DHA Case No. FCP 208209 (Wis. Div. of Hearings and Appeals May 31, 2023) (DHS) ↓ Download PDF In the Family Care program, the MCO must develop an Individual Service Plan with the client that addresses the client’s needs while being cost-effective. The MCO does not have to provide a service if there are less […] Read more
4.2 Benefits
DHA Case No. CWA 207516 (Wis. Div. of Hearings and Appeals May 18, 2023) (DHS) ↓ Download PDF An IRIS participant may request a budget amendment to pay for an ongoing need not met within the current budget. In this case, the petitioner asked for a budget increase when her home health agency ended her […] 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. FCP 207518 (Wis. Div. of Hearings and Appeals April 19, 2023) (DHS) ↓ Download PDF Assisted living is a possible residential choice in the Family Care program, but it generally must be cost-effective in addressing the member’s individual service plan. In this case, the petitioner—a 61-year-old woman with autism, anxiety, PTSD, vertigo, […] Read more
DHA Case No. CWA 207522 (Wis. Div. of Hearings and Appeals April 18, 2023) (DHS) ↓ Download PDF An IRIS participant may request a budget amendment to pay for an ongoing need not met within the current budget. In this case, the petitioner asked for a budget increase when her home health agency ended her […] Read more
DHA Case No. CWA 207408 (Wis. Div. of Hearings and Appeals April 17, 2023) (DHS) ↓ Download PDF To cover a service dog, IRIS policy requires that it be “individually trained by a reputable provider experienced in providing structured training for service dogs to do work or perform tasks for the participant that are directly […] Read more
DHA Case No. CWA 207563 (Wis. Div. of Hearings and Appeals April 3, 2023) (DHS) ↓ Download PDF An IRIS participant may request a budget amendment to pay for an ongoing need not met within the current budget. In this case, the petitioner asked for a budget increase when her home health agency ended her […] Read more
DHA Case No. CWA 207474 (Wis. Div. of Hearings and Appeals April 3, 2023) (DHS) ↓ Download PDF An IRIS participant may request a budget amendment to pay for an ongoing need not met within the current budget. In this case, the petitioner asked for a budget increase from $15.75 to $17/hr to pay for […] Read more
DHA Case No. MPA 207225 (Wis. Div. of Hearings and Appeals March 6, 2023) (DHS) ↓ Download PDF Orthodontia is normally not a covered service under Wisconsin Medicaid, but if needed by a member under age 21 it can be covered (with a prior authorization) if shown to be medically necessary. It is medically necessary if […] Read more
DHA Case No. MPA 207141 (Wis. Div. of Hearings and Appeals February 24, 2023) (DHS) ↓ Download PDF To determine the number of personal care worker (PCW) hours it will approve, the Department uses the Personal Care Screening Tool, which can then be adjusted. In this case, the petitioner, an 81-year-old woman with a history […] Read more
DHA Case No. CWA 207110 (Wis. Div. of Hearings and Appeals March 29, 2023) (DHS) ↓ Download PDF The IRIS program can pay for equine therapy, according to the participant’s needs. In this case, the petitioner was approved for three months of twice-weekly equine therapy, which proved effective, but her subsequent request to continue the […] Read more
DHA Case No. CWA 207083 (Wis. Div. of Hearings and Appeals April 5, 2023) (DHS) ↓ Download PDF When the agency reduces supportive home care (SHC) hours and the member appeals, the burden of proof is on the agency to justify the reduction. In this case, the agency reduced SHC hours after a supplemental functional […] Read more
DHA Case No. CWK 206852 (Wis. Div. of Hearings and Appeals January 10, 2023) (DHS) ↓ Download PDF Vehicle modifications are allowed as a benefit of the Children’s Long-Term Support program, but they must “meet all applicable standards of manufacture, safety, design, and installation.” In this case, the petitioner’s mother asked for a modification to […] Read more
DHA Case No. CWA 202841 (Wis. Div. of Hearings and Appeals January 5, 2022) (DHS) ↓ Download PDF An IRIS participant may request a budget amendment to pay for an ongoing need not met within the current budget. In this case, the petitioner asked for a budget increase from $15 to $17/hr to pay for […] Read more
DHA Case No. CWA 202831 (Wis. Div. of Hearings and Appeals November 29, 2021) (DHS) ↓ Download PDF An IRIS participant must use up private duty nursing (PDN) hours before using supportive home care (SHC) or companion care hours. In this case, the petitioner was found eligible for 24/7 PDN services; her supportive home care […] Read more