5.05 Home and Community-Based Waivers Long-Term Care

DHA Case No. MGE 209343 (Wis. Div. of Hearings and Appeals October 2, 2023) (DHS) ↓ Download PDF The balance of a land contract is counted as an available asset unless its terms prohibit transfer or no one is willing to purchase it. In this case, the petitioner was selling non-homestead real estate under a […] Read more

DHA Case No. CWA 208861 (Wis. Div. of Hearings and Appeals November 10, 2023) (DHS) ↓ Download PDF In general, a service covered by IRIS must be necessary and cost-effective. In this case, the petitioner sought an increase in the rate paid to his AFH from $194.37 per day to $309.20 per day. Thanks largely […] Read more

DHA Case No. CWA 208719 (Wis. Div. of Hearings and Appeals October 23, 2023) (DHS) ↓ Download PDF An IRIS participant may be involuntarily disenrolled for loss of functional eligibility. In this case, the agency attempted to disenroll the petitioner from the IRIS self-directed personal care (SDPC) program only, not IRIS itself, for loss of functional […] Read more

DHA Case No. FCP 207790 (Wis. Div. of Hearings and Appeals May 19, 2023) (DHS) ↓ Download PDF In the Family Care program, the MCO must develop an Individual Service Plan (ISP) that reasonably and effectively addresses long-term care needs and outcomes and is cost-effective. In this case, the petitioner had extreme and violent behaviors […] Read more

DHA Case No. MGE 209206 (Wis. Div. of Hearings and Appeals November 8, 2023) (DHS) ↓ Download PDF DHA Case No. CWA 209207 (Wis. Div. of Hearings and Appeals November 8, 2023) (DHS) ↓ Download PDF The principal or income of an irrevocable trust funded with a Medicaid applicant’s resources is countable if there are […] Read more

DHA Case No. FCP 209188 (Wis. Div. of Hearings and Appeals September 5, 2023) (DHS) ↓ Download PDF An appeal of a negative MA decision must be filed, at most, within 90 days (for most decisions it’s 45 days). In this case, the petitioner’s cost share was increased by notices effective September 1, 2022 and […] Read more

DHA Case No. MGE 210503 (Wis. Div. of Hearings and Appeals December 19, 2023) (DHS) ↓ Download PDF After enrollment in a long-term care Medicaid program, the institutionalized spouse must spend down or transfer resources to the community spouse to get below $2,000 by the first renewal. In this case, the petitioner failed to do […] Read more

DHA Case No. FCP 210574 (Wis. Div. of Hearings and Appeals November 30, 2023) (DHS) ↓ Download PDF An MCO must give ten days’ notice of any adverse benefit determination. In this case, the petitioner’s MCO issued a notice on September 29 disenrolling her retroactive to August 21. ALJ Brian Schneider concluded the MCO had not […] Read more

DHA Case No. CWA 208939 (Wis. Div. of Hearings and Appeals August 21, 2023) (DHS) ↓ Download PDF When a person must use adaptive aids to perform an activity of daily living (ADL), this counts as needing assistance with the ADL for functional eligibility. In this case, the petitioner was disenrolled from IRIS after a […] Read more

DHA Case No. CWA 210286 (Wis. Div. of Hearings and Appeals November 2, 2023) (DHS) ↓ Download PDF The Department may deny an IRIS application for an inability or unwillingness to develop an Individual Support and Service Plan (ISSP) that ensures the participant’s health and safety. In this case, the petitioner was previously disenrolled in […] Read more

DHA Case No. CWA 208908 (Wis. Div. of Hearings and Appeals October 27, 2023) (DHS) ↓ Download PDF In this brief case, the petitioner appealed the termination of her IRIS benefits due to losing functional eligibility. Because she did not appear at the hearing, ALJ John Tedesco dismissed the case and the IRIS termination was […] Read more

DHA Case No. FCP 208334 (Wis. Div. of Hearings and Appeals July 3, 2023) (DHS) ↓ Download PDF An ALJ may propose that Family Care enrollment be backdated only if the enrollment date was unnecessarily delayed by the ADRC or IM. In this case, the petitioner applied December 29, 2022 and the agency inaccurately processed […] Read more

DHA Case No. MGE 207780 (Wis. Div. of Hearings and Appeals July 14, 2023) (DHS) ↓ Download PDF A Medicaid applicant has an obligation to give the agency all relevant information. In this case, the petitioner applied in November 2022 and had an asset assessment as of that date, which presumably resulted in a $50,000 […] Read more

DHA Case No. CWA 198542 (Wis. Div. of Hearings and Appeals July 21, 2020) (DHS) ↓ Download PDF The IRIS program can pay for home modifications that address “disability related long-term care needs that increase self-reliance and independence, or ensure safe, accessible means of ingress/egress to a participant’s living quarters, or otherwise provide safe access […] Read more