CWA 215300 (12/17/2024)
IRIS services reduced to prevent overspending budget, a cautionary tale

Preliminary Recitals

Pursuant to a petition filed on September 27, 2024, under Wis. Admin. Code § HA 3.03, to review a decision by Connections, in its capacity as an IRIS Consultant Agency contracted by the Department of Health Services, regarding IRIS, a hearing was held on November 6, 2024, by telephone.

The issue for determination is whether the agency properly reduced Petitioner’s supportive home care hours by seven hours per week, effective July 16, 2024, in an effort to prevent Petitioner from overspending her annual IRIS budget.

There appeared at that time the following persons:

PARTIES IN INTEREST:

Petitioner:
—

Respondent:
Department of Health Services
1 West Wilson Street, Room 651
Madison, WI 53703
By: Becky Glamm, Connections
Department of Health Services
PO Box 7851
Madison, WI 53707-7851

ADMINISTRATIVE LAW JUDGE:
Teresa A. Perez
Division of Hearings and Appeals

Findings of Fact

1. Petitioner is a 46-year old resident of Milwaukee County who resides in a home with her sister, —. See Respondent’s Ex. K.
2. Petitioner has suffered from multiple strokes and suffers from ataxia as a result. She has limited use of her arms and hands, is unable to bear weight on her legs, and cannot sit up without falling forward. Petitioner has a diagnosis of neurosyphilis and suffers from memory and cognition impairments as a result. See Respondent’s Ex. K.
3. Petitioner requires assistance with all activities of daily living and all instrumental activities of daily living with the exception of using the telephone, and also requires overnight care. See Respondent’s Ex. K.
4. Petitioner has received Medical Assistance home and community based long term care waiver services through the IRIS program since 2021. Connections is her current IRIS Consultant Agency.
5. Petitioner was allocated an annual IRIS budget of $32,211.60 for plan year November 1, 2023 through October 31, 2024 and received authorization to use $20,529.29 to purchase supportive home care services. See Respondent’s Ex. J.
6. —, Petitioner’s sister, and — are Petitioner’s paid IRIS caregivers. See Respondent’s Ex. J.
7. From November 1, 2023 through July 15, 2024, Petitioner was authorized to receive 10 hours of supportive home care from —. That amount was reduced to 3 hours per week effective July 16, 2024. From November 1, 2023 through August 24, 2024, Petitioner was authorized to receive 15 hours of supportive home care from —. That amount was reduced to 13 hours per week effective August 25, 2024. See Respondent’s Ex. J.
8. Petitioner paid — for more than the 15 hours per week of “supportive home care – live in” included in Petitioner’s Individual Services and Support Plan (ISSP) every month from November 2023 through July 2024. For the plan year November 1, 2023 through October 31, 2024, Petitioner billed $5,445.99 more than what she was authorized to bill for supportive home care – live in hours. During the same time period, she billed $1,262.50 less than what she was authorized to bill for supportive home care – non-live in hours. See Respondent’s Exs. D, F, G, and H.
9. On July 17, 2024, the agency notified Petitioner in writing that she had overspent $3,304.37 in the month of June 2024 and that “her supportive home care hours for — will be reduced to 3 hours / week effective 7/17/24.” The $3,304.37 figure included an amount that Petitioner overbilled for self-directed personal care (SDPC). See Respondent’s Exs. D, I, and J.
10. On September 27, 2024, Petitioner filed an appeal.

Discussion

The IRIS program is a Medical Assistance (MA) home and community-based long term care waiver program authorized under §1915(c) of the Social Security Act. IRIS is an alternative to Family Care, Partnership, and PACE—all of which are managed care programs. The IRIS program, in contrast, is designed to allow participants to direct their own care and to hire and direct their own workers. The waiver approved by the Centers for Medicare and Medicaid Services (CMS) which proves the program’s authority is available at https://www.dhs.wisconsin.gov/iris/hcbw.pdf. State policies governing administration of the IRIS program are included in the IRIS Policy Manual (available at http://www.dhs.wisconsin.gov/publications/P0/P00708.pdf) and IRIS Work Instructions (available at http://www.dhs.wisconsin.gov/publications/P0/P00708a.pdf).

Consistent with the terms of the approved waiver, every IRIS participant is assigned a budget which is generated based on information obtained during a screening of the participant’s long-term care functional needs. See Waiver, Appendix C-4. Relevant program policy provides: “The individual budget is an estimate of the participant’s expected needs and is based on information documented in the participant’s Long-Term Care Functional Screen (LTC FS).” IRIS Policy Manual, Sec. 5.3. With the assistance of an IRIS Consultant Agency (ICA), participants identify waiver allowable services that they need to meet their long term care outcomes. The cost of those services must typically fall within the budget estimate. Id. at 5.3A.

In this case, the agency presented evidence that demonstrated Petitioner had been overspending her monthly supportive home care budget from November 2023 through June 2024. This occurred because — was providing more care than she was authorized to provide. The agency reduced the supportive home care hours that Petitioner was authorized to receive from —, her other caregiver, from 10 hours to 3 hours per week effective July 16, 2024. As I understand the agency’s position, that reduction, combined with — beginning to bill only for the amount she was authorized to provide, was intended to prevent Petitioner from overspending her annual budget for the plan year November 1, 2023 through October 31, 2024.

—, who served as Petitioner’s representative at hearing, testified that she had received confusing or inaccurate information from a prior IRIS Consultant regarding her sister’s service authorizations and the state of her sister’s budget, and that she reduced her own hours when the agency finally explained the circumstances to her. — did not however dispute that Petitioner’s monthly budgets had been routinely overspent prior to the agency’s issuance of the July 2024 Notice of Action. See Finding of Fact. No. 10.

The ICA cannot authorize services that exceed the calculated budget amount. The ICA thus acted appropriately in reducing Petitioner’s supportive home care hours effective July 16, 2024 in to attempt to ensure that Petitioner would not exceed her annual budget.

Conclusions of Law

Because Petitioner billed for more supportive home care than she was authorized to receive from November 2023 through June 2024, the agency acted appropriately in reducing Petitioner’s monthly supportive home care authorization by seven hours per week, effective July 16, 2024, to try to prevent her from overspending her 2023 – 2024 annual IRIS budget.

THEREFORE, it is

Ordered

Petitioner’s appeal is dismissed.

[Request for a rehearing and appeal to court instructions omitted.]