CWA 217841 (06/27/2025)
Wheelchair conversion for SUV was cost-effective

Preliminary Recitals

Pursuant to a petition filed on April 10, 2025, under Wis. Admin. Code § HA 3.03, to review a decision by the Department of Health Services regarding IRIS, a hearing was held on May 22, 2025, by telephone.

The issue for determination is whether the Department of Health Services properly denied a one-time expense request for a vehicle modification.

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: Pam Schreiber, TMG
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 an 18-year old resident of Eau Claire County who is enrolled in the IRIS Program. TMG is her IRIS Consultant Agency (“ICA”).
2. Petitioner resides with her parents and siblings.
3. Petitioner has a physical and developmental disability. Her diagnoses include cerebral palsy, spastic quadriplegia, developmental delay, dystonia, osteopenia, neurogenic bladder, and optic atrophy of both eyes.
4. Petitioner uses a power wheelchair.
5. Petitioner’s Individual Support and Services Plan (“ISSP”) for plan year March 1, 2025 – February 28, 2026 currently has $35,416.61 of services budgeted. Those services include companion care, respite, and supportive home care. Her annual budget amount is $35,541.24. She also receives self-directed personal cares.
6. Petitioner is currently transported in a — that has approximately 166,000 miles. It has a side conversion with a manual fold-out wheelchair ramp and can accommodate Petitioner, her parents, her siblings, and her two grandmothers who are also respite providers. The conversion was funded by the Children’s Long Term Support Waiver Program. (Petitioner does not drive and has no intention of learning to drive at this point.)
7. Petitioner’s two grandmothers each own minivans with side conversions. Because of the limited space inside those vehicles, Petitioner has hit her wheelchair and joystick against the other seats in the minivan causing damage to both the seats and requiring replacement of her joystick.
8. Petitioner begins college in the fall of 2025 at — and will require reliable transportation to commute there from her home in Eau Claire. She also requires her vehicle to attend medical appointments and social events.
9. On an unspecified date prior to April 2024, Petitioner requested IRIS authorization for a passenger side conversion of an SUV that they intend to purchase to replace the Honda Pilot.
10. On April 1, 2024, Center for Independent Living (“CIL”) for Western Wisconsin conducted an accessibility assessment. CIL observed that the second door of Petitioner’s current vehicle does not open consistently in the cold, the electronic wiring splits, the flooring is rising, and the seals are wearing out. In addition, the vehicle uses more tires than needed due to the increased weight added by the conversion and there is no air circulation inside of the vehicle due to the conversion.
11. In a written report dated April 19, 2024 and modified on April 26, 2024, CIL recommended that Petitioner acquire a vehicle with side-entry conversion from a licensed dealer specializing in accessible vehicles. CIL further recommended that the vehicle have a removable passenger seat, and a securement system on the middle and passenger side.
12. CIL indicated that either an in-floor or a fold-out ramp may be appropriate and that the securement system may be manual (i.e., tie-down straps) or power (i.e., a docking system). The docking system would allow Petitioner to independently enter and exit the vehicle. CIL did not recommend a particular type of ramp or securement system.
12. On July 12, 2024, Petitioner obtained a quote from — for a passenger side conversion of a large SUV. The base quote was $40,395. A $5,500 high end trim package was added. Petitioner also obtained a $1,850 quote from — for a power tiedown system. The total amount came to $47,745. The type of conversion requested would not require Petitioner to attempt to turn her chair around inside of the vehicle, something that is challenging for her because her impaired motor coordination and processing speed makes it difficult to make a tight turn. In addition, the door style would afford her protection from the elements while loading onto the ramp and into the vehicle.
