DHA Case No. CWA 221163 (Wis. Div. Hearings and Appeals Mar. 19, 2026) (DHS) ↓ Download PDF Services provided by IRIS must be cost-effective. In this case, the petitioner requested a budget amendment to pay for an increased hourly rate by the supported employment provider, whose rate had increased substantially over the past several years. […] Read more
Tag: 4.2 Benefits
DHA Case No. CWA 220532 (Wis. Div. Hearings and Appeals Mar. 6, 2026) (DHS) ↓ Download PDF Personal care services must be provided consistent with a written physician’s order and according to state regulations. In this case, the petitioner’s plan of care, which was signed by a physician, ordered 47.5 hour per week for a […] Read more
DHA Case No. CWA 221054 (Wis. Div. Hearings and Appeals Mar. 3, 2026) (DHS) ↓ Download PDF The IRIS program may include support broker services. A support broker “supports a participant in directing personal assistance services and services budgets” and “assists the participant in planning, securing, and directing self-supports” (essentially, helping a person maintain public […] Read more
DHA Case No. CWA 220503 (Wis. Div. Hearings and Appeals Mar. 9, 2026) (DHS) ↓ Download PDF Services provided through the IRIS program must generally be cost-effective and necessary to achieve a long-term care outcome. In this case, the petitioner had been receiving daily living skills training since 2019 but still required 24-hour support, and […] Read more
DHA Case No. FCP 221622 (Wis. Div. Hearings and Appeals Mar. 19, 2026) (DHS) ↓ Download PDF In the Family Care program, the services provided must reasonably and effectively address all long-term needs to assist the client to be as self-reliant and autonomous as possible, but it must also be cost-effective. In this case, the […] Read more
DHA Case No. CWA 220811 (Wis. Div. Hearings and Appeals Mar. 16, 2026) (DHS) ↓ Download PDF IRIS policy provides that a budget amendment (BA) may only be used for costs that exceed a recipient’s base budget and may not be transferred to a different service or service type. In this case, the agency reduced […] Read more
DHA Case No. CWA 221689 (Wis. Div. Hearings and Appeals Apr. 28, 2026) (DHS) ↓ Download PDF An IRIS participant who receives Daily Living Skills Training services (now called Life Skills Training and Education services) must generally demonstrate skill development within a year, or longer if reasonably needed to acquire the skill. Also, as skills […] Read more
DHA Case No. CWA 221317 (Wis. Div. Hearings and Appeals Feb. 27, 2026) (DHS) ↓ Download PDF Every IRIS participant enrolled in the self-directed personal cares (SDPC) program must have a care plan signed annually by the participant’s SDPC nurse and physician. In this case, the petitioner’s SDPC nurse attempted to visit multiple times to […] Read more
DHA Case No. FCP 221117 (Wis. Div. Hearings and Appeals Feb. 23, 2026) (DHS) ↓ Download PDF Residential care services provided through Family Care MCOs may be authorized only when a member’s long-term care outcomes cannot be cost-effectively supported in the member’s home, or when a member’s health and safety cannot be adequately safe guarded […] Read more
MPA 220854 (02/17/2026)
Power wheelchair upgrade denied when new chair was covered the previous year
DHA Case No. MPA 220854 (Wis. Div. Hearings and Appeals Feb. 17, 2026) (DHS) ↓ Download PDF When considering a prior authorization request, DHS must consider medical necessity, appropriateness, cost, alternatives, and whether the service is an effective and appropriate use of available services. In this case, the petitioner requested prior authorization for a power […] Read more
DHA Case No. CWA 220576 (Wis. Div. Hearings and Appeals Feb. 17, 2026) (DHS) ↓ Download PDF DHS has an obligation to ensure the IRIS program meets certain federal standards, such as the requirement that settings where home and community-based services are provided have the qualities listed in 42 C.F.R. §441.301(c)(4). In this case, the […] Read more
DHA Case No. CWK 221161 (Wis. Div. Hearings and Appeals Feb. 9, 2026) (DHS) ↓ Download PDF Respite care is a service covered by the Children’s Long-Term Support Program (CLTS), but respite care payments are not allowed to a parent or a primary caregiver in the participant’s household. In this case, the agency discovered that […] Read more
DHA Case No. HMO 220800 (Wis. Div. Hearings and Appeals Feb. 2, 2026) (DHS) ↓ Download PDF Personal care worker (PCW) services for an activity are not medically necessary if the member can perform the activity safely with the use of an assistive device. In this case, the petitioner requested 24.5 hours per week of […] Read more
DHA Case No. CWA 220708 (Wis. Div. Hearings and Appeals Feb. 2, 2026) (DHS) ↓ Download PDF IRIS participants are assigned budgets based on their Long-Term Care Functional Screens, which they must generally stay within (or request a budget amendment). In this case, petitioner received 10 home-delivered meals per week due, in part, to chronic […] Read more
DHA Case No. FCP 220551 (Wis. Div. Hearings and Appeals Jan. 9, 2026) (DHS) ↓ Download PDF MCOs may not deny a service that is reasonable and necessary, and in an amount, scope, and duration needed to cost-effectively support the member’s long-term care outcomes. In this case, the petitioner lived in a 1-2 bed adult […] Read more