CWA 220708 (02/02/2026)
Improved condition resulted in reduced IRIS budget, fewer home-delivered meals

Preliminary Recitals

Pursuant to a petition filed on November 1, 2025, under Wis. Admin. Code § HA 3.03, to review a decision by TMG, an IRIS Consultant Agency contracted by the Department of Health Services, regarding IRIS, a hearing was held on December 17, 2025, by telephone.

The issue for determination is whether TMG correctly reduced the number of home delivered meals included in Petitioner’s IRIS service and support plan from ten meals per week to five meals 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: Monica Steren
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 Ashland County who is enrolled in IRIS. TMG serves as her IRIS Consultant Agency (ICA).
2. Petitioner has been determined to be physical disabled under IRIS program rules. Her medical diagnoses include, but are not limited to: chronic pain affecting her knees and low back, fibromyalgia, thrombophilia, osteoarthritis of her knees, writs, and hands, and COPD. Petitioner’s symptoms include chronic shortness of breath, poor balance, and dizziness, debilitating pain, and limited use of her hands.
3. Petitioner requires assistance with bathing, mobility in her home, toileting, and transferring. She also requires some assistance with meal preparation / grocery shopping, laundry / chores, and transportation.
4. Petitioner resides with her adult son who she employs as a paid supportive home care provider through the IRIS Program. He provides 11.75 hours of self-directed personal care per week and 9 hours of supportive home care per week.
5. Petitioner began receiving home delivered meals through the IRIS Program in August 2023. At that time, she received an authorization for four meals per week.
6. Both supportive home care and home-delivered meals are intended to assist Petitioner in achieving the long-term care outcome (i.e., goal) of staying in her own home.
7. In April 2024, Petitioner reported a change to her functional needs which resulted in an increased IRIS budget and allowed her to obtain an authorization for ten home delivered meals per week.
8. In August 2025, TMG completed an updated long term care functional screen (LTCFS). During that process, Petitioner reported that she had received a steroid injection and that, due to the beneficial effects of that injection, she was able to stand longer, able to prepare simple meals, able to do a little more cleaning than she had previously been able to do, and able to dress.
9. The LTCFS Specialist who completed the August 2025 screen indicated that Petitioner’s functional challenges had improved in the following ways since July 2024 when her prior LTCFS was completed:
   

   Dressing: — reports she is getting shots to her back and knees. She reports she can dress herself and she doesn’t need any assistance. Which is an improvement from the past year. She wears easy on off clothing. She can pick appropriate clothing.

   Meal Prep: — is reporting since she is getting shots to her back and knees she is more independent with meals. She can heat up food in the microwave. She can transport the meal with her walker. — can open containers if loosened for her. She can open the fridge/freezer. She can recognize spoiled food. On bad days she requires assistance with making some meals. She requires assistance with grocery shopping due to shortness of breath and does use scooter when able to walk into store. — is unable to carry groceries nor put away. — won’t shop due to extreme shortness of breath and pain with lifting. Son shops for her.

   Laundry/Chores: — requires assistance with some household chores and laundry. —’s laundry facilities are in the basement. She can’t use the stairs because of her shortness of breath and severe risks of falling because she isn’t able to take walker with her. She can fold the clothing. She reports having less pain and she can assist with some cleaning and able to complete dusting. She needs help with vacuuming. — is unable to shovel, nor maintain the lawn. She reports she can put dishes in the dishwasher and run it. She reports she is feeling better since she has been getting shots. She also reported she is cleaning out the “office” a little at a time and she is doing this independently, taking rests and her time.

10. Because of Petitioner’s modest improvements, the LTCFS that was completed in August 2025 resulted in a reduction of Petitioner’s IRIS budget.
11. TMG advised Petitioner that in order to stay within the reduced budget, she would need to either reduce the authorization for home delivered meals to five meals per week, or reduce paid care that her son provides to her. Of those two options, she chose to reduce the authorization for home delivered meals.
12. On August 6, 2025, TMG issued a written notice to Petitioner confirming that, as of October 1, 2025, her home delivered meals would be reduced from 41 meals per month to 21 meals per month (i.e., five meals per week) due to a budget reduction related to her updated LTCFS.

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 determine 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.

