DHA Case No. CWA 211040 (Wis. Div. Hearings and Appeals Feb. 2, 2024) (DHS) ↓ Download PDF A budget amendment may be denied if it requests services that are duplicative of services already provided. In this case, the petitioner, an 18-year-old with Down Syndrome, requested a budget amendment to allow her to attend a 9-month […] Read more

DHA Case No. CWA 211308 (Wis. Div. Hearings and Appeals Jan. 25, 2024) (DHS) ↓ Download PDF IRIS participants choose needed supports and services to meet long-term care outcomes as identified in an Individual Support and Services Plan. In this case, the petitioner (a 29-year-old with autism) sought a budget amendment to pay for therapeutic […] Read more

DHA Case No. CWA 210734 (Wis. Div. Hearings and Appeals Jan. 5, 2024) (DHS) ↓ Download PDF IRIS can pay for an already-trained service dog, but not an untrained dog or an emotional support dog. In this case, the petitioner requested funding to buy an untrained dog and then train it as a service animal. […] Read more

DHA Case No. FCP 210801 (Wis. Div. Hearings and Appeals Jan. 3, 2024) (DHS) ↓ Download PDF To be functionally eligible for Family Care, a person must fall into one of the program’s target groups in addition to needing a nursing home level of care. In this case, the petitioner was diagnosed with schizophrenia and […] Read more

DHA Case No. CWA 210721 (Wis. Div. Hearings and Appeals Jan. 3, 2024) (DHS) ↓ Download PDF The IRIS program can cover home modifications, but they must address the participant’s independence, health, safety, or long-term care needs and be cost effective. In this case, the petitioner made a one-time expense request to pay for a […] Read more

DHA Case No. CWA 213161 (Wis. Div. Hearings and Appeals Oct. 28, 2024) (DHS) ↓ Download PDF The Department must ensure the health and safety of IRIS participants. The IRIS policy manual allows involuntary disenrollment for “health and safety risks that participants are unable or unwilling to resolve.” In this case, the participant was a […] Read more

DHA Case No. CWA 213537 (Wis. Div. Hearings and Appeals Oct. 18, 2024) (DHS) ↓ Download PDF The IRIS Policy Manual requires a notice of action and provides a right to appeal when services are reduced, terminated, or denied. In this case, the petitioner’s care worker failed to timely submit the required documentation to become […] Read more

DHA Case No. FCP 213736 (Wis. Div. Hearings and Appeals Aug. 28, 2024) (DHS) ↓ Download PDF A participant in Family Care can be involuntarily disenrolled if they are determined ineligible for MA. In this case, the petitioner submitted his renewal timely and was eligible, but his MCO disenrolled him in error and could not […] Read more

DHA Case No. CWA 213277 (Wis. Div. Hearings and Appeals Sep. 27, 2024) (DHS) ↓ Download PDF An IRIS participant may be involuntarily disenrolled for mismanagement of employer authority responsibilities. In this case, the petitioner had multiple instances of mismanagement with participant-hired workers, including calling the Fiscal Employer Agency posing as one of her workers, […] Read more

DHA Case No. FCP 213572 (Wis. Div. Hearings and Appeals Sep. 24, 2024) (DHS) ↓ Download PDF A service that is “duplicative with respect to other services being provided” is not medically necessary. In this case, the petitioner attended after-hours recreational activities in the community while living with her mother for many years. But when […] Read more

DHA Case No. FCP 213852 (Wis. Div. Hearings and Appeals Sep. 12, 2024) (DHS) ↓ Download PDF Family Care enrollment may only be backdated when the agency has caused a delay after the application date. In this case, the petitioner mistakenly applied for Institutional MA in March and was found eligible before discovering that she […] Read more

DHA Case No. MRA 213308 (Wis. Div. Hearings and Appeals Jul. 31, 2024) (DHS) ↓ Download PDF A Community Waivers member in Group B or B Plus may use spousal improverishment rules to give income to his or her spouse as an “institutionalized person,” but Group A members are excluded from that definition. In this […] Read more

DHA Case No. CWA 213191 (Wis. Div. Hearings and Appeals Jul. 15, 2024) (DHS) ↓ Download PDF Community Waivers members in Groups B and B Plus may use spousal improverishment rules to give income to their spouses, but Group A members may not. In this case, the petitioner was enrolled in Group B in 2019 […] Read more

DHA Case No. CWA 213089 (Wis. Div. Hearings and Appeals Jul. 2, 2024) (DHS) ↓ Download PDF The agency may deny an application for IRIS during the referral stage if the applicant committed substantiated fraud during a previous enrollment. In this case, the petitioner was previously enrolled in IRIS and the agency had issued a […] Read more