5.05 Home and Community-Based Waivers Long-Term Care

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

DHA Case No. FCP 207387 (Wis. Div. of Hearings and Appeals March 30, 2023) (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

DHA Case No. FCP 206978 (Wis. Div. of Hearings and Appeals April 7, 2023) (DHS) ↓ Download PDF In the Family Care program, the MCO must develop an Individual Service Plan (ISP) that reasonably and effectively addresses the enrollee’s long-term care needs and outcomes and is cost-effective. In this case, Community Care ended the petitioner’s […] Read more

DHA Case No. CWA 207243 (Wis. Div. of Hearings and Appeals May 19, 2023) (DHS) ↓ Download PDF The Department must ensure the health and safety of IRIS participants. The IRIS policy manual allows involuntary disenrollment for “health and safety risks that participants are unable or unwilling to resolve.” In this case, the petitioner’s mother […] Read more

DHA Case No. FCP 206782 (Wis. Div. of Hearings and Appeals January 11, 2023) (DHS) ↓ Download PDF To be functionally eligible for Family Care, a person must fall into one of the program’s target groups in addition to needing a nursing home level of care. In this case, the petitioner needed help with one […] Read more

DHA Case No. FCP 206604 (Wis. Div. of Hearings and Appeals January 5, 2023) (DHS) ↓ Download PDF Family Care members in Group A (due to eligibility for MAPP, for example) do not have a cost share. In this complex case, the petitioner lost MAPP eligibility when her child turned 18 and her fiscal test […] Read more

DHA Case No. CWA 206737 (Wis. Div. of Hearings and Appeals January 18, 2023) (DHS) ↓ Download PDF The IRIS Policy Manual allows involuntary disenrollment for “mismanagement of employer authority.” In this case, the petitioner’s son and approved personal care worker became incarcerated; then the petitioner’s grandson, who had the same name, took over care […] Read more

DHA Case No. FCP 203910 (Wis. Div. of Hearings and Appeals March 23, 2023) (DHS) ↓ Download PDF If payments to a relative for services exceed 10% of the maximum CSAS, the MEH requires a notarized agreement. In this case, the petitioner had an agreement to pay her daughters $500 per month, but it was […] Read more

DHA Case No. FCP 189482 (Wis. Div. of Hearings and Appeals February 27, 2019) (DHS) ↓ Download PDF To be covered under Family Care, a service must be cost-effective. In this case, the MCO denied the petitioner’s request to install an ADA-height elongated toilet in his rented apartment, saying there were less costly alternatives. ALJ […] Read more

DHA Case No. FCP 189820 (Wis. Div. of Hearings and Appeals February 6, 2019) (DHS) ↓ Download PDF To be covered under Family Care, a service must be medically necessary. In this case, the petitioner’s request for acupuncture therapy was denied because it had been tried and proved ineffective for her in the past. ALJ […] Read more

DHA Case No. CWA 189840 (Wis. Div. of Hearings and Appeals January 24, 2019) (DHS) ↓ Download PDF IRIS can pay for a participant-hired worker to attend a conference as a “Community Integration Event” if the participant is also attending. In this case, the petitioner’s mother attended a Fragile X conference alone; she apparently was […] Read more

DHA Case No. FCP 189985 (Wis. Div. of Hearings and Appeals January 14, 2019) (DHS) ↓ Download PDF MCOs must consider an MA recipient’s income when determining benefits. In this case, the petitioner’s MCO reduced his out-of-benefit food budget when he started working, reasoning he could contribute that towards the cost of his food. ALJ […] Read more

DHA Case No. FCP 189984 (Wis. Div. of Hearings and Appeals January 14, 2019) (DHS) ↓ Download PDF MCOs must consider an MA recipient’s income when determining benefits. In this case, the petitioner’s MCO reduced his out-of-benefit food budget when he started receiving the state supplemental SSI payment, reasoning he could contribute that towards the […] Read more