DHA Case No. FCP 217068 (Wis. Div. Hearings and Appeals Apr. 7, 2025) (DHS) ↓ Download PDF Aservice that is “duplicative with respect to other services being provided” is not medically necessary. In this case, the petitioner attended adult day services with a certain provider while living with her siblings for several years. But when […] Read more

DHA Case No. FCP 216051 (Wis. Div. Hearings and Appeals Mar. 28, 2025) (DHS) ↓ Download PDF Whether Family Care must cover placement in an Adult Family Home (AFH) or other group home setting depends on the general criteria of medical necessity and cost-effectivness, among others. In this case, the petitioner lived in an apartment […] Read more

DHA Case No. FCP 216227 (Wis. Div. Hearings and Appeals Mar. 27, 2025) (DHS) ↓ Download PDF A participant in Family Care cannot be disenrolled without proper advance notice. In this case, the petitioner apparently missed a yearly renewal due in August and had difficulty navigating the re-enrollment process with the ADRC (“sometime in December […] Read more

DHA Case No. CWA 216153 (Wis. Div. Hearings and Appeals Mar. 26, 2025) (DHS) ↓ Download PDF When a petitioner is disenrolled due to agency error, ALJs often correct the error by ordering continued enrollment. In this case, the petitioner made numerous attempts to timely complete a renewal but was unable to due to agency […] Read more

DHA Case No. CWA 216762 (Wis. Div. Hearings and Appeals Mar. 19, 2025) (DHS) ↓ Download PDF Around 2017 DHS instituted a policy that a caregiver should not be approved for more than 40 hours per week of paid services, including SHC covered by IRIS and other forms of caregiving such as personal care worker […] Read more

DHA Case No. CWA 216860 (Wis. Div. Hearings and Appeals Mar. 18, 2025) (DHS) ↓ Download PDF IRIS participants must pay their providers a “usual and customary rate.” In this case, the petitioner sought an increase in the daily rate of his adult day services provider from $157.50 to $168.50. Noting the difference between the customary […] Read more

DHA Case No. FCP 216638 (Wis. Div. Hearings and Appeals Feb. 20, 2025) (DHS) ↓ Download PDF Aperson is functionally eligible for Community Waivers long-term care programs if, among other criteria, the person cannot safely or appropriately perform 5 or more IADLs. In this case, the petitioner’s functional screen clearly indicated she needed help with […] Read more

DHA Case No. CWA 216647 (Wis. Div. Hearings and Appeals Feb. 17, 2025) (DHS) ↓ Download PDF An IRIS participant may be disenrolled if the agency is unable to ensure the participant’s health and safety. In this case, the petitioner lived with her daughter, who was also her caregiver and guardian. The petitioner eloped from […] Read more

DHA Case No. CWA 216141 (Wis. Div. Hearings and Appeals Feb. 13, 2025) (DHS) ↓ Download PDF IRIS participants may be involuntarily disenrolled for failure to spend the funds in their budget. In this case, the petitioner was repeatedly warned that her failure to spend her IRIS budget could result in disenrollment, and she ultimately […] Read more

DHA Case No. CWA 216117 (Wis. Div. Hearings and Appeals Feb. 11, 2025) (DHS) ↓ Download PDF IRIS benefits may be backdated if agency error causes unreasonable delay. In this case, the petitioner’s renewal was due September 17 and partially submitted on September 18, but a required signature was not provided until October 10, resulting […] Read more

DHA Case No. CWA 216047 (Wis. Div. Hearings and Appeals Feb. 3, 2025) (DHS) ↓ Download PDF IRIS benefits may be backdated if agency error causes unreasonable delay. In this case, the petitioner applied September 4 but did not complete verification until October 14, resulting in an enrollment date of November 1. Although the petitioner’s […] Read more

DHA Case No. CWA 215937 (Wis. Div. Hearings and Appeals Jan. 31, 2025) (DHS) ↓ Download PDF IRIS benefits may be backdated if agency error causes unreasonable delay. In this case, the petitioner applied August 27, verified assets on October 3, and finished verification with proof of medical premiums November 5. Although the petitioner’s guardian […] Read more

DHA Case No. MGE 215707 (Wis. Div. Hearings and Appeals Jan. 17, 2025) (DHS) ↓ Download PDF A person who has a cost share but fails to pay it is ineligible for Family Care. In this case, the petitioner lost eligibility for MAPP and thus had a cost share imposed. At the time of the […] Read more

DHA Case No. CWA 215724 (Wis. Div. Hearings and Appeals Jan. 10, 2025) (DHS) ↓ Download PDF A person is functionally eligible for Community Waivers long-term care programs if, among other criteria, the person cannot safely or appropriately perform 5 or more IADLs or 4 IADLs and has a cognitive impairment. In this case, the […] Read more