CWA — (09/03/2026)
IRIS SDPC services not backdated even after successful appeal

Preliminary Recitals

Pursuant to a petition filed on June 12, 2026, 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 July 16, 2026, by telephone.

The issue for determination is whether the IRIS Self-Directed Personal Care Oversight Agency correctly denied Petitioner backdated authorization for Self-Directed Personal Care.

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:
Wendy I. Smith
Division of Hearings and Appeals

Findings of Fact

1. Petitioner is a resident of Racine County and a participant in the IRIS program.
2. Petitioner was involuntarily disenrolled from the IRIS program as of December 31, 2025, due to renewal processing errors at her applicable Income Maintenance (IM) agency. In advance of this action, Petitioner was issued a notice warning her of the impending disenrollment from IRIS dated December 21, 2025, as well as multiple notices from the Income Maintenance agency warning of her ineligibility for Medicaid Community Waivers with information on how to request a fair hearing.
3. Petitioner appealed to the Division of Hearings (DHA) (Case No. CWA —) on January 13, 2026. Petitioner’s hearing request form checked the box to request continuation of services pending her appeal. Because Petitioner’s appeal was filed after her disenrollment, a continuation of services order was not issued by the DHA.
4. A decision was issued by the Division of Hearings and Appeals on March 23, 2026, ordering the IM agency and her IRIS Consultant Agency to (1) enroll Petitioner in the IRIS program as of January 1, 2026, and (2) to issue any IRIS benefits for which she was eligible accordingly.
5. Petitioner’s eligibility for IRIS was reinstated as of January 1, 2026.
6. Prior to her involuntary disenrollment from IRIS, Petitioner was approved to receive up to 31 hours of Self-Directed Personal Care (SDPC). This authorization was pursuant to a Physician Order & Plan of Care (PPOC) with a certification expiration date of May 28, 2026.
7. In a notice dated March 24, 2026, the IRIS SDPC Oversight Agency advised Petitioner that her request for backdated SDPC from January 1, 2026, was denied for insufficient documentation. Specifically, the notice advised:
   1. 1. Please note that Medicaid/IRIS SDPC requires a plan of care to remain active while enrolled in the program. When a person is disenrolled, their plan of care expires. Medicaid/IRIS SDPC is unable to backdate a PPOC after 60 days.
      2. Your IRIS disenrollment on 12/31/2025 also meant that your IRIS SDPC enrollment would end on the same date. However, after a state fair hearing regarding your IRIS disenrollment, it was determined that your IRIS services should be resumed without a gap in enrollment. Please be aware that the IRIS SDPC Oversight Agency was not part of the state fair hearing, and as a result, your plan of care was expired for more than 60 days.
      3. We must notify you that, per Medicaid statutes, this period cannot be backdated, necessitating the issuance of a Notice of Action. The IRIS SDPC Oversight Agency has received your re-referral and your initial SDPC assessment is scheduled for April 2, 2026.
8. A new PPOC for Petitioner dated April 10, 2026, ordered up to 31.75 of SDPC per week in a certification period expiring on April 1, 2027.
9. Petitioner now appeals to the Division of Hearings and Appeals.

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.

The IRIS Waiver Application most recently approved by the Centers for Medicare and Medicaid Services (CMS) is available online at  https://www.dhs.wisconsin.gov/iris/hcbw2026.pdf. See Application for 1915(c) HCBS Waiver: WI.0484.R04.00 – Jan 01, 2026. The version in effect prior to January 1, 2026, is Application for 1915(c) HCBS Waiver: WI.0484.R03.00 – Jan 01, 2021 (the Waiver), available at https://www.dhs.wisconsin.gov/iris/2021-iris1915cwaiver-draft.pdf. 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), and as relevant here, in the IRIS Self-Directed Personal Care Policy (the IRIS SDPC Policy) (available at https://www.dhs.wisconsin.gov/publications/p00708f.pdf).

