CWA 216919 (05/30/2025)
SHC hours reduced due to updated formula for IRIS budgets

Preliminary Recitals

Pursuant to a petition filed on February 4, 2025, under Wis. Admin. Code § HA 3.03, to review a decision by the Bureau of Long-Term Support regarding the Include, Respect I Self-Direct (IRIS) Program, a hearing was held on April 9, 2025, by telephone. The hearing was first scheduled on March 19, 2025 but rescheduled at Petitioner’s request. Per the joint request of the parties, this hearing was held concurrently with CWA Case No. 216920. A separate decision will be issued regarding that case.

The issue for determination is whether TMG, Petitioner’s IRIS Consultant Agency, properly reduced Petitioner’s authorized supportive home care from 22.25 hours per week to 5 hours per week.

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: Angela Sutherland, TMG
Bureau of Long-Term Support
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 32-year old resident of Lincoln County who is enrolled in IRIS. TMG is the IRIS Consultant Agency (“ICA”) that serves him.
2. Petitioner resides in one unit of a duplex with his 38-year old sibling, —, who is also enrolled in IRIS. —, who is their guardian, resides in the other unit of the duplex.
3. — is paid with IRIS funds to provide supportive home care to both Petitioner and his sibling. — also provides natural (i.e., uncompensated) support to both Petitioner and his sibling.
4. — has paid full-time employment outside of her home.
5. Petitioner has medical diagnoses including but not limited to hydrocephalus, cerebral degeneration, hypokalemia, tendon dysfunction, seizure disorder, gastronomy placement, esophageal atresia, esophageal colonic stricture, dysphagia, drop foot, recurrent aspiration pneumonia, depression, and hearing loss. Petitioner has been seizure-free for at least five years.
6. Petitioner requires cues and/or supervision when bathing and toileting and full assistance with eating. He is able to independently dress, ambulate in his home, and transfer.
7. Petitioner also requires assistance with meal preparation, medication set-up, reminders, and administration, money management, and laundry / chores. He is unable to drive. If Petitioner had a job, he would require employment-related assistance. He is able to independently use the telephone.
8. Petitioner requires assistance with range of motion exercises and help with respiratory treatments and tube feedings.
9. TMG completed Petitioner’s annual long term care functional screen (“LTCFS”) on October 3, 2024. This LTCFS did not show any significant changes in Petitioner’s circumstances; however, his IRIS budget decreased.
10. Petitioner’s current authorized services include supportive home care, respite care, adult day services, and community transportation.
11. Petitioner attends adult day services 21 days per month from approximately 7:30AM to 2:30PM or 3:30PM while — is at work. Petitioner is authorized to receive five hours of respite care per week.
12. By written notice dated October 28, 2024, TMG informed Petitioner that his supportive home care would be reduced from 22.25 hours to 5 hours per week effective November 10, 2024 due to the budget reduction caused by his most recent Long-Term Care Functional Screen. The notice also stated that because Petitioner did not provide a Caregiver Daily Task Schedule, a budget amendment request for additional SHC could not be submitted; that Petitioner had engaged in “duplicate billing,” that he would “likely qualify for personal cares” that could be funded by “MA card services”; that Petitioner declined to reduce authorized respite care in order to preserve a higher budget amount for supportive home care; and that the IRIS Consultant had discussed the use of natural (unpaid) supports in combination with paid services to meet Petitioner’s needs. Ex. B.
13. TMG also issued a Notice of Action on October 28, 2024 to — informing her that her supportive home care would be reduced from 34 hours to 14 hours per week. The bases for that reduction mirrored the bases set forth in the Notice of Action issued to Petitioner.
14. Prior to October 2024, — submitted several time sheets that indicated the time she worked for Petitioner significantly overlapped with the time she worked for —. For example, from August 25, 2024 through October 18, 2024, she billed 34.75 hours per week for supportive home care that she provided to — and 22.25 hours per week for supportive home care that she provided to Petitioner. She reported that she worked from 3:00PM to 9:45PM or 10:00PM five days per week for — and from 3:00PM to, usually, between 7:00PM and 8:00PM on all of the same days for Petitioner.
15. On February 4, 2025, the Division of Hearings and Appeals received an appeal from Petitioner.
16. After TMG issued the Notice of Action, the following bases for the denial were addressed: (1) It was determined that Petitioner is not eligible for personal care assistance from Medical Assistance because the majority of care that he receives is cuing and supervision; (2) — stopped “duplicate billing”; and (3) — submitted Caregiver Daily Task Schedules. Although — submitted the requested task schedules, the care documented did not demonstrate that Petitioner requires more supportive home care than the hours authorized.

Discussion

The Include, Respect, I Self-Direct (IRIS) program is a Medical Assistance long term care waiver program that serves elderly individuals and adults with physical and developmental disabilities. IRIS is an alternative to Family Care, Partnership, and PACE—all of which are managed long term care waiver 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 broad purpose of all of these programs, including IRIS, is to help participants design and implement home and community based services as an alternative to institutional care. See IRIS Policy Manual §1.1B, Medicaid Eligibility Handbook §28.1, et. seq. and 42 C.F.R. §441.300, et. seq.

The IRIS waiver application most recently approved by the Centers for Medicare and Medicaid Services (CMS) is available on-line at https://www.dhs.wisconsin.gov/iris/hcbw.pdf. See Application for 1915(c) HCBS Waiver: WI.0484.R03.00 – Jan 01, 2021 (“Waiver”). 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), IRIS Work Instructions (available at http://www.dhs.wisconsin.gov/publications/P0/P00708a.pdf), and IRIS Service Definition Manual (available at https://www.dhs.wisconsin.gov/publications/p00708b.pdf).

