CWA 220139 (01/02/2026)
Petitioner with schizophrenia did not qualify for physical disability target group

Preliminary Recitals

Pursuant to a petition filed on September 24, 2025, under Wis. Admin. Code § HA 3.03, to review a decision by TMG, in its capacity as an IRIS Consultant Agency contacted by the Department of Health Services, regarding Petitioner’s functional eligibility for IRIS, a hearing was held on November 12, 2025, by telephone. The hearing was held open until November 24, 2025 to allow Petitioner an opportunity to submit additional supporting medical documentation. On November 21, 2025, the Division of Hearings and Appeals received ten pages of medical records from the Rice Lake Clinic including office visit notes and related lab results dated November 14, 2025. On December 1, 2025, which was after the hearing record had closed, the Division of Hearings and Appeals received a letter dated December 1, 2025 from Tim Nickell, P.A.-C of the Rice Lake Clinic.

The issue for determination is whether TMG correctly found that Petitioner is no longer functionally eligible for the IRIS Program.

There appeared at that time the following persons:

PARTIES IN INTEREST:

Petitioner:
—

Respondent:
Department of Health Services
201 E. Washington Ave.
Madison, WI 53703
By: Martha Bydzoski, TMG, Screen Liaison Supervisor
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 resident of Barron County. Petitioner is a 58-year old resident of Barron County. She resides by herself in an apartment.
2. Petitioner’s medical diagnoses include schizophrenia, hyperlipidemia, hypertension, tobacco abuse smoking, and lower extremity weakness and fatigue.
3. Petitioner’s diagnosis of schizophrenia causes a cognitive impairment that is severe and persistent and is not adequately addressed with medical intervention. Despite treatment, she requires reminders and encouragement to complete the following two activities of daily living: bathing and dressing.
4. The symptoms of Petitioner’s schizophrenia also lead Petitioner to require assistance with meal preparation, medication management, money management, laundry/chores, and transportation. She is not currently employed and does not wish to be, but if she were to find employment, she would require daily assistance.
5. Petitioner suffers from shortness of breath, extremity weakness, and fatigue related to deconditioning which further adversely affect her ability to complete laundry/chores and which make mobility outside of the home difficult. She is, however, able to independently ambulate in her home and does not require durable medical equipment to do so.
6. In September 2024, the Aging and Disability Resource Center (ADRC) of Barron and Rusk Counties conduced a long term care functional screen (“LTCFS”) of Petitioner. Based on that LTCFS, Petitioner was found to meet criteria for inclusion in one qualifying target group–physical disability. She was also found to meet criteria for inclusion in the severe and persistent mental illness target group. In addition, Petitioner was found to require a nursing home level of care and to therefore be functionally eligible for IRIS.
7. Following her LTCFS in September 2024, Petitioner enrolled in IRIS.
8. Petitioner’s family calls to check in on her daily and checks to be sure that she has completed daily necessities (e.g., taken her medicine) and to see if she needs any help. Petitioner currently receives 6 hours per week of supportive home care.
9. Without assistance, Petitioner would be at imminent risk of institutionalization due to her cognitive impairment, which is related to her schizophrenia diagnosis.
10. In August 2025, Jessica Terrill, a Functional Screening Specialist, met with Petitioner in her home and reviewed her functional eligibility. On September 15, 2025, Ms. Terrill completed a LTCFS using the information gathered during the August 2025 meeting with Petitioner and from a later contact with Petitioner’s cousin, who provides Petitioner with significant support Based on the LTCFS, TMG concluded that Petitioner does not meet criteria to be included in the physical disability target group and is no longer functionally eligible for IRIS.
11. By notice dated September 17, 2025, TMG informed Petitioner that she no longer met the functional eligibility requirements to remain enrolled in IRIS and that she would therefore be disenrolled on October 1, 2025.
12. Petitioner filed a timely request for hearing and has been receiving continued IRIS benefits pending the outcome of her appeal.

Discussion

To be functionally eligible for IRIS program benefits, an individual must be a member of one of the following “target groups”: frail elderly; adult with a physical disability; or adult with a developmental disability, as that term is defined by 42 U.S.C. § 15002(8), and must also require a “nursing home” level of care. See IRIS Policy Manual, §2.1 at https://www.dhs.wisconsin.gov/publications/p0/p00708.pdf and DHA Case No. CWA-179794 (Div. of Hearings & Appeals April 5, 2017, adopted by Secretary on May 4, 2017) (DHS).

In this case, the agency contended that Petitioner does not satisfy criteria necessary to be included within one of the target groups and is therefore not functionally eligible for IRIS. The agency also contended that Petitioner no longer requires a nursing home level of care.

