Wisconsin Medicaid Include, Respect, I Self-Direct (IRIS) Waiver / Self-Directed Supports (SDS)

Last updated: August 19, 2021

 

Overview of Wisconsin’s IRIS Medicaid Waiver

Wisconsin’s Include, Respect, I Self-Direct (IRIS) Waiver Program provides home and community based services for frail seniors and disabled adults who are at risk of being institutionalized (being placed in a nursing home). Program participants are given an individualized budget with which to select long-term services and supports that best meet their needs and circumstances. They also choose from whom they receive them and the location in which they are provided. As an example, a senior who lives alone might opt for a personal emergency response system, home delivered meals, in-home personal care assistance, and homemaker services, while someone who lives with an informal caregiver might spend their budget on in-home respite care and adult day care.

While participant-direction is the backbone of the IRIS Waiver, program participants receive guidance in navigating the program by an IRIS “consultant”. This person assists in developing an individualized service and support plan based on one’s allotted budget and assists in finding service providers and vendors of goods / supplies listed on one’s plan. Persons that cannot direct their own care can choose a representative to assist, or if applicable, a legal representative can make decisions on their behalf. Program participants also work with an IRIS fiscal employer agent who issues payments for chosen services and goods / supplies.

Program participants have the option of self-directed personal care (SDPC) or receiving personal care assistance from a licensed agency care worker. With SDPC, persons can hire, train, and manage their own caregiver. Relatives, including spouses, can be hired. The fiscal employer agent handles the financial aspects of employment responsibilities, such as background checks, tax withholding, and caregiver payments.

Program beneficiaries can live in their own private home, the home of a close friend or relative, a boarding house, an adult family home (adult foster care), or residential care apartment complex (assisted living residence).

IRIS is not an entitlement program, which means meeting eligibility requirements does not equate to immediate receipt of program benefits. Instead, the waiver has a limited number of participant enrollment slots, and when these slots are full, a waitlist for program participation forms.

 Persons who are wait-listed for the IRIS Medicaid Waiver may instead enroll in the Family Care / Family Care Partnership Program, which is a Medicaid managed care program.

The Wisconsin Include, Respect, I Self-Direct (IRIS) Program is a 1915(c) Medicaid waiver that began in July 2008. This program also goes by the name of IRIS Self-Directed Supports (SDS).

 What are 1915(c) HCBS Medicaid Waivers?
Historically Medicaid only paid for long-term care in nursing homes. 1915(c) HCBS Medicaid Waivers allow states to offer benefits outside of these institutions. “HCBS” stands for “Home and Community Based Services. The goal of HCBS is to delay or prevent institutionalization, and to that end, care may be provided in one’s home, the home of a relative, assisted living, or adult foster care / adult family living. Waivers can target specific groups who require a nursing home level of care and are at risk of institutionalization such as the elderly, disabled, or persons with Alzheimer’s. Waivers are not entitlements. This means that meeting eligibility criteria does not guarantee receipt of benefits, as there are a limited number of slots for program participants.

 

Benefits of the IRIS Waiver

Include, Respect, I Self-Direct Program participants are allotted an individualized budget based on need with which they can purchase needed long-term services and supports. Follows is a list of potential ways in which one might spend their budget. Other services and goods not mentioned below may be available via IRIS.

– Adult Day Care / Adult Day Health Care
– Assistive Technology / Adaptive Aids
– Communication Aids
– Community Transition Services
– Consultant Services
– Consumer Education & Training – may include training for unpaid caregivers
– Counseling / Therapeutic Resources
– Customized Goods / Services
– Daily Living Skills Training
– Day Habilitation
– Financial Management Services – provided by fiscal employer agents
– Home Delivered Meals
– Home Modifications – i.e., addition of grab bars, ramps, stair lifts, adaptive lighting
– Housing Counseling
– Housing Startup
– Interpreter Services
– Live-In Caregiver
– Nursing Services
– Personal Emergency Response Systems
– Prevocational Services / Vocational Planning
– Respite Care – in-home and out-of-home
– Self-Directed Personal Care
– Specialized Medical Equipment / Supplies
– Supported Employment
– Supportive Home Care
– Transportation – non-medical
– Vehicle Modifications

While program participants can live in adult family homes and assisted living residences, room and board is not covered by IRIS.

 

Eligibility Requirements for Wisconsin’s IRIS Medicaid Waiver

The IRIS Program is for Wisconsin residents who are elderly (65+) or between the ages of 18 and 64 and physically, developmentally, or intellectually disabled. Persons who enroll between the ages of 18 and 64 will continue to receive waiver services upon turning 65. Additional eligibility criteria are as follows and is relevant for persons 65+ years old.

