• Eligibility Categories
  • Introduction
  • Medicaid Recipients
  • BadgerCare Recipients
  • Wisconsin Well Woman Medicaid
  • Limited Benefit Categories
    • Introduction
    • Family Planning Waiver Program
    • Presumptive Eligibility for Pregnant Women Benefit
    • Tuberculosis-Related Services-Only Benefit
    • Qualified Medicare Beneficiary-Only Recipients
    • Specified Low Income Medicare Beneficiaries
    • Qualifying Individual 1 Recipients
    • Qualified Disabled Working Individual Recipients
• Medicaid Identification Cards
  • Introduction
  • Forward Cards
    • Introduction
    • Forward Card Features
    • Identification Number Changes
    • Recipient Name Changes
    • Deactivated Cards
    • Defective Cards
    • Lost Cards
    • Managed Care Organization Enrollment Changes
  • Temporary Medicaid Cards
  • Presumptive Eligibility for Pregnant Women Temporary Cards
  • Presumptive Eligibility for the Family Planning Waiver Program Temporary Cards
• Eligibility Verification Methods
  • Introduction
  • 270/271 Transactions
  • Automated Voice Response System
    • Introduction
    • Dates of Services
    • Hours
  • Commercial Eligibility Verification Vendors
    • Introduction
    • Magnetic Stripe Card Readers
    • Personal Computer Software
    • Internet Access
  • Provider Services
    • Introduction
    • Hours
  • Recipient Forgets Identification Card
• Eligibility Rights
  • Introduction
  • Prompt Decisions on Eligibility
  • Requesting Retroactive Eligibility
  • Appealing Eligibility Determinations
    • Introduction
    • Claims for Appeal Reversals
  • Freedom of Choice
  • Notification of Discontinued Benefits
• Eligibility Responsibilities
  • Introduction
  • Prior Identification of Eligibility
  • Loss of Medicaid Eligibility — Financial Liability
  • Reporting Changes to Caseworkers
• Copayment Requirements
  • Introduction
  • Copayment Exemptions
  • Copayment Amounts
  • Copayment Limitations
  • Copayment Refund/Collection Requirement
• Special Eligibility Circumstances
  • Retroactive Eligibility
    • Introduction
    • Reimbursing Recipients in Cases of Retroactive Eligibility
  • Spenddown to Meet Medicaid Financial Eligibility Requirements
  • Persons Detained by Legal Process
  • Recipients Traveling Out of State
  • Non-U.S. Citizens — Emergency Services
  • Medicaid Recipients from Other States
• Misuse and Abuse of Benefits
  • Introduction
  • Examples of Misuse and Abuse
  • Requesting Additional Proof of Identity
  • Notifying Wisconsin Medicaid
  • Providers May Refuse to Provide Services
  • Recipient Lock-In Program
    • Introduction
    • Providers May Make Referrals
• Appendix
  • Appendix 1 — Limited Benefit Categories
  • Appendix 2 — Quick-Entry Guide for the Automated Voice Response System
  • Appendix 3 — Eligibility Verification Vendors
  • Appendix 4 — Certification of Emergency for Non-U.S. Citizens Form Completion Instructions
  • Appendix 5 — Certification of Emergency for Non-U.S. Citizens
• PDF

Select a section » Certification and Ongoing Responsibilities Claims Information Coordination of Benefits Covered and Noncovered Services Informational Resources Managed Care Prior Authorization Recipient Eligibility

 

 

Recipient Eligibility

Eligibility Rights

Appealing Eligibility Determinations

Applicants and recipients have the right to appeal certain decisions relating to Medicaid eligibility. An applicant for Wisconsin Medicaid, a Medicaid recipient, or authorized person acting on behalf of the applicant or recipient, or former recipient may file the appeal with the Division of Hearings and Appeals (DHA).

Pursuant to HA 3.03, Wis. Admin. Code, an applicant, recipient, or former recipient may appeal any adverse action or decision by an agency or department which affects their benefits. Examples of decisions that may be appealed include, but are not limited to, the following:

• Individual was denied the right to apply.
• Application for Wisconsin Medicaid was denied.
• Application for Wisconsin Medicaid was not acted upon promptly.
• Eligibility was unfairly discontinued, terminated, suspended, or reduced.

In the case when Medicaid eligibility is cancelled or terminated, the date the recipient, or authorized person acting on behalf of the recipient, files an appeal with the DHA determines what continuing coverage, if any, the recipient will receive until the hearing decision is made. The following scenarios describe the coverage allowed for a recipient who files an appeal:

• If a recipient files an appeal before his or her eligibility ends, Medicaid coverage will continue pending the hearing decision.
• If a recipient files an appeal within 45 days after his or her eligibility ends, a hearing is allowed but Medicaid coverage is not reinstated.

If the recipient files an appeal more than 45 days after his or her eligibility ends, a hearing is not allowed.

Recipients may file an appeal by submitting a Request for Fair Hearing form, DHA-28, which is available on the Forms page of the Recipient section of the Medicaid Web site.

Next — Eligibility Rights, Appealing Eligibility Determinations, Claims for Appeals Reversals
Previous — Eligibility Rights, Requesting Retroactive Eligibility