DHA Case No. CWA 205245 (Wis. Div. of Hearings and Appeals September 12, 2022) (DHS) ↓ Download PDF IRIS participants may hire their own workers to provide supportive home care (SHC). The participant is responsible for negotiating “reasonable and customary rates” with providers. In this case, the petitioner asked to increase her worker’s hourly rate […] Read more

DHA Case No. CWK 209490 (Wis. Div. of Hearings and Appeals September 15, 2023) (DHS) ↓ Download PDF The CLTS program can cover “Health and Wellness” services to maintain or improve the health, well being, socialization, or inclusion of the participant with family and peers in the community. But these services must not be duplicative […] Read more

DHA Case No. CWK 207740 (Wis. Div. of Hearings and Appeals June 9, 2023) (DHS) ↓ Download PDF One of the benefits of the Children’s Long-Term Support program is access to a Support and Service Coordinator (SSC); DHS’s Participant Rights and Responsibilities notice even says, “You have a right to meet with this person as […] Read more

DHA Case No. MGE 207256 (Wis. Div. of Hearings and Appeals April 12, 2023) (DHS) ↓ Download PDF Medicaid applicants are required to verify all countable assets. In this case, the petitioner’s application for MA noted that her spouse sold shares of stock in June and July of 2022. She failed to provide verification of […] Read more

DHA Case No. FCP 206978 (Wis. Div. of Hearings and Appeals April 7, 2023) (DHS) ↓ Download PDF In the Family Care program, the MCO must develop an Individual Service Plan (ISP) that reasonably and effectively addresses the enrollee’s long-term care needs and outcomes and is cost-effective. In this case, Community Care ended the petitioner’s […] Read more

DHA Case No. FCP 203910 (Wis. Div. of Hearings and Appeals March 23, 2023) (DHS) ↓ Download PDF If payments to a relative for services exceed 10% of the maximum CSAS, the MEH requires a notarized agreement. In this case, the petitioner had an agreement to pay her daughters $500 per month, but it was […] Read more

DHA Case No. FCP 189482 (Wis. Div. of Hearings and Appeals February 27, 2019) (DHS) ↓ Download PDF To be covered under Family Care, a service must be cost-effective. In this case, the MCO denied the petitioner’s request to install an ADA-height elongated toilet in his rented apartment, saying there were less costly alternatives. ALJ […] Read more

DHA Case No. FCP 189820 (Wis. Div. of Hearings and Appeals February 6, 2019) (DHS) ↓ Download PDF To be covered under Family Care, a service must be medically necessary. In this case, the petitioner’s request for acupuncture therapy was denied because it had been tried and proved ineffective for her in the past. ALJ […] Read more

DHA Case No. CWA 189840 (Wis. Div. of Hearings and Appeals January 24, 2019) (DHS) ↓ Download PDF IRIS can pay for a participant-hired worker to attend a conference as a “Community Integration Event” if the participant is also attending. In this case, the petitioner’s mother attended a Fragile X conference alone; she apparently was […] Read more

DHA Case No. FCP 189985 (Wis. Div. of Hearings and Appeals January 14, 2019) (DHS) ↓ Download PDF MCOs must consider an MA recipient’s income when determining benefits. In this case, the petitioner’s MCO reduced his out-of-benefit food budget when he started working, reasoning he could contribute that towards the cost of his food. ALJ […] Read more

DHA Case No. FCP 189984 (Wis. Div. of Hearings and Appeals January 14, 2019) (DHS) ↓ Download PDF MCOs must consider an MA recipient’s income when determining benefits. In this case, the petitioner’s MCO reduced his out-of-benefit food budget when he started receiving the state supplemental SSI payment, reasoning he could contribute that towards the […] Read more

DHA Case No. FCP 189662 (Wis. Div. of Hearings and Appeals January 14, 2019) (DHS) ↓ Download PDF An individual is functionally eligible for Family Care if he or she needs a “nursing home” level of care, as determined by the functional screen. In this case, the petitioner was enrolled in Family Care and receiving […] Read more

DHA Case No. CWA 189467 (Wis. Div. of Hearings and Appeals January 3, 2019) (DHS) ↓ Download PDF The IRIS program cannot cover nursing services that are already covered by the state Medicaid plan. In this case, the petitioner’s IRIS supportive home care (SHC) hours were reduced from 96 hours per week to 40 hours […] Read more

DHA Case No. MOP 190168 (Wis. Div. of Hearings and Appeals January 11, 2019) (DHS) ↓ Download PDF When a Medicaid recipient fails to report a change in income or assets that would affect eligibility, an overpayment results. In this case, the petitioner was a 92-year-old woman receiving community waivers and healthcare benefits, and it […] Read more