The issue in this case is whether TMG properly reduced the number of home-delivered meals that Petitioner receives each week as a means to keep Petitioner’s overall IRIS authorizations within her assigned budget. IRIS policy defines home-delivered meals as follows:

Home delivered meals are meals provided to participants who are unable to prepare or obtain nourishing meals without assistance, including those who may be unable to manage a special diet recommended by their physician. Home delivered meal costs may include the costs associated with the purchase and planning of food, nutrition services, supplies, equipment, labor and transportation to deliver one or two meals a day. Home delivered meals may not constitute a “full nutritional regimen” (3 meals per day).

IRIS Service Definition Manual (03/2024), pp. 21-22.

TMG’s representative testified that Petitioner reported modest improvements in her ability to stand when the LTCFS was completed in 2025 and that this ultimately caused a budget reduction necessitating Petitioner to reduce one of the two services currently included in her Individual Services and Supports Plan (ISSP). For Petitioner, that meant she needed to make the following choice: reduce the number of hours of supportive home care provided by her son, or reduce the number of home delivered meals she received each week. TMG provided the following additional detail regarding the Petitioner’s updated LTCFS: that Petitioner reported she was able to stand a little longer than she had been able to stand, that Petitioner attributed her ability to do so to a steroid injection or injections that she had received, and that Petitioner indicated that she could make a sandwich, do some household chores, and dress herself. Based on that input, the screener indicated in the LTCFS report that Petitioner continues to require support with meal preparation and chores but that she requires less assistance than she previously did and that she no longer requires assistance with dressing.

TMG noted that Petitioner lives with her son who is Petitioner’s SHC provider and that meal preparation constitutes supportive home care. TMG argued that there is some expectation that Petitioner’s son, in his role as a SHC provider, would provide assistance to Petitioner with preparing her meals thereby making 10 home delivered meals per week unnecessary.

TMG also reported that Petitioner had expressed challenges in being able to afford sufficient food and that her IRIS Consultant replied to those concerns by giving Petitioner contact information for a local food pantry. TMG asserted, however, that the IRIS Program is not intended to provide financial assistance with groceries.

Petitioner countered that she can only stand from five to ten minutes at a time, that she does not consider a sandwich to be a proper meal, and that she understands that the IRIS Program is not intended to provide financial assistance with groceries. Petitioner’s son and caregiver also appeared at hearing and testified that Petitioner relies on home delivered meals, that she can put food in the microwave but then she must lay back down.

As described above, the long term care functional screen informs the budget amounts assigned to IRIS participants. And, the model of the IRIS program contemplates participants selecting services and supports that their budget can pay for unless there is evidence that the budget is not sufficient to accommodate all of the services and supports that a participant requires to meet their long-term care outcomes.

The first question before me is, therefore, whether TMG made any errors in completing the 2025 LTCFS. Petitioner did not rebut TMG’s evidence that she has had some, albeit modest, improvements as the result of medical treatment. It was therefore appropriate of the screener to reflect that information in the LTCFS. The next question is whether there is sufficient evidence to show that ten home-delivered meals per week are necessary to allow Petitioner to remain in her own home (i.e., Petitioner’s relevant long-term care outcome). I found TMG’s argument that Petitioner’s supportive home care authorization allows her to pay for assistance to prepare her meals to be relevant and persuasive. If Petitioner lived alone and/or if she had no supportive home care, a higher number of home-delivered meals would certainly be called for. Based on the evidence in this hearing record, I find that the agency’s decision to reduce Petitioner’s home delivered meals to five per week is appropriate and that, based on Petitioner’s current circumstances, the reduction will not prevent her from meeting her long term care outcome of remaining in her home.

I note that the hearing record indicated that Petitioner is in quite poor health. Should she experience any decline in health and/or function, or if she has experienced any decline in health and/or function since the date of the hearing in this matter, she is free to notify her IRIS Consultant. When a person has a change in condition, the IRIS Program may update that person’s LTCFS which may, in turn, result in an increased budget. Alternatively, the individual’s change in circumstances may demonstrate that the budget is insufficient to meet increased needs and that a budget amendment request is therefore in order.

Conclusions of Law

TMG properly reduced Petitioner’s IRIS authorization for home-delivered meals from ten meals per week to five meals per week.

THEREFORE, it is

Ordered

That Petitioner’s appeal is dismissed.

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