Long-term care services and supports are important to assist older adults in achieving their wishes to remain living in their own home as long as possible.1
One long-term care option in Wisconsin is IRIS (Include, Respect, I Self-Direct), a Medicaid self-directed program created in 2008 for eligible individuals, including older adults. IRIS allows individuals the freedom to decide what goods, support, and services will meet their needs to help them lead a meaningful life.
According to the Wisconisn Department of Health Services (DHS), 22,105 individuals are enrolled statewide in IRIS as of Dec. 1, 2020. It is important for health care practitioners to be familiar with IRIS and Family Care as available resources for your clients.
Julianne Cox, is the compliance director for Lakeland Care in Green Bay, where she oversees its compliance program, focusing on program integrity, HIPAA, civil rights, member records, and contract compliance.
This article provides a brief overview of how an individual may be eligible for Wisconsin’s IRIS program, how an individual may enroll in IRIS, and the benefits and services available to individuals enrolled in the IRIS program.
Eligibility for IRIS
Individual eligibility for IRIS is similar to that of Family Care, but there are some differences in how eligibility requirements are established.
IRIS is an authorized program under the Medicaid Home and Community-Based Services (HCBS) waiver section 1915(c) of the federal Social Security Act. Thus, individuals who choose the IRIS program are eligible for and afforded rights to have choice, control, and freedom to design support and service plans to meet functional, vocational, medical, and social needs.
These rights and eligibility criteria are established through DHS’s program policies and procedures that ensure compliance with the federal 1915(c) HCBS Waiver application. DHS and CMS must also file subsequent renewal waiver applications.
To be eligible for Wisconsin’s IRIS program, according to DHS’s IRIS Policy Manual, an individual must meet these criteria:
be at least 18 years old;
be a Wisconsin resident;
be a frail elder or an adult with a physical or developmental disability;
need the same level of care as someone in a nursing home;
meet financial and nonfinancial eligibility criteria for Medicaid;
live in a home, apartment, adult family home, or residential care apartment complex; and
have a need for long-term care supports and services.
Enrolling in IRIS
IRIS is offered as an alternative option to the Family Care program, with both being available to eligible residents in all Wisconsin counties. Individuals and their families can obtain information about all the community resources available to them, including the IRIS program and the Family Care program, through their local Aging and Disability Resource Center (ADRC).
Each ADRC helps the general public understand the many different programs and benefits available to individuals and their families. ADRCs serve as the starting point for enrollment in many services.
IRIS participants must select their IRIS Consultant Agency (ICA) based on information provided through ADRC enrollment counseling. There are seven agencies available to eligible Wisconsin participants, each of which handle the operations of the IRIS program and assist individuals with the selection of:
an IRIS consultant: a person from an ICA who assists participants with information about services available in the area, completing paperwork, and answers questions; and
an IRIS fiscal employer agent who completes background checks on workers hired by the participant to provide services, as well as processes payroll and helps with other employer tasks. There are four fiscal employer agents available to eligible Wisconsin participants.
IRIS Benefits and Services
After selecting the IRIS program, participants meet with their IRIS consultant for program orientation information and to begin creating an Individual Support and Service Plan (ISSP).
The 1915 (c) HCBS waiver in Appendix E (E-1) requires a “person-centered approach” in the development of the participant’s ISSP. The ISSP “revolves around an individual participant and reflects his or her chosen lifestyle and culture. The participant directs development of the [ISSP], which serves as the foundation for participation in [the] waiver.”
When creating the ISSP, IRIS participants choose the supports and services they wish to receive. Based on the expected needs identified in the ISSP, a monthly IRIS budget estimate is created and ultimately approved by the ICA. The “person-centered” approach of developing the ISSP is ongoing and reflects changes in the participant’s life and reviewed annually.
IRIS participants maintain self-direction through both budget authority and employer authority in achieving their long-term care goals identified in the ISSP.
Budget authority allows the participant to choose which goods, support, and services will be used to meet their goals. DHS defines “allowable services” as those services defined in the 1915 (c) HCBS waiver in Appendix C (C-1).
Allowable services include:
adult day care;
counseling and therapeutic resources;
costs of a live-in caregiver;
respite care; and
vocational futures planning.
Employer authority provides the participant the ability to hire and manage workers to provide services, such as supportive home care, respite, or personal care. Participants can obtain workers by:
being an employer, and hiring workers directly and utilizing a fiscal employer agent to process timesheets;
recommending workers to be employed/managed by an agency;
managing workers chosen with assistance of an agency that employs the workers; or
using an agency to supply services through the workers the agency choses and employs.
A Self-Directed Care Option
Eligible Wisconsin residents who select the IRIS self-direction program have choice, control, flexibility, and responsibility to purchase their own supports and services to meet their long-term care needs.
IRIS and Family Care enrollment continue to increase, and will likely be in high demand as Wisconsin’s population continues to age. Being aware of these long-term care program options is crucial to both the legal community and Wisconsin residents.
This article was originally published on the State Bar of Wisconsin’s Health Law Blog. Visit the State Bar sections or the Health Law Section web pages to learn more about the benefits of section membership.
1 For additional background, see my previous Health Law Blog article, Family Care: Supporting Independence of Eligible Wisconsin Residents, June 17, 2019.