5.05 Home and Community-Based Waivers Long-Term Care

DHA Case No. FCP 211106 (Wis. Div. of Hearings and Appeals January 23, 2024) (DHS) ↓ Download PDF An individual is functionally eligible for Family Care if he or she needs a “nursing home” level of care, as determined by the functional screen—but occasionally the screening program is wrong. In this case, the petitioner used […] Read more

DHA Case No. FCP 210267 (Wis. Div. of Hearings and Appeals January 25, 2024) (DHS) ↓ Download PDF Supportive Home Care (SHC) can be a benefit provided through Family Care when the member needs assistance with chores. In this case, Inclusa sought to end the petitioner’s SHC, claiming vaguely that “petitioner may be able to […] Read more

DHA Case No. FCP 210269 (Wis. Div. of Hearings and Appeals January 26, 2024) (DHS) ↓ Download PDF Non-medical transportation can be a benefit provided through Family Care when the member needs assistance with transportation. In this case, Inclusa sought to end the petitioner’s non-medical transportation, claiming vaguely that “petitioner may be able to walk […] Read more

DHA Case No. FCP 211038 (Wis. Div. of Hearings and Appeals January 31, 2024) (DHS) ↓ Download PDF When an MCO seeks to reduce a member’s supportive home care budget, it has the burden of proof. In this case, the petitioner’s MCO sought to reduce his budget because his son reported some minor improvements. ALJ […] Read more

DHA Case No. FCP 206451 (Wis. Div. of Hearings and Appeals January 30, 2023) (DHS) ↓ Download PDF A medically necessary service must not be duplicative of other services already being provided. In this case, the petitioner had been in a program for 14 years that allowed him to participate in 3 community events every […] Read more

DHA Case No. FCP 206397 (Wis. Div. of Hearings and Appeals January 17, 2023) (DHS) ↓ Download PDF Family Care generally does not cover household repairs or improvements that are not directly related to the member’s care. In this case, the petitioner’s carpet was fouled and beyond cleaning, so she asked her MCO to replace […] Read more

DHA Case No. FCP 210973 (Wis. Div. of Hearings and Appeals January 16, 2024) (DHS) ↓ Download PDF Family Care enrollment can be backdated if agency error by the ADRC or IM causes unreasonable delay. In this case, the petitioner’s authorized representative failed to complete his renewal: she “apparently left employment with her payee company, […] Read more

DHA Case No. FCP 209929 (Wis. Div. of Hearings and Appeals January 12, 2024) (DHS) ↓ Download PDF Family Care enrollment can be backdated if agency error by the ADRC or IM causes unreasonable delay. In this case, the ADRC sent the Community Waivers referral to IM on June 16, but “for reasons unclear” IM […] Read more

DHA Case No. MGE 209925 (Wis. Div. of Hearings and Appeals January 12, 2024) (DHS) ↓ Download PDF Family Care enrollment can be backdated if agency error by the ADRC or IM causes unreasonable delay. In this case, the petitioner was eligibile on July 6 but not enrolled until July 21 because the ADRC mistakenly […] Read more

DHA Case No. FCP 209869 (Wis. Div. of Hearings and Appeals January 12, 2024) (DHS) ↓ Download PDF In general, the ADRC has 30 days from the date of request to determine functional eligibility or provide notice of a delay; IM has 30 days from the date of application to determine financial eligibility. In this […] Read more

DHA Case No. FCP 209037 (Wis. Div. of Hearings and Appeals November 14, 2023) (DHS) ↓ Download PDF The Department may backdate Family Care enrollment when there is an agency error that causes an unreasonable delay. In this case, the petitioner was found eligible in December of 2022 and the MCO received her enrollment form […] Read more

DHA Case No. MGE 209343 (Wis. Div. of Hearings and Appeals October 2, 2023) (DHS) ↓ Download PDF The balance of a land contract is counted as an available asset unless its terms prohibit transfer or no one is willing to purchase it. In this case, the petitioner was selling non-homestead real estate under a […] Read more

DHA Case No. CWA 208861 (Wis. Div. of Hearings and Appeals November 10, 2023) (DHS) ↓ Download PDF In general, a service covered by IRIS must be necessary and cost-effective. In this case, the petitioner sought an increase in the rate paid to his AFH from $194.37 per day to $309.20 per day. Thanks largely […] Read more

DHA Case No. CWA 208719 (Wis. Div. of Hearings and Appeals October 23, 2023) (DHS) ↓ Download PDF An IRIS participant may be involuntarily disenrolled for loss of functional eligibility. In this case, the agency attempted to disenroll the petitioner from the IRIS self-directed personal care (SDPC) program only, not IRIS itself, for loss of functional […] Read more