DHA Case No. CWA 217836 (Wis. Div. Hearings and Appeals Jul. 1, 2025) (DHS) ↓ Download PDF An IRIS participant may be involuntarily disenrolled for mismanagement of budget authority or employer authority. In this case, the petitioner was disenrolled because his family caregivers continually billed excess hours for supportive home care, overspending his budget by […] Read more

DHA Case No. CWA 217841 (Wis. Div. Hearings and Appeals Jun. 27, 2025) (DHS) ↓ Download PDF IRIS participants may submit one-time expense requests to pay for goods or services, including adaptive aids such as vehicle modifications. In this case, the petitioner requested a wheelchair conversion for a new SUV, which TMG denied as not […] Read more

DHA Case No. CWA 217818 (Wis. Div. Hearings and Appeals Jun. 17, 2025) (DHS) ↓ Download PDF Aperson enrolled in IRIS is required to pay a cost share as a condition of eligibility. In this case, the petitioner had $7,000 in unpaid cost share and was denied re-enrollment in IRIS because he was unable to […] Read more

DHA Case No. CWA 217154 (Wis. Div. Hearings and Appeals Jun. 17, 2025) (DHS) ↓ Download PDF IRIS participants may be disenrolled if they cannot or will not address health and safety concerns. In this case, the petitioner had seizures and “episodes of disorientation,” during which his caregiver would lock or barricade him in his […] Read more

DHA Case No. FCP 217987 (Wis. Div. Hearings and Appeals Jun. 10, 2025) (DHS) ↓ Download PDF A person enrolled in Family Care is required to pay a cost share, though the Department may waive or reduce the requirement if undue financial hardship would result. In this case, the petitioner enrolled in Family Care March […] Read more

DHA Case No. CWA 217677 (Wis. Div. Hearings and Appeals Jun. 9, 2025) (DHS) ↓ Download PDF To be functionally eligible for the IRIS program, an individual must require a “nursing home” level of care. In this case, the petitioner needed assistance with dressing and used adaptive equipment for bathing; he also needed assistance with […] Read more

DHA Case No. FCP 217858 (Wis. Div. Hearings and Appeals Jun. 2, 2025) (DHS) ↓ Download PDF An individual in the Family Care program must have an Individual Service Plan (ISP) that reasonably and effectively addresses their needs but is also cost-effective. In this case, the petitioner’s MCO (Inclusa) ended coverage of an independent nurse—who […] Read more

DHA Case No. CWA 216919 (Wis. Div. Hearings and Appeals May 30, 2025) (DHS) ↓ Download PDF An IRIS participant’s budget is based in their long-term care functional screen. In this case, the petitioner’s Supportive Home Care (SHC) hours were reduced from 22.25 to 5 hour per week, even though his most recent functional screen […] Read more

DHA Case No. CWA 217205 (Wis. Div. Hearings and Appeals May 13, 2025) (DHS) ↓ Download PDF To be functionally eligible for home and community based long term care services, an individual must require a “nursing home” level of care. In this case, the petitioner’s condition improved after a bone marrow transplant; an updated functional […] Read more

DHA Case No. CWA 216858 (Wis. Div. Hearings and Appeals May 9, 2025) (DHS) ↓ Download PDF A person is functionally eligible for IRIS if, among other criteria, the person cannot safely or appropriately perform one or more ADL and 3 or more IADLs and has cognitive impairment. In this case, the petitioner was a […] Read more

DHA Case No. FCP 216785 (Wis. Div. Hearings and Appeals Apr. 14, 2025) (DHS) ↓ Download PDF To be functionally eligible for home and community based long term care services through the PACE program, an individual must require a “nursing home” level of care. In this case, the petitioner required assistance with one ADL and […] Read more

DHA Case No. FCP 216652 (Wis. Div. Hearings and Appeals Apr. 14, 2025) (DHS) ↓ Download PDF Aservice that is “duplicative with respect to other services being provided” is not medically necessary. In this case, the petitioner lived in an Adult Family Home (AFH) and attended adult day services at a community provider. The MCO […] Read more

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