓ Download PDF The Children’s Long-Term Support (CLTS) Waiver Program can cover relocation services for a participant’s “relocation to a safe and accessible community living arrangement.” In this case, the participant’s apartment was not accessible, forcing her to crawl around […] Read more

DHA Case No. BCS 207937 (Wis. Div. of Hearings and Appeals June 6, 2023) (DHS) ↓ Download PDF An applicant for BadgerCare Plus must provide his or her Social Security number. In this case, the petitioner applied but failed to provide it. The agency properly issued the request for proof and mailed it to the […] Read more

DHA Case No. FCP 208424 (Wis. Div. of Hearings and Appeals July 10, 2023) (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 him functionally ineligible because […] Read more

DHA Case No. MQB 207807 (Wis. Div. of Hearings and Appeals July 7, 2023) (DHS) ↓ Download PDF QMB benefits cannot normally be backdated (compare MQB 207494), but an ALJ can order backdating following a fair hearing. In this case, the Social Security Administration conceded that its own error caused a 3-month delay in verification […] Read more

DHA Case No. FCP 206264 (Wis. Div. of Hearings and Appeals January 11, 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. When the MCO seeks to change that plan and reduce services, it has the burden of […] Read more

DHA Case No. FCP 207870 (Wis. Div. of Hearings and Appeals May 19, 2023) (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. In this case, the petitioner applied January 25, the application was processed February […] 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. 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. 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. 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. MDD 207161 (Wis. Div. of Hearings and Appeals March 27, 2023) (DHS) ↓ Download PDF A disability determination for the MAPP does not involve the usual “substantial gainful activity” test, but that is only the first step in a 5-step analysis that often comes down to “residual functional capacity” to perform different […] Read more