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

DHA Case No. MPA 206828 (Wis. Div. of Hearings and Appeals January 23, 2023) (DHS) ↓ Download PDF Medicaid can cover durable medical equipment if it is medically necessary, a determination that includes cost-effectiveness. In this case, the petitioner—a 4-year-old with a genetic disorder who was “unable to understand safety, cause and effect, risk, or […] Read more

DHA Case No. MAC 206913 (Wis. Div. of Hearings and Appeals January 31, 2023) (DHS) ↓ Download PDF An Order to Compel Payment cannot be issued until the recipient has had sufficient notice of the overpayment, notice of appeal rights, and a chance to enter into a repayment agreement. In this case, the agency had […] Read more

DHA Case No. FCP 207491 (Wis. Div. of Hearings and Appeals May 9, 2023) (DHS) ↓ Download PDF A Family Care MCO’s member-centered plan must assess and identify “long-term care outcomes that are consistent with the values and preference of the enrollee” in the areas of both “self-determination of daily routine, services, activities and living […] Read more

DHA Case No. BCS 207395 (Wis. Div. of Hearings and Appeals March 28, 2023) (DHS) ↓ Download PDF A Notice of Proof Needed must advise the applicant of the specific verification required. In this case, the petitioner received a notice requesting proof of “TUITION: Amount of student loan or grant funds and how they are […] Read more

DHA Case No. BCS 207323 (Wis. Div. of Hearings and Appeals March 15, 2023) (DHS) ↓ Download PDF BadgerCare Plus benefits can be backdated up to three months if the petitioner meets all eligibility requirements in those months. In this case, the petitioner requested backdating but his tax documents did not list any business expenses, […] Read more

DHA Case No. FCP 197060 (Wis. Div. of Hearings and Appeals February 10, 2020) (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. MGE 198010 (Wis. Div. of Hearings and Appeals March 27, 2020) (DHS) ↓ Download PDF When a member disenrolls from a managed long-term care program, DHS’s policy is to automatically test for eligibility for non-waivers programs. In this case, the petitioner voluntarily disenrolled from Family Care after moving to a nursing home […] Read more

DHA Case No. MOP 200346 (Wis. Div. of Hearings and Appeals February 10, 2021) (DHS) ↓ Download PDF In an overpayment hearing, the agency has the burden to prove, by the preponderance of the evidence, both that the petitioner failed to provide accurate or complete information and that the petitioner was not eligible during the […] 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 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