5.05 Home and Community-Based Waivers Long-Term Care

DHA Case No. MGE 209206 (Wis. Div. of Hearings and Appeals November 8, 2023) (DHS) ↓ Download PDF DHA Case No. CWA 209207 (Wis. Div. of Hearings and Appeals November 8, 2023) (DHS) ↓ Download PDF The principal or income of an irrevocable trust funded with a Medicaid applicant’s resources is countable if there are […] Read more

DHA Case No. FCP 209188 (Wis. Div. of Hearings and Appeals September 5, 2023) (DHS) ↓ Download PDF An appeal of a negative MA decision must be filed, at most, within 90 days (for most decisions it’s 45 days). In this case, the petitioner’s cost share was increased by notices effective September 1, 2022 and […] Read more

DHA Case No. MGE 210503 (Wis. Div. of Hearings and Appeals December 19, 2023) (DHS) ↓ Download PDF After enrollment in a long-term care Medicaid program, the institutionalized spouse must spend down or transfer resources to the community spouse to get below $2,000 by the first renewal. In this case, the petitioner failed to do […] Read more

DHA Case No. FCP 210574 (Wis. Div. of Hearings and Appeals November 30, 2023) (DHS) ↓ Download PDF An MCO must give ten days’ notice of any adverse benefit determination. In this case, the petitioner’s MCO issued a notice on September 29 disenrolling her retroactive to August 21. ALJ Brian Schneider concluded the MCO had not […] Read more

DHA Case No. CWA 208939 (Wis. Div. of Hearings and Appeals August 21, 2023) (DHS) ↓ Download PDF When a person must use adaptive aids to perform an activity of daily living (ADL), this counts as needing assistance with the ADL for functional eligibility. In this case, the petitioner was disenrolled from IRIS after a […] Read more

DHA Case No. CWA 210286 (Wis. Div. of Hearings and Appeals November 2, 2023) (DHS) ↓ Download PDF The Department may deny an IRIS application for an inability or unwillingness to develop an Individual Support and Service Plan (ISSP) that ensures the participant’s health and safety. In this case, the petitioner was previously disenrolled in […] Read more

DHA Case No. CWA 208908 (Wis. Div. of Hearings and Appeals October 27, 2023) (DHS) ↓ Download PDF In this brief case, the petitioner appealed the termination of her IRIS benefits due to losing functional eligibility. Because she did not appear at the hearing, ALJ John Tedesco dismissed the case and the IRIS termination was […] Read more

DHA Case No. FCP 208334 (Wis. Div. of Hearings and Appeals July 3, 2023) (DHS) ↓ Download PDF An ALJ may propose that Family Care enrollment be backdated only if the enrollment date was unnecessarily delayed by the ADRC or IM. In this case, the petitioner applied December 29, 2022 and the agency inaccurately processed […] Read more

DHA Case No. MGE 207780 (Wis. Div. of Hearings and Appeals July 14, 2023) (DHS) ↓ Download PDF A Medicaid applicant has an obligation to give the agency all relevant information. In this case, the petitioner applied in November 2022 and had an asset assessment as of that date, which presumably resulted in a $50,000 […] Read more

DHA Case No. CWA 198542 (Wis. Div. of Hearings and Appeals July 21, 2020) (DHS) ↓ Download PDF The IRIS program can pay for home modifications that address “disability related long-term care needs that increase self-reliance and independence, or ensure safe, accessible means of ingress/egress to a participant’s living quarters, or otherwise provide safe access […] Read more

DHA Case No. CWA 205245 (Wis. Div. of Hearings and Appeals September 12, 2022) (DHS) ↓ Download PDF IRIS participants may hire their own workers to provide supportive home care (SHC). The participant is responsible for negotiating “reasonable and customary rates” with providers. In this case, the petitioner asked to increase her worker’s hourly rate […] Read more

DHA Case No. MGE 209688 (Wis. Div. of Hearings and Appeals October 19, 2023) (DHS) ↓ Download PDF A recipient of IRIS must usually pay a cost share after deducting a basic needs allowance, a special housing amount, health insurance premiums, and certain out-of-pocket medical/remedial expenses. In this case, the petitioner had fairly high income […] Read more

DHA Case No. CWA 209455 (Wis. Div. of Hearings and Appeals October 2, 2023) (DHS) ↓ Download PDF An individual is functionally eligible for IRIS if he or she needs a “nursing home” level of care, as determined by the functional screen. In this case, the two most recent functional screens found the petitioner needed […] Read more

DHA Case No. FCP 192893 (Wis. Div. of Hearings and Appeals November 5, 2019) (DHS) ↓ Download PDF An ALJ may issue a proposed decision asking the DHS Secretary to backdate enrollment in Family Care if the normal enrollment date was unnecessarily delayed by either the ADRC or Income Maintenance. In this case, both the […] Read more