DHA Case No. CWA 216742 (Wis. Div. Hearings and Appeals May 14, 2025) (DHS) ↓ Download PDF One service IRIS can provide is Daily Living Skills (DLS), which teaches and improves skills to improve the participant’s independence in daily life. Because it is educational, the service is monitored to ensure progress is being made. In […] Read more
Benjamin S. Wright
DHA Case No. CWA 215300 (Wis. Div. Hearings and Appeals Dec. 17, 2024) (DHS) ↓ Download PDF IRIS participants are assigned a budget, and their IRIS Consultant Agency (ICA) cannot authorize services exceeding that budget. In this case, the petitioner overbilled her supportive home care budget for many months. Her ICA reduced her authorized supportive […] Read more
DHA Case No. MQB 215664 (Wis. Div. Hearings and Appeals Dec. 16, 2024) (DHS) ↓ Download PDF Medicaid fair hearing appeals must be filed within 45 days of the negative action. An appeal is considered filed when the written and signed fair hearing request is received by the agency or on its postmarked date, if […] Read more
DHA Case No. FCP 215954 (Wis. Div. Hearings and Appeals Dec. 13, 2024) (DHS) ↓ Download PDF An individual is functionally eligible for Community Waivers programs 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 the petitioner functionally ineligible […] Read more
DHA Case No. CWK 215379 (Wis. Div. Hearings and Appeals Dec. 12, 2024) (DHS) ↓ Download PDF Under the approved Waiver, DHS does not allow for the use of personal restraints and strictly limits the use of protective equipment. In this case, the petitioner was an 8-year-old autistic child who needed a diaper but exhibited […] Read more
DHA Case No. MPA 215583 (Wis. Div. Hearings and Appeals Dec. 9, 2024) (DHS) ↓ Download PDF Medicaid covers prescriptions drugs that are medically necessary, guided by agency policy on the effective, appropriate, and cost-effective use of the drug. For anti-obesity drugs, specifically Wegovy, agency policy limits coverage to 12 continuous months, after which the […] Read more
DHA Case No. CWA 213491 (Wis. Div. Hearings and Appeals Oct. 24, 2024) (DHS) ↓ Download PDF Home modifications for an IRIS participant must be cost-effective. In this case, the petitioner asked that his tub/shower be replaced with a walk-in shower. The accessibility study concluded this was needed and explained why less expensive options would […] Read more
DHA Case No. CWK 211705 (Wis. Div. Hearings and Appeals Sep. 10, 2024) (DHS) ↓ Download PDF Individual choice of provider is a main tenet of the CLTS program. Even when a county has concerns about a provider, the County Waiver Agency must respect the participant’s choice “unless there is compelling justification not to do […] Read more
DHA Case No. MDD 213268 (Wis. Div. Hearings and Appeals Sep. 6, 2024) (DHS) ↓ Download PDF A person is not disabled for Medicaid purposes if they can perform the same work they have done in the past at a substantially gainful level. In this case, the petitioner was ultimately determined not disabled because he […] Read more
DHA Case No. MGE 212301 (Wis. Div. Hearings and Appeals Sep. 16, 2024) (DHS) ↓ Download PDF The agency can deny Medicaid when the applicant or recipient is able to produce required verifications but refuses or fails to do so. In this case, the petitioner failed to verify, at his renewal, one of his vehicles, […] Read more
DHA Case No. FCP 216075 (Wis. Div. Hearings and Appeals Feb. 24, 2025) (DHS) ↓ Download PDF When an MCO seeks to reduce services, it has the burden of proof and must justify its action. In this case, an Inclusa representative justified its reduction of Supportive Home Care (SHC) hours from 496 to 446 per […] Read more
DHA Case No. MGE 216109 (Wis. Div. Hearings and Appeals Feb. 14, 2025) (DHS) ↓ Download PDF To be eligible for Community Waivers Medicaid programs, an individual must be elderly, blind, or disabled. In this case, the petitioner was 28 years old and working full time at $15.50 per hour, though he had at some […] Read more
DHA Case No. CWA 216242 (Wis. Div. Hearings and Appeals Feb. 14, 2025) (DHS) ↓ Download PDF Before taking any negative action, the Medicaid agency must give adequate notice. In this case, TMG mailed notice of IRIS disenrollment due to a missed renewal to the wrong address. ALJ Brian Schneider concluded the petitioner did not […] Read more
DHA Case No. BCS 216058 (Wis. Div. Hearings and Appeals Feb. 14, 2025) (DHS) ↓ Download PDF When verifying income with BadgerCare Plus, the agency must “advise the applicant of the specific verification required.” If the applicant “is able to produce required verifications but refuses or fails to do so,” the benefits will be denied […] Read more
DHA Case No. FCP 216208 (Wis. Div. Hearings and Appeals Feb. 21, 2025) (DHS) ↓ Download PDF In the Family Care program, the MCO must develop an Individual Service Plan that reasonably and effectively addresses all of the client’s long-term needs—but it must also be cost effective, and it can exclude a service the client […] Read more