Jessica Terrill, the TMG staff member who met with Petitioner and who completed the most recent LTCFS appeared at hearing and offered credible, detailed, first-hand testimony to explain the observations noted in the LTCFS. Ms. Terrill’s supervisor, Martha Bydzoski, also appeared at hearing for TMG and offered additional explanation regarding the finding that Petitioner does not meet criteria to be included in any of the three qualifying target groups and that she is therefore not functionally eligible. Ms. Terrill and Ms. Bydzoski both noted that the LTCFS completed by the local ADRC in September 2024 had noted that Petitioner had a diagnosis of lower extremity weakness. At the time the rescreen was completed in 2025, TMG staff was unable to find documentation of that diagnosis and Petitioner reported that she was unaware of any such diagnosis. As a result, that diagnosis was removed from the LTCFS. However, Ms. Terrill testified that she concluded, based on her observations of Petitioner and her conversation with Petitioner and others who know Petitioner, that her undisputed needs for assistance are related to her schizophrenia diagnosis and that any lower extremity weakness would therefore not have constituted a physical disability.

Petitioner appeared at hearing and testified that when walking long distances, she feels faint and gets short of breath. She said she relies on IRIS for transportation and to support her well-being. She also testified that she can’t carry her laundry up and down the stairs due to weakness in her legs. —, the owner of the home care agency who has been assisting Petitioner, testified that Petitioner’s family was working to schedule a doctor’s appointment for her because they were concerned that her labored breathing and difficulty walking longer distances might be symptomatic of a heart condition and that congestive heart failure runs in her family. I therefore held the record open and, as noted in the Preliminary Recitals, I received medical records from a November 14, 2025 appointment. However, those notes indicated that, fortunately, Petitioner was not diagnosed with any type of heart trouble. In a letter dated December 1, 2025, Petitioner’s health care provider noted that she does have “new diagnoses” of extremity weakness and shortness of breath and that she benefits from the in-home services that she has been receiving.

IRIS Program policy and relevant state statute define physical disability as follows:

“Physical disability” means a physical condition, including an anatomical loss, or musculoskeletal, neurological, respiratory, or cardiovascular impairment, which results from injury, disease, or congenital disorder and which significantly interferes with or significantly limits at least one major life activity of a person. Wis. Stat. § 15.197(4)(a)2.

“Major life activity” means any of the following: A. Self-care, B. Performance of manual tasks unrelated to gainful employment, C. Walking, D. Receptive and expressive language, E. Breathing, F. Working, G. Participating in educational programs, H. Mobility, other than walking, I. Capacity for independent living. Wis. Stat. § 15.197(4)(a)1.

Wisconsin Long Term Care Functional Screen Instructions, 10/2024, p. 11-4 (available on-line at https://www.dhs.wisconsin.gov/publications/p00946.pdf.); see also, Resp. Ex. F-2.

Severe and persistent mental illness is a non-qualifying target group; in other words, inclusion in this target group is not sufficient, alone, to confer IRIS eligibility. IRIS policy defines this non-qualifying target group as follows:

… a mental illness that is severe in degree and persistent in duration, that causes a substantially diminished level of functioning in the primary aspects of daily living and an inability to cope with the ordinary demands of life, that may lead to an inability to maintain stable adjustment and independent functioning without long-term treatment and support, and that may be of lifelong duration. “Serious and persistent mental illness” includes schizophrenia as well as a wide spectrum of psychotic and other severely disabling psychiatric diagnostic categories, but does not include degenerative brain disorder or a primary diagnosis of a developmental disability or of alcohol or drug dependence. Wis. Stat. § 51.01(14t).

Id. at 11-5; see also, Resp. Ex. F-3.

Based on the record in front of me, I find that TMG acted appropriately in finding that Petitioner was not functionally eligible as of October 2025 because there was insufficient evidence to establish that she met criteria to be included in the physical disability target group. Although Petitioner has undisputed needs for assistance with two activities of daily living: bathing and dressing, and also with the following instrumental activities of daily living: meal preparation, medication management, money management, transportation, and employment, those needs arise from the symptoms of her mental health diagnosis. The evidence also showed that Petitioner requires assistance with laundry and chores and that her need for that particular IADL is related to both her schizophrenia diagnosis and the extremity weakness and shortness of breath diagnoses referenced in the medical documentation submitted by Petitioner after the hearing. In addition, she has had difficulty walking longer distances outside of the home as a result of her weakness and shortness of breath. I conclude, however, that this evidence is not sufficient to establish that she has a physical disability as that term is defined by Wis. Stat. § 15.197(4)(a)2 and the Long Term Care Functional Screen Instructions cited above.

Finally, I note that Ms. Bydzovsky explained that a LTCFS is understood to be an assessment of a person’s circumstances based on a moment in time; or, as she referred to it, “a snapshot.” Ms. Bydzovsky further stated that if Petitioner has new diagnoses, she may request a new LTCFS and ask to have that new information considered. Nothing in this decision should be understood to prohibit Petitioner from doing so.

Conclusions of Law

1. TMG, agent for the Department of Health Services, properly determined that Petitioner does not meet a qualifying target group.
2. Petitioner is no longer functionally eligible for IRIS; the Department may therefore disenroll her from the IRIS program.

THEREFORE, it is

Ordered

That Petitioner’s appeal is dismissed.

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