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

DHA Case No. CWA 215905 (Wis. Div. Hearings and Appeals Apr. 11, 2025) (DHS) ↓ Download PDF IRIS enrollment and benefits may be backdated if agency error caused unreasonable delay. In this case, the petitioner’s renewal processing was delayed more than a month when a lead worker mistakenly required Letters of the Estate for a […] Read more

DHA Case No. CWA 212475 (Wis. Div. Hearings and Appeals Jan. 15, 2025) (DHS) ↓ Download PDF For Community Waivers benefits to be backdated, a delay in enrollment must be caused by agency error. In this case, the petitioner argued notices regarding her renewal were defective for various reasons, making some creative arguments. She also […] Read more

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