4.2 Benefits

DHA Case No. FCP 206451 (Wis. Div. of Hearings and Appeals January 30, 2023) (DHS) ↓ Download PDF A medically necessary service must not be duplicative of other services already being provided. In this case, the petitioner had been in a program for 14 years that allowed him to participate in 3 community events every […] Read more

DHA Case No. FCP 206397 (Wis. Div. of Hearings and Appeals January 17, 2023) (DHS) ↓ Download PDF Family Care generally does not cover household repairs or improvements that are not directly related to the member’s care. In this case, the petitioner’s carpet was fouled and beyond cleaning, so she asked her MCO to replace […] Read more

DHA Case No. HMO 206640 (Wis. Div. of Hearings and Appeals January 5, 2023) (DHS) ↓ Download PDF Medicaid HMOs must provide the same services as fee-for-service MA or BadgerCare Plus—they must cover services that are medically necessary. In this case, the petitioner wanted her HMO to cover an out-of-network doctor when in-network doctors either […] Read more

DHA Case No. CWA 208861 (Wis. Div. of Hearings and Appeals November 10, 2023) (DHS) ↓ Download PDF In general, a service covered by IRIS must be necessary and cost-effective. In this case, the petitioner sought an increase in the rate paid to his AFH from $194.37 per day to $309.20 per day. Thanks largely […] Read more

DHA Case No. FCP 207790 (Wis. Div. of Hearings and Appeals May 19, 2023) (DHS) ↓ Download PDF In the Family Care program, the MCO must develop an Individual Service Plan (ISP) that reasonably and effectively addresses long-term care needs and outcomes and is cost-effective. In this case, the petitioner had extreme and violent behaviors […] Read more

DHA Case No. MPA 208980 (Wis. Div. of Hearings and Appeals November 9, 2023) (DHS) ↓ Download PDF Wisconsin Medicaid covers gender-affirming medical and surgical treatments when medically necessary. In this case, the petitioner sought a prior authorization for six sessions of laser hair removal from the face as part of gender-affirming care. The Department […] Read more

DHA Case No. CWA 198542 (Wis. Div. of Hearings and Appeals July 21, 2020) (DHS) ↓ Download PDF The IRIS program can pay for home modifications that address “disability related long-term care needs that increase self-reliance and independence, or ensure safe, accessible means of ingress/egress to a participant’s living quarters, or otherwise provide safe access […] Read more

DHA Case No. CWA 205245 (Wis. Div. of Hearings and Appeals September 12, 2022) (DHS) ↓ Download PDF IRIS participants may hire their own workers to provide supportive home care (SHC). The participant is responsible for negotiating “reasonable and customary rates” with providers. In this case, the petitioner asked to increase her worker’s hourly rate […] Read more

DHA Case No. CWK 209490 (Wis. Div. of Hearings and Appeals September 15, 2023) (DHS) ↓ Download PDF The CLTS program can cover “Health and Wellness” services to maintain or improve the health, well being, socialization, or inclusion of the participant with family and peers in the community. But these services must not be duplicative […] Read more

DHA Case No. CWK 207740 (Wis. Div. of Hearings and Appeals June 9, 2023) (DHS) ↓ Download PDF One of the benefits of the Children’s Long-Term Support program is access to a Support and Service Coordinator (SSC); DHS’s Participant Rights and Responsibilities notice even says, “You have a right to meet with this person as […] Read more

DHA Case No. FCP 206978 (Wis. Div. of Hearings and Appeals April 7, 2023) (DHS) ↓ Download PDF In the Family Care program, the MCO must develop an Individual Service Plan (ISP) that reasonably and effectively addresses the enrollee’s long-term care needs and outcomes and is cost-effective. In this case, Community Care ended the petitioner’s […] Read more

DHA Case No. FCP 189482 (Wis. Div. of Hearings and Appeals February 27, 2019) (DHS) ↓ Download PDF To be covered under Family Care, a service must be cost-effective. In this case, the MCO denied the petitioner’s request to install an ADA-height elongated toilet in his rented apartment, saying there were less costly alternatives. ALJ […] Read more

DHA Case No. FCP 189820 (Wis. Div. of Hearings and Appeals February 6, 2019) (DHS) ↓ Download PDF To be covered under Family Care, a service must be medically necessary. In this case, the petitioner’s request for acupuncture therapy was denied because it had been tried and proved ineffective for her in the past. ALJ […] Read more

DHA Case No. CWA 189840 (Wis. Div. of Hearings and Appeals January 24, 2019) (DHS) ↓ Download PDF IRIS can pay for a participant-hired worker to attend a conference as a “Community Integration Event” if the participant is also attending. In this case, the petitioner’s mother attended a Fragile X conference alone; she apparently was […] Read more

DHA Case No. FCP 189985 (Wis. Div. of Hearings and Appeals January 14, 2019) (DHS) ↓ Download PDF MCOs must consider an MA recipient’s income when determining benefits. In this case, the petitioner’s MCO reduced his out-of-benefit food budget when he started working, reasoning he could contribute that towards the cost of his food. ALJ […] Read more