CWA 221013 (02/25/2026)
Budget amendment funds cannot be used for other services

Preliminary Recitals

On December 3, 2025, Petitioner, an enrollee of the IRIS Program, filed a request for fair hearing, pursuant to Wis. Admin. Code § HA 3.03, regarding the Department of Health Services’ denial of a budget amendment request for funds sufficient to pay — a $750 daily rate for supportive home care. A hearing was held on January 22, 2026 via teleconference initiated from Madison, Wisconsin.

The issue for determination is whether the Department of Health Services correctly denied Petitioner’s request to authorize IRIS funds sufficient to allow her to pay — a $750 daily rate for 17.75 hours per day of supportive home care.

There appeared at that time the following persons:

PARTIES IN INTEREST:

Petitioner:
—

Petitioner’s Representative:
Attorney Jack Longert
Law Office of Jack Longert, LLC
1709 S. Park St. Suite G
Madison, WI 53713

Respondent:
Department of Health Services
201 E. Washington Ave.
Madison, WI 53703
By: Helen Isidoro, 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 a 32-year old resident of Columbia County who has been enrolled in the IRIS Program for 14 years. TMG is her chosen IRIS Consultant Agency. Resp. Ex. C and Testimony of —.
2. Petitioner has lived independently in her own home for approximately ten years. Testimony of —.
3. Petitioner requires care 24 hours per day. Resp. Ex. C.
4. Prior to September 7, 2025, Petitioner’s parents were employed as her self-directed personal care workers and — was authorized as her supportive home care provider. Testimony of —.
5. In July 2025, Petitioner notified TMG that her parents would no longer be able to provide self-directed personal care and she asked that —, with whom she has worked for approximately four years, to receive an authorization to provide all of her care needs (i.e., both personal care and supportive home care). Testimony of Helen Isidoro, — and Resp. Ex. I1.
6. TMG agreed that — could be authorized to provide all of Petitioner’s cares, with the caveat that —, a personal care agency, would need to provide oversight for the personal care performed by — because — is not a personal care agency. Testimony of Helen Isidoro and Resp. Ex. I1.
7. In August 2025, TMG submitted a budget amendment request to the Department of Health Services on Petitioner’s behalf sufficient to allow — to receive a three-month authorization to provide round the clock supportive home care at a rate of $36 per hour (i.e., $864 per day). The Department approved the BA request for three months beginning September 7, 2025. Testimony of Helen Isidoro and Resp. Ex. E.
8. On September 7, 2025, — took over as Petitioner’s sole care provider under the terms of the temporary budget amendment. As of that date, Petitioner was receiving 24 hours per day of supportive home care and no care under the category of either “self-directed personal care” or “Medical Assistance personal care”—though the actual nature of the cares she received did not change. Testimony of Helen Isidoro.
9. During the three month budget amendment authorization period that began on September 7, 2025, — conducted an assessment of Petitioner’s personal care needs and submitted a prior authorization request to the Department in order to determine the amount of personal care that would be authorized by Medical Assistance going forward. Testimony of Helen Isidoro and Resp. Exs. E and I.
10. In November 2025, the Department approved a prior authorization request for 43.75 hours per week of Medical Assistance personal care (i.e., 6.25 hours per day). Testimony of Helen Isidoro and Resp. Ex. I.
11. The standard Medical Assistance personal care hourly rate is currently $19.10 per hour. Thus, the approved prior authorization for 43.75 hours per week of Medical Assistance personal care guarantees approximately $835.63 per week or $119.38 per day of funding for —. Testimony of Helen Isidoro and —.
12. On November 19, 2025, TMG filed a new budget amendment request to the Department seeking a $750 daily rate for — to provide 17.75 hours per day of supportive home care—the number of hours needed to ensure round the clock care for Petitioner. Resp. Ex. G.
13. A $750 daily rate for supportive home care added to the approximate $119.38 per day funding for Medical Assistance personal care comes to approximately $869, which is nearly the same amount of funding per day that — received to provide round-the-clock care under the service category of supportive home care during the three-month temporary budget amendment. See Finding of Fact No. 7 and Testimony of —.
14. On November 21, 2025, the Department denied Petitioner’s BA request to fund a $750 daily rate for supportive home care. On November 24, 2025, TMG notified Petitioner that the Department had denied the budget amendment request for a $750 daily rate and explained rationale for the denial as follows:
    

    You currently receive 24/7 care from —/—. You originally had a Budget Amendment (BA) approval effective for dates 9/7/2025 through 12/7/2025. This BA was to cover the cost of your Routine Support Home Care hours (168 hours per week at $36 per hour) while the agency (—) waited for approval to begin MAPC services (which is funded by Medicaid).

    You have been approved to receive 6.25 hours per day of MAPC through —. DHS has agreed to pay the new daily rate of $639 (17.75 hours per day x $36 per hour) for your Routine Supportive Home Care.

