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. MRA 9/41969 (Wis. Div. Hearings and Appeals Dec. 9, 1999) (DHS) ↓ Download PDF Federal law defines “institutionalized spouse” as someone who is either: (a) in a medical institution and whose spouse is not in a medical institution, or (b) receiving Community Waivers services and whose spouse is not in a medical […] Read more

DHA Case No. MRA 70/21384 (Wis. Div. Hearings and Appeals Mar. 30, 1998) (DHS) ↓ Download PDF The Medicaid Eligibility Handbook defines a “community spouse” as someone who is both married to an institutionalized person and not living in a medical institution for 30 or more days. In this case, the petitioner resided in a […] Read more

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

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