5.05 Home and Community-Based Waivers Long-Term Care

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. CWA 189325 (Wis. Div. of Hearings and Appeals January 8, 2019) (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 held onto the bed rail when […] 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

DHA Case No. MDV 196288 (Wis. Div. of Hearings and Appeals December 4, 2019) (DHS) ↓ Download PDF Aland contract must have a term within the lender’s life expectancy, provide for equal payments, and not allow cancellation on the death of the lender to avoid being considered a divestment. In this case, the county argued […] Read more

DHA Case No. CWA 208405 (Wis. Div. of Hearings and Appeals October 16, 2023) (DHS) ↓ Download PDF Community transportation can be covered by IRIS, but the service assumes that someone besides the participant is doing the driving. In this case, the petitioner had a community transportation budget with his wife as the “participant-hired worker” […] Read more

DHA Case No. CWA 208350 (Wis. Div. of Hearings and Appeals September 19, 2023) (DHS) ↓ Download PDF The IRIS program can cover “individual directed goods and services” that are not covered under another service category and not obtainable from another source. In this case, the petitioner somehow had IRIS paying for food from vendors […] Read more

DHA Case No. FCP 207851 (Wis. Div. of Hearings and Appeals August 31, 2023) (DHS) ↓ Download PDF An MCO must determine whether a requested service is medically necessary and cost-effective. But in this case, the petitioner’s mother and guardian refused to cooperate with the MCO’s attempts to get the information it needed to make […] Read more

DHA Case No. FCP 208522 (Wis. Div. of Hearings and Appeals June 28, 2023) (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’s functional screen found her functionally ineligible because […] Read more

DHA Case No. CWA 208070 (Wis. Div. of Hearings and Appeals June 6, 2023) (DHS) ↓ Download PDF Home and community-based waiver programs may cover “other services … as cost effective and necessary to avoid institutionalization.” In this case, the IRIS program paid the petitioner’s internet under the “other services” authorization since 2019 but stopped […] Read more

DHA Case No. FCP 208424 (Wis. Div. of Hearings and Appeals July 10, 2023) (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’s functional screen found him functionally ineligible because […] Read more

DHA Case No. FCP 207586 (Wis. Div. of Hearings and Appeals July 20, 2023) (DHS) ↓ Download PDF MCOs in the Family Care program may authorize residential services—such as placement in an Adult Family Home (AFH)—only if they are the most cost-effective option, if they are needed to support the member’s long-term care outcomes, or […] Read more

DHA Case No. FCP 208218 (Wis. Div. of Hearings and Appeals June 12, 2023) (DHS) ↓ Download PDF Cost share reductions are effective the month of the change report, even if the actual change in income or expense was earlier. In this case, the petitioner enrolled in Family Care with a cost share effective November […] Read more

DHA Case No. CWA 208193 (Wis. Div. of Hearings and Appeals October 2, 2023) (DHS) ↓ Download PDF When DHS increases a member’s cost share, it has the burden of proof on appeal. In this rather messy case, it was clear that the cost share should have been lower but it was not clear whose […] Read more