Personal care services must be provided consistent with a written physician’s order and according to state regulations. In this case, the petitioner’s plan of care, which was signed by a physician, ordered 47.5 hour per week for a twelve-month period ending on October 2025. This included the petitioner’s needed ultrasound therapy; however, the agency later notified the petitioner that ultrasound therapy could not be provided by a personal care worker according to state regulation. The petitioner’s new plan of care ordered only 47 hours per week. ALJ Teresa Perez concluded that the petitioner was not entitled to the additional time because the SDPC Oversight Agency had authorized the amount of personal care ordered in the current physician’s plan of care, and ultrasound therapy cannot be provided by a personal care worker according to state regulation. She also noted that a notice of action was not required in this type of determination.
This decision was published with support from the Elder Law & Special Needs Section of the State Bar of Wisconsin, the Wisconsin chapter of the National Academy of Elder Law Attorneys, and Krause Financial.
Preliminary Recitals
Pursuant to a petition filed on October 17, 2025, under Wis. Admin. Code § HA 3.03, to review a decision by the IRIS Self-Directed Personal Care Oversight Agency to reduce Petitioner’s self-directed personal care, a hearing was held on January 6, 2026, by telephone. The agency sent copies of all exhibits that it introduced at hearing to Petitioner prior to the hearing. At the time of the hearing, Petitioner had received most but not all of those exhibits. Accordingly, the hearing record was held open until January 23, 2026, Respondent was directed to resend the exhibits that Petitioner had not yet received to Petitioner no later than January 9, 2026, and Petitioner was given the remainder of that time to file a response. On January 20, 2026, the Division of Hearings and Appeals received three documents from Petitioner entitled “Addendum A to case”, “Addendum B”, and “Addendum C to Fair Hearing”, respectively.
The issue for determination is whether Petitioner is entitled to 30 minutes of additional self-directed personal care per week.
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: Chris Gosnall
IRIS Self-Directed Personal Care Oversight Agency
PO Box 7851
Madison, WI 53707-7851
ADMINISTRATIVE LAW JUDGE:
Teresa A. Perez
Division of Hearings and Appeals
Findings of Fact
- Petitioner is a resident of Monroe County who is enrolled in the IRIS Program.
- Petitioner is authorized to receive self-directed personal care (SDPC).
- In July 2024, the IRIS Self Directed Personal Care Oversight Agency (“SDPC Agency”) completed a Personal Care Screening Tool (PCST) which indicated that Petitioner required personal care worker (PCW) assistance once a day, 7 days per week, with “TENS/ultrasound treatment.” Comments following that entry included the following detail: “[Petitioner] has a TENS unit and ultrasound machine he uses for pain treatment. The treatments are done alternating with TENS unit 4 days a week and US 3 days a week.” Resp. Ex. E5.
- In an Addendum to the PCST completed in July 2024, the SDPC agency allocated 70 minutes of PCW assistance per week for “TENS/Ultrasound treatment.” Resp. Ex. F1.
- Pursuant to a Physician Order and Plan of Care signed by — on October 4, 2024, Petitioner was authorized to receive 47.5 hours of SDPC throughout a twelve-month certification period that ended on October 17, 2025. Resp. Ex. G1.
- In August 2025, the IRIS SDPC Agency completed an updated PCST as part of an annual recertification process. That PCST indicated that Petitioner required less overall PCW assistance. Petitioner notified the SDPC Agency that he disagreed with some of the changes reflected in the PCST and the SDPC Agency subsequently issued an Addendum to the PCST to allow Petitioner to continue receiving PCW assistance with all the tasks with which he reported needing assistance with the following exception: ultrasound treatment three days per week. Resp. Exs. B and C and Testimony of Tammy Washington, SDPC Agency Associate Director.
- In an Addendum to the PCST completed in August 2025, the SDPC agency allocated 35 minutes of PCW assistance per week for “TENS Unit” treatment and eliminated any time for PCW assistance with ultrasound treatment. Resp. Ex. C1.
- Pursuant to a Physician Order and Plan of Care signed by — on October 14, 2025, Petitioner has been authorized to receive 47 hours of SDPC through October 17, 2026. This is a reduction of 4.25 minutes per day. Resp. Ex. D1.
- The SDPC agency notified Petitioner of the reduction but did not send him a Notice of Adverse Benefit Determination or Notice of Action.
- On October 17, 2025, Petitioner filed a request for fair hearing with the Division of Hearings and Appeals.
Discussion
The Include, Respect, I Self-Direct (IRIS) program is a Medical Assistance home and community-based long term care 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 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 shared purpose of all of these programs, including IRIS, is to allow participants who require long term care services and supports to receive those services and supports in the community rather than in institutional settings.
These programs are collectively referred to as “home and community based long term care waiver programs” because States must apply for a “waiver” from the federal government to use Medicaid funds to pay for long term care services and supports that Medicaid typically does not pay for and that enable program participants to live in community settings. See Medicaid Eligibility Handbook §28.1, et. seq., IRIS Policy Manual §1.1B, and 42 C.F.R. §441.300, et. seq. The most recently approved waiver application that sets forth the structure of the IRIS Program 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, 2026 (“Waiver Application”).