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. IRIS Policy Manual § 8.0; IRIS SDPC Policy, Sec. A. The Department contracts with the IRIS SDPC Oversight Agency (the “Oversight Agency”) to operate the IRIS SDPC program. IRIS SDPC Policy, Sec. A.3. Every IRIS participant enrolled in the SDPC program must have a care plan detailing the services needed. Id. at Sec. A.1. This information is obtained using the IRIS SDPC – My Cares form and the IRIS SDPC – Physician Order & Plan of Care (PPOC) form. See id. at Sec. A.1.b. The participant, the IRIS SDPC nurse, and the participant’s prescribing provider must sign these forms annually prior to implementation of the plan of care. Id. at Sec. A.1.c. The Oversight agency is responsible for adding a SDPC authorization to the participant’s plan and terminating an authorization if the participant becomes ineligible. The IRIS SDPC nurse must conduct face-to-face oversight visits with the participant at least every 60 days unless the IRIS SDPC nurse grants a deviation and the participant’s physician approves the deviation. Id. at Sec. A.3.a; see also Wis. Admin. Code DHS § 107.112(3)(c).

In this case, Petitioner was involuntarily disenrolled from IRIS as of January 1, 2026. She appealed the disenrollment by requesting a fair hearing with the DHA after the disenrollment action went into effect. The DHA issued a decision on March 23, 2026, finding that her disenrollment was improper and ordered reinstatement of her enrollment in IRIS as of January 1, 2026, and ordering the agency to issue any benefits for which she may have been accordingly entitled. Petitioner seeks backdated authorization of SDPC services as of January 1, 2026. After issuance of the DHA decision, the Oversight Agency issued a denial notice stating that Petitioner’s PPOC expired as of the date of her disenrollment and that it was unable to backdate a PPOC after 60 days from its expiration date.

According to the federal regulations concerning Medicaid fair hearings and the IRIS Policy Manual, continuation of services is available to a participant while their appeal is under consideration if the agency sends the required advance notices advising of a negative action and the participant’s request for a hearing is received by the state on or before the effective date of the negative action. 42 C.F.R. § 431.230(a); IRIS Policy Manual § 7.1A. In this case, the agency did send Petitioner multiple notices warning that she would lose her Medicaid Community Waivers eligibility and that she would be disenrolled from IRIS as of January 1, 2026. These notices appear to have been issued by the required 10-day advance notice timeframe required by law. However, Petitioner did not file her fair hearing request until after she was disenrolled. Petitioner is therefore not entitled by law to a continuation of her IRIS or SDPC services while her appeal was pending, nor was continuation ordered.

While she was disenrolled and her appeal pending, Petitioner’s SDPC plan of care was not maintained and Petitioner did not continue to participate in required 60-day nurse oversight visits. The Oversight Agency contends that Petitioner’s PPOC became invalid as of the date of her disenrollment from the IRIS program and that it could not provide the required oversight during this time. As cited above, SDPC services are generally subject to in-person nursing oversight visits at least every 60 days. These visits could not occur while Petitioner’s appeal was pending (82 days between the date of her disenrollment and the date of the DHA decision) and, as a result, Petitioner was not assessed by a nurse for evaluation of her condition, supervisory review of the personal care worker, and assessment and discussion with the prescribing provider for any necessary changes to the plan of care. Wis. Admin. Code DHS § 107.112(3)(c). These express limitations on personal care services are set by law which I do not have the authority to waive. Without the oversight visits, the record is otherwise inadequate to assure that Petitioner was still entitled to the previously authorized level of care or that the services rendered were appropriate.

Unfortunately, I cannot order backdated SDPC services for the requested period while Petitioner’s appeal was pending because she was disenrolled from IRIS and her plan of care was not maintained as required by law. As mentioned at the hearing, Petitioner may consult with her IRIS Consultant Agency to consider whether an IRIS Budget Amendment may be sought to fund the services performed during this period as an alternative.

Conclusions of Law

The IRIS Self-Directed Personal Care Oversight Agency correctly denied Petitioner backdated authorization for Self-Directed Personal Care while Petitioner’s appeal of her IRIS disenrollment was pending as Petitioner was not entitled to a continuation of her IRIS and Self-Directed Personal Care services and her Self-Directed Personal Care plan of care was not maintained in accordance with applicable law.

THEREFORE, it is

Ordered

That the agency’s denial is affirmed.

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