DHA Case No. MDD 219938 (Wis. Div. Hearings and Appeals Oct. 23, 2025) (DHS) ↓ Download PDF The MAPP program allows disabled individuals to work but to retain eligibility for MA. In this case, the petitioner lost his SSI and “regular” MA when a new job put him over the substantial gainful activity limit, but […] Read more

DHA Case No. CWA 219663 (Wis. Div. Hearings and Appeals Oct. 13, 2025) (DHS) ↓ Download PDF An IRIS participant may be involuntarily disenrolled if the program cannot ensure the participant’s health and safety. In this case, the petitioner had 25 critical incidents (a critical incident is a medical emergency, law enforcement contact, or hospitalization) […] Read more

DHA Case No. BCS 219613 (Wis. Div. Hearings and Appeals Sep. 26, 2025) (DHS) ↓ Download PDF To be eligible for Wisconsin Medicaid programs, a person must be a resident of Wisconsin. In this case, the 21-year-old petitioner claimed to be a homeless resident of Wisconsin while attending college in Mississippi, where she had an […] Read more

DHA Case No. CWA 219278 (Wis. Div. Hearings and Appeals Sep. 11, 2025) (DHS) ↓ Download PDF Any negative action regarding a person enrolled in Medicaid must be preceded by proper notice. In this case, the petitioner lost her SSI eligibility but the agency never sent a notice before terminating her from IRIS. ALJ Brian […] Read more

DHA Case No. FCP 219093 (Wis. Div. Hearings and Appeals Aug. 25, 2025) (DHS) ↓ Download PDF The Family Care program must generally cover services that reasonably and effectively address the participant’s long-term needs, but those services must also be cost-effective. In this case, the petitioner’s home-delivered meals ended because his plan already included Supportive […] Read more

DHA Case No. CWA 219215 (Wis. Div. Hearings and Appeals Aug. 22, 2025) (DHS) ↓ Download PDF Any negative action regarding a person enrolled in Medicaid must be preceded by proper notice that includes appeal rights. In this case, the petitioner lost her SSI eligibility but the agency never sent a notice with appeal rights […] Read more

DHA Case No. CWA 218656 (Wis. Div. Hearings and Appeals Jul. 30, 2025) (DHS) ↓ Download PDF To be functionally eligible for community waivers programs, an individual must require a “nursing home” level of care and be part of a target group. In this case, the petitioner had a unique diagnosis of Functional Neurologic Disorder/Conversion […] Read more

DHA Case No. CWK 218183 (Wis. Div. Hearings and Appeals Jun. 17, 2025) (DHS) ↓ Download PDF The Children’s Long-Term Support Program (CLTS) can cover health and wellness activities, but services generally cannot be duplicative and payments cannot be made directly to the participant or to another person on behalf of the participant. In this […] 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. 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. 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. 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. MPA 216849 (Wis. Div. Hearings and Appeals Mar. 14, 2025) (DHS) ↓ Download PDF Orthodontia is generally not an MA-covered service, but must be covered for recipients under age 21 if the Early and Periodic Screening, Diagnosis and Treatment (EPSDT) health assessment and evaluation indicates that it is needed. Finding exceptional circumstances […] Read more

DHA Case No. CWK 216266 (Wis. Div. Hearings and Appeals Mar. 12, 2025) (DHS) ↓ Download PDF Achild in the Children’s Long-Term Support (CLTS) program must be recertified annually, including an updated functional screen. In this case, the petitioner was found functionally ineligible at her recertification, based on the criteria for the psychiatric hospital level […] Read more