Consistent with the terms of the approved waiver, every IRIS participant is assigned a budget. See Waiver, Appendix C-4, p. 175. That 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. The method that the Department uses to calculate the estimate of a participant’s expected needs is described in the waiver application as follows:

An IRIS participant’s budget estimate relies on data from Wisconsin’s Long-Term Care Functional Screen (LTCFS). Developed by the [Department], the LTCFS provides an automated and objective way to identify the long-term care needs of elders and people with physical or intellectual/developmental disabilities and determines the degree of assistance required to address those needs. Specifically, the LTCFS looks at a person’s ability to complete both Activities of Daily Living (ADLs) and Instrumental Activities of Daily Living (IADLs). It also looks at a person’s cognition, behavior(s), diagnoses, medically oriented tasks and employment; as well as indicators for mental health issues, substance use issues and other conditions that put a person at risk of institutionalization in a nursing home or Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF-IID). The screen was developed with input from stakeholders, consumers and clinical practitioners. Several studies to test its validity and reliability were also completed.

The [Department] contracted actuaries to develop the regression model that predicts the total cost of an IRIS participant’s needed long-term supports and services as determined by the participant’s LTCFS results. The model was developed using past, corresponding IRIS services and supports expenditure and LTCFS data. After a participant goes through the LTCFS, that individual’s information is inputted into the model and results in the participant’s individual budget estimate. This budget estimate is what is used to allocate supports, services, and goods in the participant’s [Individual Support and Services Plan] during the self-directed planning process. This is applied consistently to each IRIS participant …

Waiver, Appendix E-2b.ii., pp. 204 – 205.

After a participant’s budget is calculated, they identify IRIS allowable services that they need to meet their long term care outcomes. IRIS Policy Manual at 5.3A and 5.4 and Waiver, Appendix C-4, p. 175. The cost of those services must typically fall within the assigned budget. Id. Participants may however submit a budget amendment request to the Department of Health Services with the assistance of their ICA. IRIS Policy Manual at 5.7. A budget amendment request is “…a request made by the IRIS participant to increase the participant’s budget to pay for an ongoing need not met within the current budget.” Id.

In this case, TMG contended that Petitioner’s budget decreased following his October 2024 LTCFS and that he must, consistent with IRIS Program rules, select services and supports that fit within that reduced budget unless there is evidence that he needs services and supports that cost more than the budget can accommodate. TMG acknowledged that that Petitioner’s most current LTCFS did not show any significant changes in his circumstances; however, TMG explained that the model (i.e., formula) the Department of Health Services uses to calculate IRIS budget estimates was updated in 2023 using more recent data and that model predicted lower costs. IRIS participants did not see the immediate effect of the application of that updated formula because there was a federal mandate in place that prohibited implementation of budget reductions at that time. In 2024, that mandate was removed and States were permitted to implement budget reductions directed by the updated formula.

Petitioner’s mother argued that Petitioner continues to need the services that were previously authorized. Although the argument that Petitioner’s budget should remain unchanged since his circumstances have remained relatively stable is reasonable, the federal government authorized the State of Wisconsin’s use of the long term care functional screen in combination with actuarially determined regression models to calculate budget amounts when it approved the State’s application to operate the IRIS program. And, I do not have the authority to declare that methodology to be erroneous or invalid.

As stated above, the Department has established a budget amendment request process to address situations in which an individual’s needs cannot be met by the assigned budget. TMG argued that it did not have evidence that the authorized supportive home care was insufficient to meet Petitioner’s needs, in part, because — did not submit the daily log of caregiver tasks until after she filed this appeal. TMG thus reasonably concluded that they did not have sufficient basis on which to file a BA request and issued the NOA on October 28, 2024.

As noted above, — subsequently filed the requested task schedule with TMG but TMG contended that the task schedule did not demonstrate that Petitioner requires more than the 5 hours of supportive home care per week that his reduced budget can accommodate. I concur. First, as noted by TMG, all or nearly all of the care Petitioner requires is supervision or cueing as opposed to hands-on care. Hands-on care, in the absence of persuasive evidence to the contrary, can be reasonably expected to require more time than the less intensive tasks of supervision or cueing. Second, and more significantly, Petitioner’s guardian acknowledged that she was routinely billing for more time than she worked when Petitioner was authorized to receive more SHC. Although she undoubtedly provided care to both Petitioner and his sibling, it does not follow that she can claim that she worked more than the actual amount of time that elapsed while she provided those cares. Consider this example: If two individuals who share the same caregiver are each authorized to receive four hours of SHC and their caregiver provides all the SHC that they both need in a single four hour shift, that is persuasive evidence that neither of those individuals requires four complete hours of supportive home care.

Petitioner’s mother’s testimony was sincere and credible. As TMG acknowledged, the quality of the care she provides is not in doubt. I also think it is important to state that I do not doubt that her prior practice of double billing was based on a good faith misunderstanding and trust her assertion that she did not have any fraudulent intent. However, the evidence offered at hearing was not sufficiently detailed to rebut the agency’s case that Petitioner’s needs can be met with the time that has been authorized.

I note that this decision does not prohibit Petitioner’s guardian from keeping more detailed track of the specific cares she provides or from gathering additional relevant evidence to demonstrate that Petitioner requires more supportive home care. If she does so, she may submit that to TMG for consideration in the future and TMG would be obliged to review it and to decide whether the new evidence justified the filing of a budget amendment request. In addition, Petitioner, like all IRIS participants, may request a budget amendment whenever he experiences a change in condition that results in an increase in care needs that the current budget cannot meet.

Conclusions of Law

TMG properly reduced Petitioner’s IRIS authorization for supportive home care from 22.25 hours per week to 5 hours per week.

THEREFORE, it is

Ordered

That Petitioner’s appeal is dismissed.

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