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
Tag: 4 Program Administration
DHA Case No. MGE 216321 (Wis. Div. Hearings and Appeals May 9, 2025) (DHS) ↓ Download PDF An MA recipient has a right to a fair hearing when aggrieved by an action or inaction of the Department or a county when the county is acting as the agency which administers an income maintenance program. In […] 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. MLL 216729 (Wis. Div. Hearings and Appeals Apr. 21, 2025) (DHS) ↓ Download PDF When estate recovery makes a claim, Wisconsin law gives a right to appeal the issues of the value of the property and the extent of the decedent’s interest in it. In this case, the petitioner disputed the Department’s […] 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. BCS 216832 (Wis. Div. Hearings and Appeals Apr. 7, 2025) (DHS) ↓ Download PDF The agency must mail a notice of adverse action at least 10 days prior to the effective date. In this case, the petitioner never received a notice that her BadgerCare Plus renewal was due, but the agency did […] 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. FCP 216227 (Wis. Div. Hearings and Appeals Mar. 27, 2025) (DHS) ↓ Download PDF A participant in Family Care cannot be disenrolled without proper advance notice. In this case, the petitioner apparently missed a yearly renewal due in August and had difficulty navigating the re-enrollment process with the ADRC (“sometime in December […] Read more
COP 216759 (03/20/2025)
No right to appeal denial of funding in Children’s Community Options Program
DHA Case No. COP 216759 (Wis. Div. Hearings and Appeals Mar. 20, 2025) (DHS) ↓ Download PDF A denial of eligibility or a reduction in services for the Children’s Community Options Program is appealable to DHA, “except that lack of adequate funding may not serve as the basis.” In this case, the petitioner’s county denied […] 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. CWK 216100 (Wis. Div. Hearings and Appeals Mar. 6, 2025) (DHS) ↓ Download PDF A child in the Children’s Long-Term Support (CLTS) program must be recertified annually, including an updated functional screen. In this case, the agency tried many times to schedule a home visit with the petitioner’s mother, but she repeatedly […] Read more
DHA Case No. MGE 216433 (Wis. Div. Hearings and Appeals Mar. 3, 2025) (DHS) ↓ Download PDF Medicaid eligibility requires verifying income, assets, and other information as part of the application or renewal process, and on an ongoing basis. In this case, the county agency noticed during a quality control review that it never fully […] Read more