5 Subprograms

DHA Case No. MDD 207614 (Wis. Div. of Hearings and Appeals April 24, 2023) (DHS) ↓ Download PDF To be eligible for the MAPP program, the applicant must meet the SSI definition of disability. This disability determination considers the applicant’s functional capacity to do various kinds of work. In this case, the applicant was 30 […] Read more

DHA Case No. MPA 207590 (Wis. Div. of Hearings and Appeals April 3, 2023) (DHS) ↓ Download PDF A specialized bed may be provided under the MA program when prescribed by a physician, but it must be cost-effective and not solely for the comfort or convenience of the recipient. In this case, the petitioner was […] Read more

DHA Case No. CWK 207268 (Wis. Div. of Hearings and Appeals March 28, 2023) (DHS) ↓ Download PDF The Children’s Long-Term Support (CLTS) Waiver program can pay for needed home modifications, but they must be cost-effective and solely benefit the participant. In this case, the participant’s mother asked for an interior open-concept remodel, a fence, […] Read more

DHA Case No. FCP 206703 (Wis. Div. of Hearings and Appeals February 16, 2023) (DHS) ↓ Download PDF Family Care can provide supportive home care (SHC) hours to cover services that are necessary, reasonable, appropriate, and cost-effective. In this case, the petitioner’s mother sought an increase in SHC hours so she could be paid to […] Read more

DHA Case No. MPA 206828 (Wis. Div. of Hearings and Appeals January 23, 2023) (DHS) ↓ Download PDF Medicaid can cover durable medical equipment if it is medically necessary, a determination that includes cost-effectiveness. In this case, the petitioner—a 4-year-old with a genetic disorder who was “unable to understand safety, cause and effect, risk, or […] Read more

DHA Case No. CWA 206353 (Wis. Div. of Hearings and Appeals January 17, 2023) (DHS) ↓ Download PDF Services included in an IRIS member’s budget must be cost effective and at the usual and customary rate for the area. In this case, the petitioner’s medical transportation provider increased its rate for transporting him to his […] Read more

DHA Case No. MPA 207077 (Wis. Div. of Hearings and Appeals January 27, 2023) (DHS) ↓ Download PDF Personal care services under Medicaid must be medically necessary and cost-effective. In this case, the petitioner asked for 19.5 Personal Care Worker (PCW) hours per week but was only approved for 10.25. ALJ Brian Schneider upheld the […] Read more

DHA Case No. CWA 206183 (Wis. Div. of Hearings and Appeals January 17, 2023) (DHS) ↓ Download PDF The moving party generally has the burden of proof; when an IRIS participant requests new services, the participant must prove that the requested services meet approval criteria by a preponderance of the evidence. In this case, the […] Read more

DHA Case No. FCP 206264 (Wis. Div. of Hearings and Appeals January 11, 2023) (DHS) ↓ Download PDF In the Family Care program, the MCO must develop an Individual Service Plan with the client that addresses the client’s needs. When the MCO seeks to change that plan and reduce services, it has the burden of […] Read more

DHA Case No. FCP 208209 (Wis. Div. of Hearings and Appeals May 31, 2023) (DHS) ↓ Download PDF In the Family Care program, the MCO must develop an Individual Service Plan with the client that addresses the client’s needs while being cost-effective. The MCO does not have to provide a service if there are less […] Read more

DHA Case No. FCP 207870 (Wis. Div. of Hearings and Appeals May 19, 2023) (DHS) ↓ Download PDF Family Care benefits generally cannot be backdated, except that retroactive enrollment can be ordered by an ALJ to correct delay caused by agency error. In this case, the petitioner applied January 25, the application was processed February […] Read more

DHA Case No. CWA 207516 (Wis. Div. of Hearings and Appeals May 18, 2023) (DHS) ↓ Download PDF An IRIS participant may request a budget amendment to pay for an ongoing need not met within the current budget. In this case, the petitioner asked for a budget increase when her home health agency ended her […] Read more

DHA Case No. FCP 207491 (Wis. Div. of Hearings and Appeals May 9, 2023) (DHS) ↓ Download PDF A Family Care MCO’s member-centered plan must assess and identify “long-term care outcomes that are consistent with the values and preference of the enrollee” in the areas of both “self-determination of daily routine, services, activities and living […] Read more

DHA Case No. MQB 207494 (Wis. Div. of Hearings and Appeals May 1, 2023) (DHS) ↓ Download PDF For the Qualified Medicare Beneficiary (QMB) program, benefits cannot begin until the month after the application is processed. In this straightforward case, the petitioner applied but did not complete verification until November 14. ALJ John Tedesco concluded […] Read more