CWA 221317 (02/27/2026)
Participant disenrolled from IRIS SDPC for failing to cooperate

Preliminary Recitals

Pursuant to a petition filed on October 31, 2025, under Wis. Admin. Code § HA 3.03, to review a decision by the Bureau of Long-Term Support regarding Medical Assistance (MA), a hearing was held on February 5, 2026, by telephone. The hearing was rescheduled multiple times at the request or with the consent of the petitioner.

The issue for determination is whether respondent correctly disenrolled the petitioner from the IRIS SDPC 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: IRIS SDPC Oversight Agency
Bureau of Long-Term Support
PO Box 7851
Madison, WI 53707-7851

ADMINISTRATIVE LAW JUDGE:
Jason M. Grace
Division of Hearings and Appeals

Findings of Fact

1. Petitioner is a resident of Milwaukee County. The petitioner was enrolled in the IRIS program, with Advocates4U his IRIS consultant agency.
2. Petitioner has medical conditions that include dementia, anxiety, depression, schizophrenia, arthritis, hypertension, diabetes, and pulmonary embolism.
3. Petitioner needs assistance with the activities of Daily Living (ADLs) of Bathing, Dressing, Eating, Mobility, Toileting, and Transfers. He also needs assistance with the Instrumental Activities of Daily Living (IADLs) of meal preparation, medication administration/management, money management, laundry/chores, telephone, and transportation. It is noted he needs overnight care and that he has memory loss.
4. The petitioner was enrolled in the IRIS Self-Directed Personal Care (SDPC) program since 2017. This program allowed the petitioner to self-direct his personal cares.
5. On October 21, 2024, petitioner’s doctor signed the IRIS SDPC-Physician Order & Plan of Care, providing a certification period for SDPC services through October 2025.
6. On November 7, 2025, the IRIS SDPC program issued notice to petitioner that he was being involuntarily disenrolled from the SDPC program. The basis for the action was as follows:
   

   In accordance with IRIS SDPC Policy 13.1 IRIS Eligibility: The State determines eligibility for Self-Directing Personal Assistance Services in the same manner as eligibility is determined for traditional State Plan personal care services. Program eligibility criteria includes the review and signature of the My Cares Instruction Sheet by the primary MD.

   This Notice of Action serves to inform you that you no longer meet eligibility due to the lack of a physician signed My Cares Instruction Sheet, as part of your annual assessment process. Numerous attempts have been made by the IRIS SDPC, RN to follow-up with you to ensure your eligibility was continued prior to the expiration of your MY CARES – Plan of Care. Your plan expired on 10/29/2025. Due to this change in eligibility, you will be disenrolled from the IRIS SDPC program effective 11/25/2025.

   NOTE: Involuntary disenrollment from IRIS SDPC does NOT mean disenrollment from the IRIS program. You remain enrolled in IRIS.

7. The petitioner appealed.

Discussion

I would note that a consolidated hearing was held on February 5, 2026, to address petitioner’s disenrollment from the IRIS SDPC program (DHA Case No. CWA-221317) and his termination from the IRIS program (DHA Case No. CWA-220664). This decision addresses the disenrollment from the IRIS SDPC program. A separate decision will be issued addressing petitioner’s termination from the IRIS program.

The IRIS program is a Medicaid 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 Self- Directed Personal Care (SDPC) Program allows the IRIS participant to self-direct their personal care instead of obtaining services through a Medicaid personal care agency. See IRIS Policy Manual,§ 8.0. The Department contracts with the IRIS SDPC Oversight Agency to operate the IRIS SDPC program. Id. Eligibility for SDPC is determined in the same manner as traditional State Plan personal care services. IRIS Policy Manual,§ 8.1.

Every IRIS participant enrolled in the SDPC program must have a care plan detailing their needed services. Id., at 8.4. This information is obtained using the IRIS Self-Directed Personal Care (SDPC) – My Cares and the IRIS Self-Directed Personal Care (SDPC) – Physician Order & Plan of Care forms. Id. The participant, the IRIS SDPC nurse, and the participant’s primary care physician must sign these forms annually prior to implementation of the plan of care. Id and see IRIS Policy Manual: Work Instructions, §9.0. The IRIS SDPC nurse must conduct face-to-face visits with the participant every 60 days unless the IRIS SDPC nurse grants a deviation and the participant’s physician approves the deviation. IRIS Policy Manual, § 8.7. The IRIS SDPC nurse is responsible for reviewing participant’s health status and care. IRIS Policy Manual: Work Instructions, § 9.1. The IRIS SDPC Oversight Agency is required to use the Personal Care Screening Tool (PCST) to establish initial eligibility and at least on an annual basis thereafter. Id. at § 9.0.

Here, the IRIS SDPC Oversight Agency disenrolled petitioner from the IRIS SDPC program for failing to cooperate in completing the annual PCST needed to create a Plan of Care that would be submitted to his primary care physician for approval and signature. The 2024 Plan of Care signed by the primary care physician provided a certification period for SDPC services through October 2025.

The IRIS SDPC Oversight Agency has the authority to involuntarily disenroll a participant from the IRIS SDPC program when the participant’s failure to report information necessary to adequately monitor their situation. Id. at § 8.8.B. If disenrolled from the IRIS SDPC program, the participant is then connected to MAPC providers to ensure continuity of care for PC services. A participant who is disenrolled from the IRIS program is no longer eligible to participate in the IRIS SDPC program.

The record demonstrates multiple instances of failed completion of required 60 day oversight visits by the SDPC nurse. It also documents an incident on September 5, 2025, wherein the SDPC nurse met with petitioner in an attempt to complete the required annual PCST to create a POC to submit to his primary care physical for approval. The PCST was not able to be completed due to verbal statement petitioner made to the SDPC nurse that was reasonably interpreted as a threat involving a firearm. As a result, there is no signed POC that authorizes SDPC services beyond October 2025. Moreover, a participant must be enrolled in the IRIS program to maintain eligibility for the IRIS SDPC program. In DHA Case No. CWA- 220664, the notice of action disenrolling the petitioner from the IRIS program was upheld. The record supports the petitioner’s involuntary disenrollment from the IRIS SDPC program.

Conclusions of Law

The respondent correctly disenrolled the petitioner from the IRIS SDPC program.

THEREFORE, it is

Ordered

That petitioner’s appeal is dismissed.

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