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

DHA Case No. MGE 221661 (Wis. Div. Hearings and Appeals Feb. 20, 2026) (DHS) ↓ Download PDF The state must maintain Medicaid coverage while completing regularly scheduled renewals as long as the renewal is received before the end of the month the renewal is due. In this case, the petitioner was enrolled in Family Care […] Read more

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. CWK 220881 (Wis. Div. Hearings and Appeals Feb. 6, 2026) (DHS) ↓ Download PDF To be functionally eligible for the Children’s Long-Term Support Program, a child with a developmental disability who needs intermediate care must demonstrate substantial functional limitations in three areas. In this case, the petitioner was a 7-year-old with autism who […] Read more

DHA Case No. BCS 221175 (Wis. Div. Hearings and Appeals Feb. 4, 2026) (DHS) ↓ Download PDF When applying for MAPP, an applicant may be determined presumptively disabled. A presumptive disability decision stands until the DDB makes a final disability determination, at which point IM must send a manual notice. In this case, the petitioner […] 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. MGE 220279 (Wis. Div. Hearings and Appeals Jan. 28, 2026) (DHS) ↓ Download PDF To be eligible for Wisconsin Medicaid, a person must be a Wisconsin resident. In this case, the petitioner initially resided in an nursing home in Wisconsin and attempted to exempt more than $1,500 in burial funds. When the […] 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

DHA Case No. FCP 220498 (Wis. Div. Hearings and Appeals Jan. 5, 2026) (DHS) ↓ Download PDF Services provided through the Family Care program must be cost-effective. In this case, the petitioner lived at an AFH and attended a nearby adult day service program that proved very beneficial. When he moved to a different AFH, […] Read more

DHA Case No. CWA 221013 (Wis. Div. Hearings and Appeals Feb. 25, 2026) (DHS) ↓ Download PDF IRIS funds approved through the budget amendment process must be used for the requested service and cannot be transferred to a different service or service type, or a different provider type. In this case, the petitioner was enrolled […] Read more

DHA Case No. CWK 221068 (Wis. Div. Hearings and Appeals Feb. 20, 2026) (DHS) ↓ Download PDF A “Notice of Action” must be provided to CLTS participants at least fifteen days before a reduction or termination of services, which participants have the right to appeal. In this case, the petitioner’s respite services were terminated effective […] Read more