DHA Case No. CWA 218425 (Wis. Div. Hearings and Appeals Aug. 11, 2025) (DHS) ↓ Download PDF Prevocational services may be funded through IRIS, but the participant must have a goal of community-integrated employment. In this case, the petitioner received prevocational services for three years as part of his IRIS budget (and it appears he […] Read more
Tag: 5.05 Home and Community-Based Waivers Long-Term Care
DHA Case No. MGE 218652 (Wis. Div. Hearings and Appeals Jul. 30, 2025) (DHS) ↓ Download PDF A participant must maintain MA eligibility to remain enrolled in the Family Care program. In this case, the petitioner submitted his renewal and all verification timely, but the agency mistakenly disenrolled him. ALJ Jason Grace ordered Family Care […] Read more
DHA Case No. CWA 218656 (Wis. Div. Hearings and Appeals Jul. 30, 2025) (DHS) ↓ Download PDF To be functionally eligible for community waivers programs, an individual must require a “nursing home” level of care and be part of a target group. In this case, the petitioner had a unique diagnosis of Functional Neurologic Disorder/Conversion […] Read more
DHA Case No. CWA 218446 (Wis. Div. Hearings and Appeals Jul. 17, 2025) (DHS) ↓ Download PDF A participant in IRIS may be disenrolled if they lose their Medicaid eligibility after a renewal. In this case, the petitioner completed a FoodShare renewal that the agency mistakenly processed as a Medicaid renewal, even though her Medicaid […] Read more
DHA Case No. CWA 217836 (Wis. Div. Hearings and Appeals Jul. 1, 2025) (DHS) ↓ Download PDF An IRIS participant may be involuntarily disenrolled for mismanagement of budget authority or employer authority. In this case, the petitioner was disenrolled because his family caregivers continually billed excess hours for supportive home care, overspending his budget by […] Read more
DHA Case No. CWA 217841 (Wis. Div. Hearings and Appeals Jun. 27, 2025) (DHS) ↓ Download PDF IRIS participants may submit one-time expense requests to pay for goods or services, including adaptive aids such as vehicle modifications. In this case, the petitioner requested a wheelchair conversion for a new SUV, which TMG denied as not […] Read more
DHA Case No. CWA 217818 (Wis. Div. Hearings and Appeals Jun. 17, 2025) (DHS) ↓ Download PDF Aperson enrolled in IRIS is required to pay a cost share as a condition of eligibility. In this case, the petitioner had $7,000 in unpaid cost share and was denied re-enrollment in IRIS because he was unable to […] Read more
DHA Case No. CWA 217154 (Wis. Div. Hearings and Appeals Jun. 17, 2025) (DHS) ↓ Download PDF IRIS participants may be disenrolled if they cannot or will not address health and safety concerns. In this case, the petitioner had seizures and “episodes of disorientation,” during which his caregiver would lock or barricade him in his […] Read more
FCP 217987 (06/10/2025)
Petitioner enrolled for 19 days with no services still had to pay cost share
DHA Case No. FCP 217987 (Wis. Div. Hearings and Appeals Jun. 10, 2025) (DHS) ↓ Download PDF A person enrolled in Family Care is required to pay a cost share, though the Department may waive or reduce the requirement if undue financial hardship would result. In this case, the petitioner enrolled in Family Care March […] Read more
CWA 217677 (06/09/2025)
Petitioner functionally eligible after considering use of adaptive equipment
DHA Case No. CWA 217677 (Wis. Div. Hearings and Appeals Jun. 9, 2025) (DHS) ↓ Download PDF To be functionally eligible for the IRIS program, an individual must require a “nursing home” level of care. In this case, the petitioner needed assistance with dressing and used adaptive equipment for bathing; he also needed assistance with […] Read more
DHA Case No. FCP 217858 (Wis. Div. Hearings and Appeals Jun. 2, 2025) (DHS) ↓ Download PDF An individual in the Family Care program must have an Individual Service Plan (ISP) that reasonably and effectively addresses their needs but is also cost-effective. In this case, the petitioner’s MCO (Inclusa) ended coverage of an independent nurse—who […] Read more
DHA Case No. CWA 216919 (Wis. Div. Hearings and Appeals May 30, 2025) (DHS) ↓ Download PDF An IRIS participant’s budget is based in their long-term care functional screen. In this case, the petitioner’s Supportive Home Care (SHC) hours were reduced from 22.25 to 5 hour per week, even though his most recent functional screen […] Read more
DHA Case No. CWA 217205 (Wis. Div. Hearings and Appeals May 13, 2025) (DHS) ↓ Download PDF To be functionally eligible for home and community based long term care services, an individual must require a “nursing home” level of care. In this case, the petitioner’s condition improved after a bone marrow transplant; an updated functional […] Read more
DHA Case No. CWA 216858 (Wis. Div. Hearings and Appeals May 9, 2025) (DHS) ↓ Download PDF A person is functionally eligible for IRIS if, among other criteria, the person cannot safely or appropriately perform one or more ADL and 3 or more IADLs and has cognitive impairment. In this case, the petitioner was a […] Read more
DHA Case No. FCP 216785 (Wis. Div. Hearings and Appeals Apr. 14, 2025) (DHS) ↓ Download PDF To be functionally eligible for home and community based long term care services through the PACE program, an individual must require a “nursing home” level of care. In this case, the petitioner required assistance with one ADL and […] Read more