13. Sometime prior to December 2024, TMG submitted a one-time expense request for $47,114.70 to the Department of Health Services on her behalf. The requested amount was the total quote from — minus the amount remaining in Petitioner’s annual budget.
14. On December , 2024, the Department denied Petitioner’s request finding that it was not the most cost effective way to support her outcome. The written notice of denial issued to Petitioner included the following detailed rationale:
    1. Note: The Department has denied the One-Time Expense request for a Vehicle Modification (Vehicle Conversion). This decision is based on the information provided within the One-Time Expense Request (F-01206) and the Long- Term Care Functional Screen (LTCFS), the Accessibility Assessment Report (AA) and the Quote from —. The participant is requesting an adapted large SUV (Suburban or Yukon XL) passenger side conversion vehicle, with the long term outcome to provide the participant (PPT) with safe and reliable transportation to do things needed and enjoyed in the community. Currently the participant has a — with approximately 166,000 miles. The vehicle has a side conversion with a manual fold-out wheelchair ramp. The AA report recommends acquiring a vehicle with side entry conversion with either an in-floor or fold-out ramp and a securement system. The PPT is requesting a large SUV conversion with a complete passenger side door modification into a gull wing style door, along with a 12” lowered floor to allow user headroom while positioned behind the wheel in the wheelchair. The conversion cost also includes an up charge for heated seats. In addition, there is an added ATC High End Trim Package cost of $5,500.00. The total cost of the conversion is $47,745.00 ($630.30 from the PPTs IRIS Budget Allocation is being used). The average range of cost for converted vehicles approved through IRIS is $28,000 – $38,000. The AA report does not specifically recommend a SUV or gull wing style doors. The PPT does not currently drive and there is no need for the option of sitting behind the wheel. It is fair to say that about 99% of all approved vehicle modifications through IRIS Waiver funds are for mini-van conversions. The ramps (Manual or powered) and securement systems (manual or powered tie downs) vary with each individual mobility needs, and use of wheelchair, scooter etc. Additionally, IRIS Waiver funds have never approved gull wing style doors. The high end trim package is a cost added due to the vehicle not being a typical (chassis) van conversion. If the PPT and family wish to purchase a large SUV they must absorb the cost difference or choose a different vehicle that is more cost effective. Further, it must be specific to the PPTs needs for adaptation for transportation. IRIS Waiver funds do not pay for the needs of the family or specific preferences of the PPT. This request is not justifiable as cost-effective and is not a wise use of public funds, which is one of the 5 core principles of self-determination, under 1.1D of the IRIS Policy Manual. The conclusion of the request is denied based on cost effectiveness and the outcome can be met through a more cost effective vehicle conversion.
15. On January 10, 2025, the Department completed an Independent Review of Petitioner’s request and upheld the original denial on the same bases.
16. On March 27, 2025, Petitioner obtained an amended quote that removed the $5,500 up charge for heated seats and the ATC High End Trim Package. The base quote remained $40,395 and included the following:
    1. Large SUV Passenger Side Conversion. Fully accessible conversion allows user to remotely open the door, a platform swings out and lowers to the ground, chair user drives on to the platform and is raised up and into the front passenger side of the truck. Conversion consists of a complete passenger side door modification into a gull wing style door which is standard for the ATC Conversion, along with a 12″ lowered floor. OEM passenger seat can also be easily reinstalled to allow others to ride in the vehicle. Seat is mounted on a quick release, roll around base.
17. The quote for the power tiedown system increased to $2,250.
17. Petitioner provided the following quotes for converting minivans: $37,600 to convert a 2024 Toyota Sienna, $43,725 to convert a 2024 Toyota Sienna, $34,600 to convert a 2024 Chrysler Pacifica, $38,515 to convert a 2024 Chrysler Voyager, and $41,070 to convert a 2023 Chevy Traverse.

