DHA Case No. CWK 218183 (Wis. Div. Hearings and Appeals Jun. 17, 2025) (DHS) ↓ Download PDF The Children’s Long-Term Support Program (CLTS) can cover health and wellness activities, but services generally cannot be duplicative and payments cannot be made directly to the participant or to another person on behalf of the participant. In this […] Read more

DHA Case No. FCP 217858 (Wis. Div. Hearings and Appeals Jun. 2, 2025) (DHS) ↓ Download PDF An individual in the Family Care program must have an Individual Service Plan (ISP) that reasonably and effectively addresses their needs but is also cost-effective. In this case, the petitioner’s MCO (Inclusa) ended coverage of an independent nurse—who […] Read more

DHA Case No. CWA 216919 (Wis. Div. Hearings and Appeals May 30, 2025) (DHS) ↓ Download PDF An IRIS participant’s budget is based in their long-term care functional screen. In this case, the petitioner’s Supportive Home Care (SHC) hours were reduced from 22.25 to 5 hour per week, even though his most recent functional screen […] Read more

DHA Case No. CWK 216983 (Wis. Div. Hearings and Appeals Apr. 28, 2025) (DHS) ↓ Download PDF For a CLTS participant age 12 or older, covered “child care” can include school and community-based settings such as after school programs and 4-H. In this case, the petitioner requested funding for two three-week camp programs at the […] Read more

DHA Case No. FCP 216652 (Wis. Div. Hearings and Appeals Apr. 14, 2025) (DHS) ↓ Download PDF Aservice that is “duplicative with respect to other services being provided” is not medically necessary. In this case, the petitioner lived in an Adult Family Home (AFH) and attended adult day services at a community provider. The MCO […] Read more

DHA Case No. FCP 217068 (Wis. Div. Hearings and Appeals Apr. 7, 2025) (DHS) ↓ Download PDF Aservice that is “duplicative with respect to other services being provided” is not medically necessary. In this case, the petitioner attended adult day services with a certain provider while living with her siblings for several years. But when […] Read more

DHA Case No. FCP 216051 (Wis. Div. Hearings and Appeals Mar. 28, 2025) (DHS) ↓ Download PDF Whether Family Care must cover placement in an Adult Family Home (AFH) or other group home setting depends on the general criteria of medical necessity and cost-effectivness, among others. In this case, the petitioner lived in an apartment […] Read more

DHA Case No. CWA 216762 (Wis. Div. Hearings and Appeals Mar. 19, 2025) (DHS) ↓ Download PDF Around 2017 DHS instituted a policy that a caregiver should not be approved for more than 40 hours per week of paid services, including SHC covered by IRIS and other forms of caregiving such as personal care worker […] Read more

DHA Case No. CWA 216860 (Wis. Div. Hearings and Appeals Mar. 18, 2025) (DHS) ↓ Download PDF IRIS participants must pay their providers a “usual and customary rate.” In this case, the petitioner sought an increase in the daily rate of his adult day services provider from $157.50 to $168.50. Noting the difference between the customary […] Read more

DHA Case No. MPA 216849 (Wis. Div. Hearings and Appeals Mar. 14, 2025) (DHS) ↓ Download PDF Orthodontia is generally not an MA-covered service, but must be covered for recipients under age 21 if the Early and Periodic Screening, Diagnosis and Treatment (EPSDT) health assessment and evaluation indicates that it is needed. Finding exceptional circumstances […] Read more

DHA Case No. CWA 216141 (Wis. Div. Hearings and Appeals Feb. 13, 2025) (DHS) ↓ Download PDF IRIS participants may be involuntarily disenrolled for failure to spend the funds in their budget. In this case, the petitioner was repeatedly warned that her failure to spend her IRIS budget could result in disenrollment, and she ultimately […] Read more

DHA Case No. CWK 215882 (Wis. Div. Hearings and Appeals Feb. 3, 2025) (DHS) ↓ Download PDF In the CLTS program, the County Waiver Agency plays a limited role in qualifying and authorizing participants’ chosen service providers, including checking certifications and licensure and conducting a background check. In this case, the county denied the petitioner’s […] Read more

DHA Case No. MPP 215826 (Wis. Div. Hearings and Appeals Jan. 16, 2025) (DHS) ↓ Download PDF If a Medicaid recipient knowingly obtains health care that exceeds program limits or is not medically necessary, the Department may enroll the recipient in the “lock-in program,” which limits the recipient to one prescriber and one pharmacy for […] Read more

DHA Case No. MNP 216025 (Wis. Div. Hearings and Appeals Jan. 13, 2025) (DHS) ↓ Download PDF Fair hearings allow recipients to appeal department actions that result in the denial, discontinuation, termination, suspension, or reduction of benefits. They are not for lodging complaints against providers. In this case, the petitioner filed a fair hearing that […] Read more