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. 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. 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. 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 215065 (Wis. Div. Hearings and Appeals Nov. 1, 2024) (DHS) ↓ Download PDF For a single person, up to $1,500 can be exempted as a “burial fund” to the extent other exempt burial assets (burial trusts, life-insurance funded burial contracts, exempt life insurance policies, and burial insurance) do not exceed that […] Read more

DHA Case No. MGE 215261 (Wis. Div. Hearings and Appeals Oct. 21, 2024) (DHS) ↓ Download PDF Community Waivers members who are eligible for any other full-benefit Medicaid program (such as MAPP) are put in Group A and have no cost share; otherwise, they are put in Group B or B Plus and do have […] 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

DHA Case No. FCP 212237 (Wis. Div. Hearings and Appeals May 9, 2024) (DHS) ↓ Download PDF Family Care may cover home modifications such as ramps and lifts to provide safe access to the home, reduce risk of injury, and facilitate independence and self-reliance. In this case, the petitioner was an 81-year-old woman unable to […] Read more

DHA Case No. FCP 211691 (Wis. Div. Hearings and Appeals Mar. 20, 2024) (DHS) ↓ Download PDF To be functionally eligible for Community Waivers long-term care programs, a person must fall into one of the target groups (frail elder, physical disability, or developmental disability) in addition to needing a nursing home level of care. In […] Read more

DHA Case No. CWA 211701 (Wis. Div. Hearings and Appeals Mar. 5, 2024) (DHS) ↓ Download PDF Services provided through the IRIS program must generally be cost-effective and necessary to achieve a long-term care outcome. In this case, the petitioner’s request for twice-weekly mowing was denied. Although she claimed this was necessary to maintain a […] Read more

DHA Case No. FCP 211227 (Wis. Div. Hearings and Appeals Feb. 15, 2024) (DHS) ↓ Download PDF In the Family Care program, MCOs must provide medically necessary services that reasonably and effectively address the participant’s long-term care outcomes. In this case, the petitioner wanted to attend a summer camp that cost $2,970. His MCO denied […] Read more

DHA Case No. CWA 211232 (Wis. Div. Hearings and Appeals Feb. 6, 2024) (DHS) ↓ Download PDF IRIS participants who fail to comply with program requirements or lose functional eligibility may be disenrolled. In this case, the petitioner needed to complete an annual long-term care functional screen but failed to respond to “multiple attempts” by […] Read more

DHA Case No. CWA 211033 (Wis. Div. Hearings and Appeals Feb. 6, 2024) (DHS) ↓ Download PDF To be functionally eligible for the IRIS program, a person must have a long-term care functional screen that determines them to need a “nursing home” level of assistance with activities of daily living (ADLs) and instrumental activities of […] Read more