The Department of Health Services contracts with private entities to work directly with IRIS Program participants. Among these private entities are IRIS Consultant Agencies and a single IRIS Self Directed Personal Care Oversight agency. These entities are required to act in concert with applicable legal authorities including but not limited to: the Waiver Application, applicable federal regulations, and various Department-issued policies (e.g., IRIS Policy Manual–available at http://www.dhs.wisconsin.gov/publications/P0/P00708.pdf), IRIS Policy Manual: Work Instructions–available at http://www.dhs.wisconsin.gov/publications/P0/P00708a.pdf), and various addenda to the policy manual and work instructions–available at https://www.dhs.wisconsin.gov/iris/resources.htm.).
The IRIS Program gives eligible participants who require personal cares the option to receive those cares either through a Medicaid personal care agency or to self-direct their personal cares. See IRIS Policy Manual, Sec. 8.0; see generally, IRIS Policy and Procedure: Self-Directed Personal Care P-00705F. The Department “determines eligibility for Self-Directed Personal [Care] in the same manner as eligibility is determined for traditional State Plan personal care services…”. IRIS Policy Manual, Sec. 8.1. Accordingly, prior authorization is required for self-directed personal care (SDPC) services that exceed 50 hours per year. Id. at Sec. 8.1 and Wis. Admin. Code §107.112(2). In addition, SDPC services must be provided upon written orders of a physician. Id. at Sec. 8.4 and Wis. Admin. Code §DHS 107.112(1)(a).
The issue presented by this case is whether the SDPC Oversight Agency properly reduced Petitioner’s SDPC authorization by 30 minutes per week or 4.25 minutes per day based on a finding that it had previously authorized time for ultrasound treatments in error.
The SDPC Agency did not dispute that Petitioner’s physician has recommended ultrasound treatments as a pain management strategy nor did the agency dispute that Petitioner requires ultrasound treatment. Rather, the SDPC Oversight Agency contended that ultrasound treatment is not a service that a personal care worker may assist an individual with pursuant to state Medicaid regulation and that it has previously authorized time for ultrasound treatment in error. Specifically, the agency noted that “therapy services” are not coverable as personal care pursuant to Wis. Admin. Code §DHS 107.112(4)(h) and that therapy services include ultra-sound treatment pursuant to Wis. Admin. Code §DHS 107.16(1)(d) 5.c.; see also, Wis. Admin. Code §DHS 101.03(165) and IRIS Policy and Procedure: Self-Directed Personal Care P-00708F, Sec. A.2.c.i. The agency noted that Petitioner’s spouse, who is his primary personal care worker, may provide the assistance he needs with ultrasound treatment three times per week, without payment, in her capacity as his spouse, and also indicated that there is a possibility that such treatment could be authorized as an IRIS Waiver service.
I concur with the agency’s analysis. Even if I did not agree, I would not have the authority to order reinstatement of the 30 minutes per week that Petitioner seeks. This is because the plan of care, which is signed by a prescribing medical provider, ordered 47.5 hours per week was for a twelve-month certification period that ended in October 2025 and the current plan of care orders only 47 hours. As noted above personal care services must be provided consistent with a written physician’s order. Wis. Admin. Code §DHS 107.112(1)(a).
Petitioner also argued that the SDPC Agency was required to provide a Notice of Action because they reduced his personal care hours, and that by failing to provide him with that notice, the agency deprived him of the opportunity to request continuing, unreduced benefits pending the outcome of this appeal. The agency noted that Petitioner was notified of the change though acknowledged that it did not issue a Notice of Action. The agency argued that it did not do so because a Notice of Action was not required under the circumstances presented by this case. The agency’s argument is consistent with the following Department policy:
The established annual SDPC hour allocation is not appealable, as this is a prescriptive service where hours are determined and preauthorized by the RN and prescribing provider. However, if a prescribing provider refuses to sign an order for care or signs an order for less than three months, a notice of action must be sent to the participant. Additionally, if the participant experiences a change in condition which results in the participant’s active order for care being decreased or stopped during the recertification process, a notice of action decision must be sent to the participant informing them of the ability to appeal the RN and/or prescribing provider’s determination.
IRIS Policy and Procedure: Self-Directed Personal Care P-00708F, Sec. A.1.c.
This is a complex benefit program and I understand Petitioner’s interpretation of what has occurred here as a service reduction. However, self-directed personal cares must be, as stated above, set forth in a physician’s order and such orders have a start date and an end date. The nature of the action here is the denial of a request, not the reduction of a service, and Petitioner therefore could not have received continuing benefits. And, though Petitioner did not receive a Notice of Action, he was provided constructive notice of the newly authorized, lesser amount of personal care. In other words, even if a Notice of Action was required, the Petitioner in this case received actual notice as demonstrated by the agency’s evidence of, and Petitioner’s testimony regarding, ongoing communications between the two parties. Moreover, Petitioner was not deprived of any potential right to appeal, as evidenced by the fact that he did, in fact appeal.
Conclusions of Law
Petitioner is not entitled to 30 minutes of additional self-directed personal care per week because the SDPC Oversight Agency has authorized the amount of personal care ordered in the current Physician’s Plan of Care and because ultrasound therapy cannot be provided as a personal care.
THEREFORE, it is
Ordered
Petitioner’s appeal is dismissed.
[Request for a rehearing and appeal to court instructions omitted.]
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