DHA Case No. FCP 221245 (Wis. Div. Hearings and Appeals Mar. 19, 2026) (DHS) ↓ Download PDF In the Family Care program, the MCO does not have to provide a service the participant wants if there are less expensive alternatives that achieve the same results. In this case, the MCO terminated the petitioner’s AFH funding […] Read more

DHA Case No. FCP 220220 (Wis. Div. Hearings and Appeals Mar. 19, 2026) (DHS) ↓ Download PDF An MCO may not deny a service that is reasonable and necessary to cost-effectively support a member’s long-term care outcomes. In this case, the petitioner had been living at home and receiving adult day care services. When she […] Read more

DHA Case No. CWA 221163 (Wis. Div. Hearings and Appeals Mar. 19, 2026) (DHS) ↓ Download PDF Services provided by IRIS must be cost-effective. In this case, the petitioner requested a budget amendment to pay for an increased hourly rate by the supported employment provider, whose rate had increased substantially over the past several years. […] Read more

DHA Case No. FCP 220337 (Wis. Div. Hearings and Appeals Mar. 17, 2026) (DHS) ↓ Download PDF Enrollment in Family Care may be backdated if an unreasonable delay was caused by agency error. In this Milwaukee County case, the ADRC took four months to complete a functional screen and another three months to complete enrollment. […] Read more

DHA Case No. CWA 220073 (Wis. Div. Hearings and Appeals Mar. 3, 2026) (DHS) (decision after rehearing) ↓ Download PDF IRIS participants must treat the people who are part of the program with respect, including having a safe space in the participant’s home for meetings. In this case, the agency sought disenrollment after a meeting […] Read more

DHA Case No. MGE 220385 (Wis. Div. Hearings and Appeals Jan. 26, 2026) (DHS) ↓ Download PDF Enrollment in Family Care may be backdated if an unreasonable delay was caused by agency error. In this case, the petitioner was disenrolled when she failed to complete her renewal, then reapplied and was enrolled again eight months […] Read more

DHA Case No. MLL 220239 (Wis. Div. Hearings and Appeals Dec. 10, 2025) (DHS) ↓ Download PDF A request for a hardship waiver of estate recovery must be mailed within 45 days of the Department’s claim. In this case, the petitioner “was under the mistaken understanding that his oral communications with department representatives were sufficient” […] Read more

DHA Case No. CWA 219952 (Wis. Div. Hearings and Appeals Dec. 10, 2025) (DHS) ↓ Download PDF The Department may deny enrollment in the IRIS program for substantiated fraud during a previous enrollment, living in an ineligible residential setting, or inability or unwillingness to develop an Individual Support and Service Plan (ISSP) that ensures the […] Read more

DHA Case No. CWK 220287 (Wis. Div. Hearings and Appeals Dec. 16, 2025) (DHS) ↓ Download PDF To be covered by the CLTS program, a service dog must (a) do work or perform tasks for the benefit of a person with a disability, who (b) has a disability that substantially limits his/her ability to perform […] Read more

DHA Case No. MDV 220070 (Wis. Div. Hearings and Appeals Dec. 10, 2025) (DHS) ↓ Download PDF The action of avoiding the receipt of income that a Medicaid member is entitled to is a divestment. In this case, the petitioner revocably renounced a VA survivor’s pension, which was $948 normal pension and $567 Aid and […] Read more

DHA Case No. CWA 220073 (Wis. Div. Hearings and Appeals Dec. 5, 2025) (DHS) ↓ Download PDF When the IRIS program ends a participant’s enrollment involuntarily, it bears the burden of proof to show that the disenrollment was proper. In this case, the IRIS Consultant (IC) submitted only an unsigned, unsworn written statement about an […] Read more

DHA Case No. FCP 219522 (Wis. Div. Hearings and Appeals Oct. 28, 2025) (DHS) ↓ Download PDF When an MCO reduces a service, it has the burden to prove that the reduction is appropriate. In this case, Inclusa sought to end a lawn care service because it expected the petitioner’s wife to do the yard […] Read more

DHA Case No. CWA 219173 (Wis. Div. Hearings and Appeals Oct. 1, 2025) (DHS) ↓ Download PDF When a person’s eligibility for SSI ends, agency policy is to automatically run Medicaid eligibility under other criteria. In this case, the petitioner’s SSI ended and she even received a notice saying she didn’t need to do anything […] Read more

DHA Case No. MGE 219014 (Wis. Div. Hearings and Appeals Oct. 6, 2025) (DHS) ↓ Download PDF IRIS enrollment dates may be revised if the agency is the cause of a wrongful termination of IRIS enrollment. In this case, the agency sent advance notice of the renewal deadline and a notice requiring verification of a […] Read more