    — has requested a daily rate of $750 (the agency calculated this by taking 24 hours per day x $36 per hour = $864 per day and subtracting 6.25 hours per day x $19.10 per hour = $119.38; this generates a daily rate of $744.62 and the agency rounded it up to $750 to create a buffer).

    There are two rates for two different services that are provided by —. IRIS is a publicly funded program and is a funding source of last resort. All other funding sources, including Medicaid and Medicare cards benefits, must be maximized before using IRIS dollars.

    See Resp. Exs. B3 and H.

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. These entities, are known as IRIS Consultant Agencies, and are required to act in concert with the IRIS 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.

Consistent with the terms of the approved IRIS Waiver Application, every program participant is assigned a budget. See Waiver Application, Appendix C-4, p. 185. 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). Id. and IRIS Policy Manual, Sec. 6.2. After a participant’s budget is assigned, they identify services they need to meet their long term care outcomes. These services may include services funded by the IRIS program; services funded by other sources, such as non-IRIS Medicaid funds, Medicare, private entities, community organizations; and services provided by non-paid supports (e.g., neighbors, family, friends). IRIS Policy and Procedure: IRIS Service Plan, P-00708D (12/2025), Sec. B.3.f. The cost of those services must typically fall within the assigned budget. Id. at B.1.a. Participants may, however, submit a budget amendment request to the Department of Health Services with the assistance of their ICA. Id. A budget amendment request is “…additional funding requested when a participant has identified a need and associated long-term care outcome that cannot be met by the participant’s established base budget or other Medicaid benefit.” Id.; see also, IRIS Policy and Procedure: Additional Funding Requests, P-03656 (11/2024).

The issue in this case is whether the Department correctly denied the budget amendment request to allow Petitioner to pay — a $750 daily rate. Petitioner, both of her parents, and —, who is the general manager of —, all appeared at hearing and offered compelling testimony as to why the requested daily rate is a reasonable amount to pay to meet Petitioner’s needs and why — being employed as Petitioner’s sole provider would be the best way to meet Petitioner’s considerable needs.

— testimony made plain that the $750 daily rate was requested as a means of supplementing the $19.10 per hour Medical Assistance personal care rate so that — could continue to receive an effective hourly rate of $36 per hour for all 24 hours per day of care that it provides to Petitioner. He observed that personal care is typically more complex and more rigorous than supportive home care and argued that it makes little sense to receive lesser funding for more challenging care. I do not disagree. Petitioner and her parents explained in detail the struggle that they have faced over the years to arrange quality care, the importance of having quality care, and the relief they felt in finally finding reliable care upon hiring — to provide supportive home care. They also explained their concerns that Petitioner’s health and independence may be jeopardized if — declines to provide her personal care and she ends up working with a personal care agency that employs less reliable staff—a reality that Petitioner faced frequently in past years. The testimony offered by, and on behalf of, Petitioner was credible, sincere, and rational.

Here is the sticking point. IRIS policy explicitly states: “Funds approved through the [budget amendment] process must be used for the requested service(s) and cannot be transferred to a different service or service type (example: community transportation vs. respite), or different provider type (example: agency vs. Participant Hired Worker).” See IRIS Policy and Procedure: Additional Funding Requests P-03656 (11/2024), Sec. A. (Resp. Ex. J3). In addition, as Respondent noted, Medicaid regulations require providers who bill Medicaid to accept Medicaid payment as payment in full and personal care is funded by Medicaid. See 42 CFR § 447.15 (Resp. Ex. J14). Petitioner did not contend that either the above-cited IRIS policy or the federal regulation was misapplied, misconstrued, or irrelevant to the facts of this case.

Petitioner presented several prior hearing decisions that addressed the question of whether Respondent properly denied funding for provider rate increases where no other available providers were identified. Although prior hearing decisions are not binding, they may certainly be persuasive, if they present analogous facts or relevant legal analysis. There is, however, no clear indication that the budget amendments sought by the petitioners in the cases cited by Petitioner were requested to help pay for a service other than the service identified in the respective budget amendment requests–which is the reality in this case. In several of the cited cases, the respondent argued that the rates sought by the Petitioners were not “usual and customary” without providing any evidence of the usual and customary rate. Although the Department questioned the comparable rates provided by Petitioner in this case, my decision is not based on a finding that those rates are or are not comparable to the rate requested by —.

For the reasons set forth above, I find that I do not have the authority to order the IRIS program to grant a BA request sought for the purpose of subsidizing the Medical Assistance personal care hourly rate.

Conclusions of Law

The Department of Health Services correctly denied the budget amendment request for IRIS funds that would allow Petitioner to pay the provider a $750 daily rate for supportive home care because that rate was sought as a means to supplement the Medical Assistance personal care rate.

THEREFORE, it is

Ordered

Petitioner’s appeal is dismissed.

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