CWA 220503 (03/09/2026)
BA for daily living skills training denied as duplicative of SHC

Preliminary Recitals

Pursuant to a petition filed October 16, 2025, under Wis. Admin. Code, §HA 3.03, to review a decision by the Division of Medicaid Services (DMS) to deny a service under the Include, Respect, I Self-Direct Program (IRIS), a hearing was held on March 4, 2026, by telephone. Hearings set for December 3, 2025, January 7, and February 4, 2026 were rescheduled at the petitioner’s request.

The issue for determination is whether the DMS correctly denied a budget amendment for daily living skills group training.

PARTIES IN INTEREST:

Petitioner:
—

Respondent:
Department of Health Services
201 E. Washington Ave.
Madison, WI 53703
By: Alexa Butzbaugh
Progressive Community Services
100 Enterprise Drive
Verona, WI 53593

ADMINISTRATIVE LAW JUDGE:
Brian C. Schneider
Division of Hearings and Appeals

Findings of Fact

1. Petitioner is a 24-year-old resident of Dane County.
2. Petitioner is diagnosed with autism, intellectual disability, encephalopathy, epilepsy, coordination impairment, anxiety, and ADHD. She has been eligible for IRIS since 2019 with Progressive Community Services (PCS) as her current consulting agency. Her current IRIS budget is $8,713.83 monthly that covers primarily supportive home care (SHC). She also has budget amendments in place for community transportation, behavioral services, a gym membership, and day services.
3. Petitioner lives alone in an apartment building that includes apartments for other special needs individuals. Petitioner requires 24-hour agency support.
4. On July 7, 2025, PCS filed two budget amendments for daily living skills training through —. and the — staff, one for group training at $29 per hour for 3.75 hours per week (the subject of appeal no. CWA-220503) and one for individual training at $63 per hour for 6.25 hours per month (the subject of appeal no. CWA-220505). By notices dated August 1 and August 20, 2025, the DMS denied the requests as not being cost effective.
5. Petitioner has been receiving daily living skills training through — since 2019. She has developed a close relationship with her individual trainer. Most recently, they are working on money management skills, although it is acknowledged that petitioner likely will always require assistance with money management.

Discussion

The IRIS program was developed pursuant to a Medical Assistance waiver obtained by the State of Wisconsin, pursuant to section 6087 of the Deficit Reduction Act of 2005 (DRA), and section 1915(c) of the Social Security Act. It is a self-directed personal care program.

The federal government has promulgated 42 C.F.R. §441.300 – .310 to provide general guidance for this program. Those regulations require that the Department’s agent must assess the participant’s needs and preferences (including health status) as a condition of IRIS participation. Id., §441.301(c)(2). The Department’s agent must also develop a service plan based on the assessed needs.

The 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.

State policies governing administration of the IRIS program are included in the IRIS Policy Manual (available at www.dhs.wisconsin.gov/publications/P0/P00708.pdf), IRIS Work Instructions (available at www.dhs.wisconsin.gov/publications/P0/P00708a.pdf), and IRIS Service Definition Manual (available at www.dhs.wisconsin.gov/publications/p00708b.pdf).

A budget amendment can be requested to pay for an ongoing need that is not met within the current budget. IRIS Policy Manual, §4.1, referencing IRIS policy P-03656. Requests for budget amendments are reviewed by DMS staff with expertise in the IRIS program and knowledge of similar requests made by other IRIS participants. Policy P-03656, page 5. The items to be evaluated include:

• Is the request needs-based (i.e., identified on the screen) and outcome-driven (i.e., an allowable long-term care outcome)?
• Is the request allowable and cost-effective for this long-term care Medicaid program?
• Is the request addressing an unmet need, rather than duplicating an existing service on the plan?

Policy P-03856, page 3. The DMS denied the request here with the finding that the training is not cost effective and that it duplicates existing services. Specifically, money management is an SHC function, as are other instrumental activities of daily living such as meal preparation, medication administration, and laundry/chores. I note that although petitioner has been receiving daily living skills training for six years, she still requires 24-hour support, and when I asked if there was a potential end date to daily living skills training, the response was that petitioner might need it for the rest of her life.

In this instance, I will accede to the expertise of the DMS experts. They have knowledge of the types of services provided under IRIS and when the services lose cost effectiveness and become duplicative. Even after hearing the testimony of petitioner’s mother and her — counsellor, my impression is that the primary reason for the request is that petitioner has developed a close relationship to the counsellor, and that the group outings are fun activities, not necessarily activities that are helping petitioner reduce caretaking requirements.

I thus will affirm that DMS denial of the budget amendment requests. The daily living skills training has not been shown to be cost effective and necessary in light of other services provided to petitioner.

Conclusions of Law

The requested daily living skills training has not been shown to be cost effective and necessary in light of other services provided to petitioner, and thus the DMS correctly denied the budget amendment requests for continued daily living skills training.

THEREFORE, it is

Ordered

That the petition for review is hereby dismissed.

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