DHA Case No. CWA 216468 (Wis. Div. Hearings and Appeals Aug. 4, 2025) (DHS) ↓ Download PDF Late renewals can cause a gap in Community Waivers enrollment, though the Department has allowed for an expedited re-enrollment process to minimize this. In this case, the petitioner completed a late renewal and would have used the expedited […] Read more

DHA Case No. CWA 217265 (Wis. Div. Hearings and Appeals Jul. 22, 2025) (DHS) ↓ Download PDF IRIS benefits may be backdated if agency error causes unreasonable delay. In this case, the petitioner admittedly failed to complete her renewal timely, resulting in a gap in benefits and needing to re-enroll with a new Fiscal Employer […] Read more

DHA Case No. CWA 217260 (Wis. Div. Hearings and Appeals Jul. 8, 2025) (DHS) ↓ Download PDF IRIS members may be disenrolled if they move to an ineligible living setting. In this case, the petitioner lived in his car for nine months before being disenrolled and did not have a plan to transition to an […] Read more

DHA Case No. CWA 218281 (Wis. Div. Hearings and Appeals Jun. 25, 2025) (DHS) ↓ Download PDF As stated in the recent DMS Ops Memo 25-07, 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 […] Read more

DHA Case No. CWA 216899 (Wis. Div. Hearings and Appeals Jun. 18, 2025) (DHS) ↓ Download PDF IRIS benefits may be backdated if agency error causes unreasonable delay. In this case, the petitioner had a gap in IRIS enrollment due to a late renewal, but it took an additional 77 days after her exedited re-enrollment […] Read more

DHA Case No. CWA 216814 (Wis. Div. Hearings and Appeals Jun. 18, 2025) (DHS) ↓ Download PDF IRIS benefits may be backdated if agency error causes unreasonable delay. In this case, the petitioner mistakenly reported a new life insurance policy during his renewal that was actually owned by his ex-wife. He then had understandable difficulty […] Read more

DHA Case No. CWA 217048 (Wis. Div. Hearings and Appeals Jun. 10, 2025) (DHS) ↓ Download PDF IRIS benefits may be backdated if agency error causes unreasonable delay. In this case, the petitioner was disenrolled from IRIS for failing to verify her husband’s income, but provided that verification and completed a Medicaid renewal the following […] Read more

DHA Case No. CWA 217567 (Wis. Div. Hearings and Appeals June 6, 2025) (DHS) ↓ Download PDF IRIS policy requires IRIS Consultant Agencies (ICAs) to provide assistance and education regarding eligibility, including assisting with maintaining financial eligibility at annual renewals. In this case, the petitioner’s ICA failed to help him navigate his annual renewal and […] Read more

DHA Case No. CWA 216813 (Wis. Div. Hearings and Appeals May 9, 2025) (DHS) ↓ Download PDF The IRIS waiver requires IRIS Consultant Agencies (ICAs) to monitor participants’ health and safety, address health and safety concerns with the participant, and ultimately disenroll participants when health and safety concerns remain despite remediation efforts. In this case, […] Read more

DHA Case No. CWA 217415 (Wis. Div. Hearings and Appeals May 5, 2025) (DHS) ↓ Download PDF The Department may disenroll IRIS participants if it cannot develop a plan that ensures the participant’s health and safety. In this case, the petitioner’s behavior support plan—staff call 911 and seek refuge in their cars if he gets […] Read more

DHA Case No. CWA 215899 (Wis. Div. Hearings and Appeals Jan. 30, 2025) (DHS) ↓ Download PDF An appeal of an adverse benefit determination by an MCO must generally be filed within 90 days. Additionally, issues that have been decided in a previous appeal are precluded. In this case, the petitioner faxed her appeal of […] Read more

DHA Case No. CWA 215921 (Wis. Div. Hearings and Appeals Jan. 22, 2025) (DHS) ↓ Download PDF Providers are generally not allowed to restrain MA participants, but this rule can be waived after an application to the Department. In this case, the petitioner had a waiver that expired June 21, 2024. Although his mother reapplied […] Read more

DHA Case No. CWA 216742 (Wis. Div. Hearings and Appeals Aug. 4, 2025) (DHS) ↓ Download PDF Under the Wisconsin Equal Access to Justice Act (WEAJA), petitioners who prevail in a fair hearing are entitled to an award of costs unless the agency’s action was “substantially justified.” In this case, the petitioner successfully appealed the […] Read more

DHA Case No. MGE 216221 (Wis. Div. Hearings and Appeals May 2, 2025) (DHS) ↓ Download PDF Re-enrollment in IRIS can be expedited if a renewal is completed late but within 30 days of disenrollment. In this case, the petitioner was disenrolled October 1 but ready to re-enroll October 7. But because his old fiscal […] Read more