State of Wisconsin Department of Health Services

HISTORY

The policy on this page is from a previous version of the handbook. 

21-03 Version of 29.2 Fair Hearings

Applicants and members have the right to a fair hearing, timely case decisions, and accurate notices of decision.  

29.2.1 Fair Hearing Request

For BadgerCare Plus and FPOS, 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 BadgerCare Plus and FPOS 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, 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.

29.2.2 Prior to the Hearing

At least 10 days prior to the hearing, DHA sends a Notice of Scheduled Hearing to the applicant, member, and/or representative. 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:

1. DHA will dismiss the request if the applicant, member, or any representative fails to appear without good cause,
2. The name, address, and phone number of whom to notify if the applicant, member, or representative cannot attend, and
3. The applicant or member and any representative may examine the case record prior to the hearing.

29.2.3 Continued Benefits

DHA may order a member’s BadgerCare Plus or FPOS 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.  

29.2.4 Time Limits

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 and/or adequate notice requirement applies for the issue that was appealed. BadgerCare Plus or FPOS benefits will be discontinued or reduced immediately. 

The DHA decision includes a description for the applicant or member of their right to rehearing and/or judicial review. It is not necessary to request a rehearing before going to circuit court.

29.2.5 Recoupment

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 28.4 Overpayment Calculation.
 

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The information concerning the BadgerCare Plus program provided in this handbook release is published in accordance with: Titles XI, XIX and XXI of the Social Security Act; Parts 430 through 481 of Title 42 of the Code of Federal Regulations; Chapter 49 of the Wisconsin Statutes; and Chapters HA 3, DHS 2 and 101 through 109 of the Wisconsin Administrative Code.

Publication Number: P-10171