DHA Case No. CWA 220139 (Wis. Div. Hearings and Appeals Jan. 2, 2026) (DHS) ↓ Download PDF To be functionally eligible for the IRIS program, an individual must belong to one of the following target groups (in addition to needing a nursing home level of care): frail elderly, adult with a physical disability, or adult […] Read more

DHA Case No. FCP 153514 (Wis. Div. Hearings and Appeals Jan. 31, 2014) (DHS) ↓ Download PDF The Medicaid Eligibility Handbook provides that spouses who live together are part of each other’s fiscal test group. In this case, the petitioner resided in assisted living on Family Care while his spouse resided in a separate home. […] Read more

DHA Case No. FCP 220016 (Wis. Div. Hearings and Appeals Dec. 8, 2025) (DHS) ↓ Download PDF Medicaid appeals must be filed within 45 days of the date of the notice of action. In this case, the petitioner was sent a cost share notice on April 11 but did not file an appeal until September […] Read more

DHA Case No. FCP 219890 (Wis. Div. Hearings and Appeals Nov. 13, 2025) (DHS) ↓ Download PDF Income received less often than monthly is generally prorated and counted, but the MEH directs: “do not count the prorated income until it is received.” In this case, the petitioner received a yearly annuity payment in January and […] Read more

DHA Case No. CWA 219979 (Wis. Div. Hearings and Appeals Oct. 27, 2025) (DHS) ↓ Download PDF To be eligible for Community Waivers programs, a person must be in one of the target groups—physical disability, frail elder, or developmental disability—in addition to needing a nursing home level of care. In this case, the 21-year-old petitioner […] Read more

DHA Case No. CWA 219333 (Wis. Div. Hearings and Appeals Oct. 15, 2025) (DHS) ↓ Download PDF Aperson enrolled in IRIS is required to pay a cost share as a condition of eligibility. In this case, the petitioner had more than $4,000 in overdue cost share and had previously entered a repayment agreement, but failed […] Read more

DHA Case No. CWA 217818 (Wis. Div. Hearings and Appeals Jun. 17, 2025) (DHS) ↓ Download PDF Aperson enrolled in IRIS is required to pay a cost share as a condition of eligibility. In this case, the petitioner had $7,000 in unpaid cost share and was denied re-enrollment in IRIS because he was unable to […] Read more

DHA Case No. FCP 217987 (Wis. Div. Hearings and Appeals Jun. 10, 2025) (DHS) ↓ Download PDF A person enrolled in Family Care is required to pay a cost share, though the Department may waive or reduce the requirement if undue financial hardship would result. In this case, the petitioner enrolled in Family Care March […] Read more

DHA Case No. MGE 215707 (Wis. Div. Hearings and Appeals Jan. 17, 2025) (DHS) ↓ Download PDF A person who has a cost share but fails to pay it is ineligible for Family Care. In this case, the petitioner lost eligibility for MAPP and thus had a cost share imposed. At the time of the […] Read more

DHA Case No. MGE 215261 (Wis. Div. Hearings and Appeals Oct. 21, 2024) (DHS) ↓ Download PDF Community Waivers members who are eligible for any other full-benefit Medicaid program (such as MAPP) are put in Group A and have no cost share; otherwise, they are put in Group B or B Plus and do have […] Read more

DHA Case No. MRA 213308 (Wis. Div. Hearings and Appeals Jul. 31, 2024) (DHS) ↓ Download PDF A Community Waivers member in Group B or B Plus may use spousal improverishment rules to give income to his or her spouse as an “institutionalized person,” but Group A members are excluded from that definition. In this […] Read more

DHA Case No. CWA 213191 (Wis. Div. Hearings and Appeals Jul. 15, 2024) (DHS) ↓ Download PDF Community Waivers members in Groups B and B Plus may use spousal improverishment rules to give income to their spouses, but Group A members may not. In this case, the petitioner was enrolled in Group B in 2019 […] Read more

DHA Case No. CWA 212695 (Wis. Div. of Hearings and Appeals June 24, 2024) (DHS) ↓ Download PDF Continuing enrollment in IRIS requires payment of the cost share. In this case, the petitioner had $1,102.50 of unpaid cost share that she argued was discharged in a bankruptcy court order. ALJ Teresa Perez concluded she lacked […] Read more

DHA Case No. MGE 211474 (Wis. Div. of Hearings and Appeals May 20, 2024) (DHS) ↓ Download PDF IRIS Consultant Agencies (ICAs) must now help participants maintain MA eligibility, including monitoring and reporting any medical or remedial expenses. In this case, the petitioner had more than $2,000 in privately paid personal care expenses that were […] Read more