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State of Wisconsin |
HISTORY |
The policy on this page is from a previous version of the handbook.
For Medicaid, the applicant, member, or representative may request a fair hearing in writing by filling out the Request for Fair Hearing form or writing a letter with the request and sending it to the Division of Hearings and Appeals (DHA).
Division of Hearings and Appeals
P.O. Box 7875
Madison, WI 53707-7875
Fax (608) 264-9885
Email: DHAMail@wisconsin.gov
DHA will schedule a hearing upon receipt of the hearing request. DHA has jurisdiction to conduct hearings for Medicaid if the request is received by DHA within 45 days of the action effective date. DHA may dismiss a request if the action being appealed is a result of a change in federal or state law or policy affecting a significant number of members, unless the member questions its application specific to their case. When a hearing request is dismissed, DHA will notify the applicant or member.
A hearing request from an applicant or member who plans to move from Wisconsin before a decision would normally be issued, such as a migrant worker, will be expedited so the applicant or member can receive a decision and any restored benefits before they leave the state.
A group of individuals may request a group hearing if individual issues of fact are not disputed, and the sole issue being appealed is a state or federal law or policy. DHA may also consolidate several hearings on the same topic into one, but only on questions of policy. Procedures for group hearings are the same as in individual hearings. Each applicant or member must be notified of the right to withdraw from a group hearing and pursue an individual hearing.
At least 10 days prior to the hearing, DHA sends a Notice of Scheduled Hearing to the applicant or member, their representative, or both. This allows the applicant or member 10 days to prepare for the hearing. The applicant or member may request less advance notice to expedite scheduling the hearing.
The notice states that:
DHA may order a member’s Medicaid benefits to continue while a decision on the hearing is pending. The IM agency must comply with DHA's initial order until otherwise notified or the member waives this continuation of benefits. The IM agency must inform members that they may have to pay back any continued benefits received if they lose the hearing decision and of their right to waive continued benefits.
DHA can reverse its continuance order only when the hearing was not requested prior to the action's effective date. If DHA does not order benefits reinstated and the agency believes that the member is entitled to them, the agency must notify DHA.
Once benefit continuation has begun, the IM agency must maintain those benefits until DHA orders a change or some other change in eligibility occurs.
DHA must conduct the hearing and issue its decision and the IM agency must implement the decision within 90 days of the date DHA receives the hearing request.
When a decision is favorable to the applicant or member, the IM agency must carry out the decision’s orders within 10 days of the order or 90 days of the date DHA receives the hearing request, whichever comes first.
When the decision is not favorable to the applicant or member, the decision notice is the final notice for the case, with the exception of overpayment notices. No further timely or adequate notice requirement applies for the issue that was appealed. Medicaid benefits will be discontinued or reduced immediately.
The DHA decision includes a description for the applicant or member of their right to rehearing, judicial review, or both. It is not necessary to request a rehearing before going to circuit court.
If an agency's adverse action is upheld, or the fair hearing is withdrawn or is abandoned, any overpayments caused by benefits having been continued may be subject to recovery based on the overpayment policies in SECTION 22.2.2 OVERPAYMENT CALCULATION.
This page last updated in Release Number: 22-02
Release Date: 08/01/2022
Effective Date: 08/01/2022
The information concerning the Medicaid program provided in this handbook release is published in accordance with: Titles XI and XIX of the Social Security Act; Parts 430 through 481 of Title 42 of the Code of Federal Regulations; Chapters 46 and 49 of the Wisconsin Statutes; and Chapters HA 3, DHS 2, 10 and 101 through 109 of the Wisconsin Administrative Code.
Notice: The content within this manual is the sole responsibility of the State of Wisconsin's Department of Health Services (DHS). This site will link to sites outside of DHS where appropriate. DHS is in no way responsible for the content of sites outside of DHS.
Publication Number: P-10030