5.05 Home and Community-Based Waivers Long-Term Care

DHA Case No. FCP 173457 (Wis. Div. of Hearings and Appeals September 15, 2016) (DHS) ↓ Download PDF The Medicaid Eligibility Handbook used to direct that the snapshot date for a spousal asset assessment was the “date of the first request for Community Waivers.” In this case, the petitioner was determined functionally eligible on August […] Read more

DHA Case No. FCP 206703 (Wis. Div. of Hearings and Appeals February 16, 2023) (DHS) ↓ Download PDF Family Care can provide supportive home care (SHC) hours to cover services that are necessary, reasonable, appropriate, and cost-effective. In this case, the petitioner’s mother sought an increase in SHC hours so she could be paid to […] Read more

DHA Case No. CWA 206353 (Wis. Div. of Hearings and Appeals January 17, 2023) (DHS) ↓ Download PDF Services included in an IRIS member’s budget must be cost effective and at the usual and customary rate for the area. In this case, the petitioner’s medical transportation provider increased its rate for transporting him to his […] Read more

DHA Case No. CWA 206183 (Wis. Div. of Hearings and Appeals January 17, 2023) (DHS) ↓ Download PDF The moving party generally has the burden of proof; when an IRIS participant requests new services, the participant must prove that the requested services meet approval criteria by a preponderance of the evidence. In this case, the […] Read more

DHA Case No. FCP 206264 (Wis. Div. of Hearings and Appeals January 11, 2023) (DHS) ↓ Download PDF In the Family Care program, the MCO must develop an Individual Service Plan with the client that addresses the client’s needs. When the MCO seeks to change that plan and reduce services, it has the burden of […] Read more

DHA Case No. FCP 208209 (Wis. Div. of Hearings and Appeals May 31, 2023) (DHS) ↓ Download PDF In the Family Care program, the MCO must develop an Individual Service Plan with the client that addresses the client’s needs while being cost-effective. The MCO does not have to provide a service if there are less […] Read more

DHA Case No. FCP 207870 (Wis. Div. of Hearings and Appeals May 19, 2023) (DHS) ↓ Download PDF Family Care benefits generally cannot be backdated, except that retroactive enrollment can be ordered by an ALJ to correct delay caused by agency error. In this case, the petitioner applied January 25, the application was processed February […] Read more

DHA Case No. CWA 207516 (Wis. Div. of Hearings and Appeals May 18, 2023) (DHS) ↓ Download PDF An IRIS participant may request a budget amendment to pay for an ongoing need not met within the current budget. In this case, the petitioner asked for a budget increase when her home health agency ended her […] Read more

DHA Case No. FCP 207491 (Wis. Div. of Hearings and Appeals May 9, 2023) (DHS) ↓ Download PDF A Family Care MCO’s member-centered plan must assess and identify “long-term care outcomes that are consistent with the values and preference of the enrollee” in the areas of both “self-determination of daily routine, services, activities and living […] Read more

DHA Case No. FCP 207518 (Wis. Div. of Hearings and Appeals April 19, 2023) (DHS) ↓ Download PDF Assisted living is a possible residential choice in the Family Care program, but it generally must be cost-effective in addressing the member’s individual service plan. In this case, the petitioner—a 61-year-old woman with autism, anxiety, PTSD, vertigo, […] Read more

DHA Case No. CWA 207522 (Wis. Div. of Hearings and Appeals April 18, 2023) (DHS) ↓ Download PDF An IRIS participant may request a budget amendment to pay for an ongoing need not met within the current budget. In this case, the petitioner asked for a budget increase when her home health agency ended her […] Read more

DHA Case No. CWA 207408 (Wis. Div. of Hearings and Appeals April 17, 2023) (DHS) ↓ Download PDF To cover a service dog, IRIS policy requires that it be “individually trained by a reputable provider experienced in providing structured training for service dogs to do work or perform tasks for the participant that are directly […] Read more

DHA Case No. CWA 207563 (Wis. Div. of Hearings and Appeals April 3, 2023) (DHS) ↓ Download PDF An IRIS participant may request a budget amendment to pay for an ongoing need not met within the current budget. In this case, the petitioner asked for a budget increase when her home health agency ended her […] Read more

DHA Case No. CWA 207474 (Wis. Div. of Hearings and Appeals April 3, 2023) (DHS) ↓ Download PDF An IRIS participant may request a budget amendment to pay for an ongoing need not met within the current budget. In this case, the petitioner asked for a budget increase from $15.75 to $17/hr to pay for […] Read more