DHA Case No. CWA 212613 (Wis. Div. Hearings and Appeals May 30, 2024) (DHS) ↓ Download PDF IRIS participants must pay their providers a “usual and customary rate.” In this case, the petitioner’s supported employment provided asked for a rate increase to maintain a competitive wage for employees and pay for rising health insurance, mileage, […] Read more

DHA Case No. CWA 212824 (Wis. Div. Hearings and Appeals Jun. 26, 2024) (DHS) ↓ Download PDF The Department may deny an IRIS budget amendment (BA) request if it is not cost-effective or necessary to achieve the participant’s long-term care outcomes. In this case, the petitioner sought a BA to fund a 4% increase in […] Read more

DHA Case No. CWA 212682 (Wis. Div. Hearings and Appeals Jul. 12, 2024) (DHS) ↓ Download PDF Customized goods or services under the IRIS program must generally be necessary and cost-effective. In this case, the petitioner already had one trained service dog (the training was approved in a prior appeal) but wanted IRIS to pay […] Read more

DHA Case No. CWK 212876 (Wis. Div. Hearings and Appeals Jul. 15, 2024) (DHS) ↓ Download PDF The CLTS program covers home modifications that maximize a participant’s independent functioning in their home. In this case, the petitioner was an autistic child with destructive behaviors. His mother requested durable, solid-wood kitchen cabinetry because he would break […] Read more

DHA Case No. CWK 213060 (Wis. Div. Hearings and Appeals Jul. 15, 2024) (DHS) ↓ Download PDF The parent or caretaker of a CLTS participant may have respite services provided in another’s home if the length of stay is 72 hours or less, even if background checks cannot be completed on all the residents in […] Read more

DHA Case No. 212756 (Wis. Div. Hearings and Appeals Aug. 19, 2024) (DHS) ↓ Download PDF To be approved, IRIS home modifications must address long-term care needs that increase independence; or ensure safe, accessible means of ingress/egress to living quarters; or “otherwise provide safe access to rooms, facilities or equipment within the participant’s living quarters.” […] Read more

DHA Case No. CWK 213700 (Wis. Div. Hearings and Appeals Aug. 30, 2024) (DHS) ↓ Download PDF Educational services funded by the Department of Public Instruction cannot also be covered under CLTS’ “Empowerment and Self-Determination Supports” service code. In this case, the petitioner was initially approved to see a one-on-one provider for help with functional […] Read more

DHA Case No. CWA 214423 (Wis. Div. Hearings and Appeals Nov. 6, 2024) (DHS) ↓ Download PDF IRIS funds may only be used for services, supports, or goods that address a long-term support need. In this case, the petitioner asked IRIS to pay for his participant-hired worker’s travel and lodging costs so he could attend […] Read more

DHA Case No. MPA 214372 (Wis. Div. Hearings and Appeals Nov. 15, 2024) (DHS) ↓ Download PDF To approve a prior authorization request, the service must be medically necesary. In this case, the petitioner sought a prior authorization for genetic testing to rule out a certain condition. ALJ Kelly Cochrane concluded the request was properly […] Read more

DHA Case No. MDV 214223 (Wis. Div. Hearings and Appeals Nov. 27, 2024) (DHS) ↓ Download PDF A divestment penalty is generally imposed when an applicant reports a divestment and would be otherwise eligible. In this case, the petitioner originally applied in 2020 after creating an irrevocable trust, but no divestment penalty was imposed because […] Read more

DHA Case No. MDV 214942 (Wis. Div. Hearings and Appeals Nov. 20, 2024) (DHS) ↓ Download PDF The deadline to file an appeal of a denied Medicaid application is 45 days from the notice. If a separate undue harship waiver is requested, the petitioner has 20 days from the request to provide any additional proof […] Read more

DHA Case No. MGE 214870 (Wis. Div. Hearings and Appeals Nov. 19, 2024) (DHS) ↓ Download PDF One exception to the usual divestment rule is if the individual intended to dispose of the resource at fair market value. In this case, the petitioner’s husband had “invested” $275,000 in an online scam, for which the county […] Read more

DHA Case No. MGE 214773 (Wis. Div. Hearings and Appeals Nov. 1, 2024) (DHS) ↓ Download PDF The county agency is required to verify a Medicaid applicant’s income and assets, including potential divestments. In this case, the petitioner reported a $5,000 transfer to his sister for “paid bills” and his bank statements showed withdrawals of […] Read more

DHA Case No. FCP 212977 (Wis. Div. Hearings and Appeals May 13, 2024) (DHS) ↓ Download PDF When an MCO seeks to reduce services, it has the burden of proof to show the need for the change. In this case, Inclusa sought to restrict the petitioner’s non-medical transportation to see movies in the community to […] Read more