DHA Case No. CWA 215749 (Wis. Div. Hearings and Appeals May 16, 2025) (DHS) ↓ Download PDF Federal regulations require that Medicaid notices of a negative action include an explanation of the right to appeal. In this case, the petitioner received three notices that informed him of a pending disenrollment but said nothing about a […] Read more

DHA Case No. CWA 216742 (Wis. Div. Hearings and Appeals May 14, 2025) (DHS) ↓ Download PDF One service IRIS can provide is Daily Living Skills (DLS), which teaches and improves skills to improve the participant’s independence in daily life. Because it is educational, the service is monitored to ensure progress is being made. In […] Read more

DHA Case No. CWA 215300 (Wis. Div. Hearings and Appeals Dec. 17, 2024) (DHS) ↓ Download PDF IRIS participants are assigned a budget, and their IRIS Consultant Agency (ICA) cannot authorize services exceeding that budget. In this case, the petitioner overbilled her supportive home care budget for many months. Her ICA reduced her authorized supportive […] Read more

DHA Case No. CWA 213491 (Wis. Div. Hearings and Appeals Oct. 24, 2024) (DHS) ↓ Download PDF Home modifications for an IRIS participant must be cost-effective. In this case, the petitioner asked that his tub/shower be replaced with a walk-in shower. The accessibility study concluded this was needed and explained why less expensive options would […] Read more

DHA Case No. CWA 216242 (Wis. Div. Hearings and Appeals Feb. 14, 2025) (DHS) ↓ Download PDF Before taking any negative action, the Medicaid agency must give adequate notice. In this case, TMG mailed notice of IRIS disenrollment due to a missed renewal to the wrong address. ALJ Brian Schneider concluded the petitioner did not […] Read more

DHA Case No. CWA 215956 (Wis. Div. Hearings and Appeals Feb. 28, 2025) (DHS) ↓ Download PDF To be approved as part of an IRIS budget, services must generally be cost-effective. In this case, the petitioner requested a budget amendment to pay $30 and $35 per hour for Supportive Home Care (SHC) services. The agency […] Read more

DHA Case No. CWA 215403 (Wis. Div. Hearings and Appeals Feb. 5, 2025) (DHS) ↓ Download PDF The IRIS program can pay for residential services, such as those provided in an adult family home (AFH), but “residential services” does not include the cost of room and board. In this case, the petitioner asked to increase […] Read more

DHA Case No. CWA 212613 (Wis. Div. Hearings and Appeals May 30, 2024) (DHS) ↓ Download PDF IRIS participants must pay their providers a “usual and customary rate.” In this case, the petitioner’s supported employment provided asked for a rate increase to maintain a competitive wage for employees and pay for rising health insurance, mileage, […] Read more

DHA Case No. CWA 212824 (Wis. Div. Hearings and Appeals Jun. 26, 2024) (DHS) ↓ Download PDF The Department may deny an IRIS budget amendment (BA) request if it is not cost-effective or necessary to achieve the participant’s long-term care outcomes. In this case, the petitioner sought a BA to fund a 4% increase in […] Read more

DHA Case No. CWA 212682 (Wis. Div. Hearings and Appeals Jul. 12, 2024) (DHS) ↓ Download PDF Customized goods or services under the IRIS program must generally be necessary and cost-effective. In this case, the petitioner already had one trained service dog (the training was approved in a prior appeal) but wanted IRIS to pay […] Read more

DHA Case No. 212756 (Wis. Div. Hearings and Appeals Aug. 19, 2024) (DHS) ↓ Download PDF To be approved, IRIS home modifications must address long-term care needs that increase independence; or ensure safe, accessible means of ingress/egress to living quarters; or “otherwise provide safe access to rooms, facilities or equipment within the participant’s living quarters.” […] Read more

DHA Case No. CWA 214423 (Wis. Div. Hearings and Appeals Nov. 6, 2024) (DHS) ↓ Download PDF IRIS funds may only be used for services, supports, or goods that address a long-term support need. In this case, the petitioner asked IRIS to pay for his participant-hired worker’s travel and lodging costs so he could attend […] Read more

DHA Case No. CWA 211701 (Wis. Div. Hearings and Appeals Mar. 5, 2024) (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’s request for twice-weekly mowing was denied. Although she claimed this was necessary to maintain a […] Read more

DHA Case No. CWA 211232 (Wis. Div. Hearings and Appeals Feb. 6, 2024) (DHS) ↓ Download PDF IRIS participants who fail to comply with program requirements or lose functional eligibility may be disenrolled. In this case, the petitioner needed to complete an annual long-term care functional screen but failed to respond to “multiple attempts” by […] Read more