DHA Case No. FCP 220397 (Wis. Div. Hearings and Appeals Dec. 29, 2025) (DHS) ↓ Download PDF The Family Care program, through MCOs, must generally provide services that reasonably and effectively address all of the recipient’s long-term needs and outcomes, assist the recipient to be as self-reliant and autonomous as possible, and are cost effective. […] Read more
Tag: 5.05 Home and Community-Based Waivers Long-Term Care
DHA Case No. CWA 219952 (Wis. Div. Hearings and Appeals Dec. 10, 2025) (DHS) ↓ Download PDF The Department may deny enrollment in the IRIS program for substantiated fraud during a previous enrollment, living in an ineligible residential setting, or inability or unwillingness to develop an Individual Support and Service Plan (ISSP) that ensures the […] 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. CWA 219262 (Wis. Div. Hearings and Appeals Dec. 29, 2025) (DHS) ↓ Download PDF IRIS enrollment and services generally require the participant to reside in a permanent living arrangement, though the participant can apply while in transitional housing and there is an exception for temporary absences up to 90 days. In this […] Read more
DHA Case No. MDV 220070 (Wis. Div. Hearings and Appeals Dec. 10, 2025) (DHS) ↓ Download PDF The action of avoiding the receipt of income that a Medicaid member is entitled to is a divestment. In this case, the petitioner revocably renounced a VA survivor’s pension, which was $948 normal pension and $567 Aid and […] Read more
DHA Case No. CWA 220073 (Wis. Div. Hearings and Appeals Dec. 5, 2025) (DHS) ↓ Download PDF When the IRIS program ends a participant’s enrollment involuntarily, it bears the burden of proof to show that the disenrollment was proper. In this case, the IRIS Consultant (IC) submitted only an unsigned, unsworn written statement about an […] Read more
DHA Case No. FCP 220319 (Wis. Div. Hearings and Appeals Nov. 17, 2025) (DHS) ↓ Download PDF MCOs must develop service plans that reasonably and effectively address the member’s long-term needs and outcomes while also being cost-effective. In this case, My Choice sought to end the petitioner’s placement in an AFH in favor of a […] 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 219687 (Wis. Div. Hearings and Appeals Nov. 13, 2025) (DHS) ↓ Download PDF While ADRCs do not have primary responsibility for assisting people with Medicaid applications, they are contracted to provide general assistance, including assistance with obtaining verification. In this case, the ADRC faxed verification documents for the petitioner to Income […] Read more
DHA Case No. MDV 220057 (Wis. Div. Hearings and Appeals Nov. 10, 2025) (DHS) ↓ Download PDF A divestment does not affect eligibility if the resource was “transferred exclusively for some purpose other than to become eligible for MA.” In this case, the petitioner gave $5,000 to each of her three daughters (to one for […] Read more
DHA Case No. FCP 219522 (Wis. Div. Hearings and Appeals Oct. 28, 2025) (DHS) ↓ Download PDF When an MCO reduces a service, it has the burden to prove that the reduction is appropriate. In this case, Inclusa sought to end a lawn care service because it expected the petitioner’s wife to do the yard […] Read more
DHA Case No. MGE 219667 (Wis. Div. Hearings and Appeals Oct. 21, 2025) (DHS) ↓ Download PDF When a person receiving SSI and Medicaid loses SSI eligibility because they start receiving SSDI Disabled Adult Child (DAC) payments, the Medicaid program must treat the person as if they were still receiving SSI. In this case, that […] Read more
DHA Case No. FCP 219433 (Wis. Div. Hearings and Appeals Oct. 16, 2025) (DHS) ↓ Download PDF Family Care MCOs must generally cover services that are needed, but those services must also be cost-effective. In this case, the petitioner was 36 years old, had a corporate guardian, was looking for employment in the community, and […] Read more
DHA Case No. FCP 218749 (Wis. Div. Hearings and Appeals Oct. 14, 2025) (DHS) ↓ Download PDF When an agency error causes delay in an individual’s enrollment in an MCO, the Department may adjust the individual’s enrollment date. In this case, the petitioner contacted the ADRC October 28 but an options counselor was not assigned […] Read more
DHA Case No. CWA 219315 (Wis. Div. Hearings and Appeals Oct. 9, 2025) (DHS) ↓ Download PDF The IRIS program must generally cover services that are needed and cost-effective. In this case, the petitioner had severe violent behavior that culminated in felony charges after attacking a staff member. After that, only one AFH was both […] Read more