DHA Case No. FCP 220337 (Wis. Div. Hearings and Appeals Mar. 17, 2026) (DHS) ↓ Download PDF Enrollment in Family Care may be backdated if an unreasonable delay was caused by agency error. In this Milwaukee County case, the ADRC took four months to complete a functional screen and another three months to complete enrollment. […] Read more
Tag: 5.05 Home and Community-Based Waivers Long-Term Care
DHA Case No. CWA 220811 (Wis. Div. Hearings and Appeals Mar. 16, 2026) (DHS) ↓ Download PDF IRIS policy provides that a budget amendment (BA) may only be used for costs that exceed a recipient’s base budget and may not be transferred to a different service or service type. In this case, the agency reduced […] Read more
DHA Case No. CWA 220073 (Wis. Div. Hearings and Appeals Mar. 3, 2026) (DHS) (decision after rehearing) ↓ Download PDF IRIS participants must treat the people who are part of the program with respect, including having a safe space in the participant’s home for meetings. In this case, the agency sought disenrollment after a meeting […] Read more
DHA Case No. CWA 221689 (Wis. Div. Hearings and Appeals Apr. 28, 2026) (DHS) ↓ Download PDF An IRIS participant who receives Daily Living Skills Training services (now called Life Skills Training and Education services) must generally demonstrate skill development within a year, or longer if reasonably needed to acquire the skill. Also, as skills […] Read more
DHA Case No. CWA 221317 (Wis. Div. Hearings and Appeals Feb. 27, 2026) (DHS) ↓ Download PDF Every IRIS participant enrolled in the self-directed personal cares (SDPC) program must have a care plan signed annually by the participant’s SDPC nurse and physician. In this case, the petitioner’s SDPC nurse attempted to visit multiple times to […] Read more
DHA Case No. FCP 221117 (Wis. Div. Hearings and Appeals Feb. 23, 2026) (DHS) ↓ Download PDF Residential care services provided through Family Care MCOs may be authorized only when a member’s long-term care outcomes cannot be cost-effectively supported in the member’s home, or when a member’s health and safety cannot be adequately safe guarded […] Read more
DHA Case No. MGE 221661 (Wis. Div. Hearings and Appeals Feb. 20, 2026) (DHS) ↓ Download PDF 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 this case, the petitioner was enrolled in Family Care […] Read more
DHA Case No. CWA 220576 (Wis. Div. Hearings and Appeals Feb. 17, 2026) (DHS) ↓ Download PDF DHS has an obligation to ensure the IRIS program meets certain federal standards, such as the requirement that settings where home and community-based services are provided have the qualities listed in 42 C.F.R. §441.301(c)(4). In this case, the […] Read more
DHA Case No. CWK 220881 (Wis. Div. Hearings and Appeals Feb. 6, 2026) (DHS) ↓ Download PDF To be functionally eligible for the Children’s Long-Term Support Program, a child with a developmental disability who needs intermediate care must demonstrate substantial functional limitations in three areas. In this case, the petitioner was a 7-year-old with autism who […] Read more
DHA Case No. HMO 220800 (Wis. Div. Hearings and Appeals Feb. 2, 2026) (DHS) ↓ Download PDF Personal care worker (PCW) services for an activity are not medically necessary if the member can perform the activity safely with the use of an assistive device. In this case, the petitioner requested 24.5 hours per week of […] Read more
DHA Case No. CWA 220708 (Wis. Div. Hearings and Appeals Feb. 2, 2026) (DHS) ↓ Download PDF IRIS participants are assigned budgets based on their Long-Term Care Functional Screens, which they must generally stay within (or request a budget amendment). In this case, petitioner received 10 home-delivered meals per week due, in part, to chronic […] Read more
DHA Case No. MGE 220385 (Wis. Div. Hearings and Appeals Jan. 26, 2026) (DHS) ↓ Download PDF Enrollment in Family Care may be backdated if an unreasonable delay was caused by agency error. In this case, the petitioner was disenrolled when she failed to complete her renewal, then reapplied and was enrolled again eight months […] Read more
DHA Case No. MGE 220307 (Wis. Div. Hearings and Appeals Jan. 12, 2026) (DHS) ↓ Download PDF To be eligible for Family Care, an applicant must have a long-term care functional screen to determine his or her functional eligibility. In this case, the petitioner submitted an online ACCESS application indicating that she needed help with […] Read more
DHA Case No. FCP 220551 (Wis. Div. Hearings and Appeals Jan. 9, 2026) (DHS) ↓ Download PDF MCOs may not deny a service that is reasonable and necessary, and in an amount, scope, and duration needed to cost-effectively support the member’s long-term care outcomes. In this case, the petitioner lived in a 1-2 bed adult […] Read more
DHA Case No. FCP 220498 (Wis. Div. Hearings and Appeals Jan. 5, 2026) (DHS) ↓ Download PDF Services provided through the Family Care program must be cost-effective. In this case, the petitioner lived at an AFH and attended a nearby adult day service program that proved very beneficial. When he moved to a different AFH, […] Read more