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 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 (available at https://www.dhs.wisconsin.gov/publications/p0/p00708.pdf).

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. 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 which is generated based on information obtained during a screening of the participant’s long-term care functional needs. See 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. Participants may however submit a one-time expense request to the Department of Health Services with the assistance of their ICA to increase the budget to pay for goods or services, including but not limited to home modifications and adaptive aids. Id. at 5.8. When the Department of Health Services denies such a request, the participant may file a request for fair hearings. Id.

At issue here is whether the Department properly denied Petitioner’s One-Time Expense request for a side conversion of an SUV, high end trim package, and power tie down system. The Department evaluated Petitioner’s request under the benefit category adaptive aid. The State of Wisconsin’s federally approved IRIS Waiver includes the following definition of adaptive aids.

Service Definition (Scope):
Adaptive aids include controls or appliances which enable people to increase their ability to perform ADLs or control the environment in which they live (including patient lifts, control switches, etc.). Adaptive aids also provide services and material benefits which enable individuals to access, participate and function in the community. These include the purchase of vehicle modifications (such as van lifts, hand controls, equipment modifications, etc.) that allow the vehicle to be used by the participant to access the community, or those costs associated with the maintenance of repair of these items.

Application for 1915(c) HCBS Waiver: WI.0484.R02.00 – May 01, 2016 (available at https://www.dhs.wisconsin.gov/iris/hcbw.pdf); see also, IRIS Service Definition Manual, p. 22 and IRIS Policy Manual Sec. 5.8A, pp. 44-45.

As noted in Finding of Fact No. 14, the Department acknowledged that Petitioner requires a vehicle conversion but concluded that her outcome can be met through a more cost effective conversion. The Department identified a number of factors that it considered in reaching that conclusion. First, the Department understandably balked at the inclusion of a $5,500 high end trim package. By the time of the hearing, Petitioner had obtained an updated quote that removed that high end trim package entirely.

Second, the Department also noted that 99% of approved vehicle modifications through IRIS are for mini vans but did not explain what type(s) of vehicles are included in the other 1%. No written policy or other authority was offered to indicate that conversions of SUVs are prohibited. Moreover, as Petitioner noted, the Department previously paid for conversion of the SUV that her family currently uses to transport her. Ostensibly, what the Department objects to is an assumption that converting an SUV is more expensive than converting a minivan but Petitioner offered quotes at hearing showing that the costs are comparable.

Third, the Department stated that IRIS funds have never been used for gull style doors but did not explain why and included no citation to any legal authority that prohibits such authorization. Moreover, the Department’s representative at hearing did not rebut testimony offered by Petitioner’s long-term occupational therapist regarding the significant benefit this particular style door offers Petitioner in light of her health status and specific functional deficits.

Fourth, the Department noted that the average cost range for converted vehicles approved through IRIS is $28,000 to $38,000. No supporting documentation was provided to demonstrate how the Department calculated that average or any additional detail regarding the nature of those conversions. The Department’s use of the word “average” suggests that IRIS sometimes pays more and sometimes pays less than the identified range. And, the Department did not specify whether that range included or excluded the cost of a tie down system. Petitioner’s amended request for a $40,395 conversion plus $2,250 for a tie down system is thus not on its face unreasonable.

Fifth, TMG at hearing asserted that fixing Petitioner’s current vehicle might be less expensive than paying for a new conversion and that funding repairs may therefore be more cost-effective. The Department did not, however, identify that as a reason for denial in its written notice and there is no evidence that anyone from TMG or the Department ever asked Petitioner to produce an estimate for repairs of the current vehicle. Moreover, the current vehicle is 10 years old and has 166,000 miles. It is thus not at all obvious that funding repairs, even if cheaper than paying for a new conversion, would be cost-effective.

I am going to remand this matter to the agency to authorize a passenger side conversion of an SUV and tiedown system, as detailed in the March 27, 2025 quote offered at hearing with one caveat. The Department objected to paying for an up charge for heated seats. I agree that the IRIS program should not fund that type of upcharge. However, that charge is not itemized in the first quote and is not mentioned at all in the second quote. The Department may therefore request that Petitioner provide documentation from — to clarify whether the charge for a heated seat is included in the March 27, 2025 quote and, if so, the Department should subtract that amount from the authorization.

Conclusions of Law

A preponderance of the credible evidence demonstrated that authorization of the tiedown system and SUV passenger side conversion, as detailed in the March 27, 2025 Quotation from — (minus any amount intended to fund a heated seat), is an effective and cost-effective way to meet Petitioner’s long term care outcomes.

THEREFORE, it is

Ordered

That the matter is remanded to the Department and its agents to grant Petitioner’s One-Time Expense Request for the SUV passenger side conversion and tiedown system described in the March 27, 2025 Quotation from — minus any amount intended to fund a heated seat. Within ten days of the date of this decision, the Department and its agents must notify Petitioner in writing that the conversion and tiedown system are authorized and instruct Petitioner to provide documentation regarding the charge for the heated seat so that the authorization amount can be reduced to exclude that charge.

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