DHA Case No. HMO 210862 (Wis. Div. of Hearings and Appeals January 10, 2024) (DHS) ↓ Download PDF Although orthodontia is not usually covered by MA, it must be covered for recipients under age 21 if the Early and Periodic Screening, Diagnosis and Treatment (EPSDT) health assessment and evaluation indicates that it is medically necessary. […] Read more

DHA Case No. FCP 211038 (Wis. Div. of Hearings and Appeals January 31, 2024) (DHS) ↓ Download PDF When an MCO seeks to reduce a member’s supportive home care budget, it has the burden of proof. In this case, the petitioner’s MCO sought to reduce his budget because his son reported some minor improvements. ALJ […] Read more

DHA Case No. SSO 206537 (Wis. Div. of Hearings and Appeals January 18, 2023) (DHS) ↓ Download PDF In a fair hearing on an overpayment determination, the agency has the burden of proof. In this case, the petitioner lived in her car and drove to Arizona for the winter. She continued to receive federal SSI […] Read more

DHA Case No. MGE 210257 (Wis. Div. of Hearings and Appeals December 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 deadline to appeal the initial denial of the Medicaid application […] Read more

DHA Case No. MGE 210600 (Wis. Div. of Hearings and Appeals December 22, 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 CSIA was increased in […] Read more

DHA Case No. MLL 210337 (Wis. Div. of Hearings and Appeals December 11, 2023) (DHS) ↓ Download PDF One way to get an undue hardship waiver of estate recovery is to show that the decedent’s real property is used as part of the waiver applicant’s business and recovery would take away the applicant’s livelihood. In […] Read more

DHA Case No. FCP 192893 (Wis. Div. of Hearings and Appeals November 5, 2019) (DHS) ↓ Download PDF An ALJ may issue a proposed decision asking the DHS Secretary to backdate enrollment in Family Care if the normal enrollment date was unnecessarily delayed by either the ADRC or Income Maintenance. In this case, both the […] Read more

DHA Case No. FCP 206604 (Wis. Div. of Hearings and Appeals January 5, 2023) (DHS) ↓ Download PDF Family Care members in Group A (due to eligibility for MAPP, for example) do not have a cost share. In this complex case, the petitioner lost MAPP eligibility when her child turned 18 and her fiscal test […] Read more

DHA Case No. CWK 208175 (Wis. Div. of Hearings and Appeals June 13, 2023) (DHS) ↓ Download PDF DHA Case No. CWK 208176 (Wis. Div. of Hearings and Appeals June 13, 2023) (DHS) ↓ Download PDF Two services that may be provided under the Children’s Long-Term Support (CLTS) Waiver Program are respite care and child […] Read more

DHA Case No. MNP 208124 (Wis. Div. of Hearings and Appeals June 6, 2023) (DHS) ↓ Download PDF Emergency Medicaid covers treatment for emergency medical conditions given to non-citizens. An emergency medical condition requires “acute” symptoms severe enough to put the person’s health in “serious” jeopardy. In this case, the petitioner was denied coverage for […] Read more

DHA Case No. CWA 208070 (Wis. Div. of Hearings and Appeals June 6, 2023) (DHS) ↓ Download PDF Home and community-based waiver programs may cover “other services … as cost effective and necessary to avoid institutionalization.” In this case, the IRIS program paid the petitioner’s internet under the “other services” authorization since 2019 but stopped […] Read more

DHA Case No. MDD 208783 (Wis. Div. of Hearings and Appeals August 15, 2023) (DHS) ↓ Download PDF In making a disability determination, the Disability Determination Bureau (DDB) applies a 5-step test. Step 5 considers whether the individual can adjust to types of work the individual has not performed in the past, considering his or […] Read more

DHA Case No. FCP 207586 (Wis. Div. of Hearings and Appeals July 20, 2023) (DHS) ↓ Download PDF MCOs in the Family Care program may authorize residential services—such as placement in an Adult Family Home (AFH)—only if they are the most cost-effective option, if they are needed to support the member’s long-term care outcomes, or […] Read more

DHA Case No. MKB 207607 (Wis. Div. of Hearings and Appeals April 28, 2023) (DHS) ↓ Download PDF To qualify for the Katie Beckett Medicaid program, a child must meet the Social Security standards for childhood disability, which requires “a disabling impairment … that causes marked and severe functional limitations.” In this case, the child […] Read more