 The American Council on Aging now offers a free, quick and easy Wisconsin Medicaid eligibility test for seniors. 

 

Financial Criteria: Income, Assets & Home Ownership

Income
The 2021 applicant income limit, which increases on an annual basis in January, is set at $2,382 / month. When both spouses are applicants, each spouse is considered individually, with each spouse allowed income up to $2,382 / month. When only one spouse is an applicant, the income of the non-applicant spouse is not counted towards the income eligibility of his/her spouse. Furthermore, monthly income from the applicant spouse can be transferred to the non-applicant spouse as a spousal income allowance, also called a monthly maintenance needs allowance.

There is a minimum income allowance, set at $2,903.34 / month (effective July 2021 – June 2022), which is intended to bring a non-applicant spouse’s monthly income up to this amount. There is also a maximum income allowance, which is $3,259.50 / month (effective January 2021 – December 2021), and is dependent on the non-applicant spouse’s shelter and utility costs. This monthly maintenance needs allowance is intended to ensure the non-applicant spouse does not become impoverished.

Assets
In 2021, the asset limit is $2,000 for a single applicant. For married couples, with both spouses as applicants, each spouse can have up to $2,000 in assets. When only one spouse is an applicant, the assets of both the applicant and non-applicant spouse are limited, though the non-applicant spouse is allocated a larger portion of the assets to prevent spousal impoverishment. (Unlike with income, Medicaid considers the assets of a married couple to be jointly owned). In this case, the applicant spouse can retain up to $2,000 in assets and the non-applicant spouse can keep up to $130,380. This larger allocation of assets to the non-applicant spouse is called a community spouse resource allowance.

Some assets are not counted towards Medicaid’s asset limit. These generally include an applicant’s primary home, household furnishings and appliances, personal effects, and a vehicle.

Assets should not be given away or sold under fair market value within 60-months of long-term care Medicaid application. This is because Medicaid has a look back rule and violating it results in a penalty period of Medicaid ineligibility.

 To determine if you might have assets over Medicaid’s countable limit, and if so, receive an estimate of the amount, use our spend down calculator

Home Ownership
The home is often the highest valued asset a Medicaid applicant owns, and many persons worry that WI Medicaid will take their home. Fortunately, for eligibility purposes, Medicaid considers the home exempt (non-countable) in the following circumstances.

– The applicant lives in the home or has “intent” to return to the home and his / her home equity interest is no greater than $750,000. Home equity interest is the current value of the home minus any outstanding mortgage.
– A spouse lives in the home.
– A minor (under 18 years old) lives in the home.
– A disabled child lives in the home.

To learn more about the potential of Medicaid taking the home, click here.

 

Medical Criteria: Functional Need

An applicant must require a nursing facility level of care (NFLOC). For the IRIS Program, the tool used to make this determination is the Wisconsin Adult Long-term care Functional Screen (LTC FS). One’s ability / inability to independently complete their activities of daily living (i.e., transferring from the bed to a chair, mobility, eating, toileting, eating) and instrumental activities of daily living (i.e., meal preparation, money management, housework) is considered when making this determination. While persons with Alzheimer’s disease or another irreversible dementia may be eligible, a diagnosis of dementia in and of itself does not mean one will meet the criteria for NFLOC.

 For more information about long-term care Medicaid in Wisconsin, click here.

 

Qualifying When Over the Limits

Having income and / or assets over Wisconsin’s Medicaid’s limit(s) does not mean an applicant cannot still qualify for Medicaid. There are a variety of planning strategies that can be used to help persons who would otherwise be ineligible to become eligible. Some of these strategies are fairly easy to implement, and others, exceedingly complex. Below are the most common.

WI has a Medically Needy Medicaid Program called the Medicaid Deductible Program for Medicaid applicants who have high medical expenses relative to their income. Also known as a spend-down program, applicants are permitted to spend “excess” income on medical expenses and health care premiums, such as Medicare Part B, in order to meet Medicaid’s income limit. The amount that must be “spent down” for each six-month period can be thought of as a deductible. Once one’s “deductible” has been met for the period, IRIS will pay for care services and supports.

When persons have assets over the limits, trusts are an option. Irrevocable Funeral Trusts are pre-paid funeral and burial expense trusts that Medicaid does not count as assets. Another option are Medicaid Asset Protection Trusts, which not only protects assets from Medicaid’s asset limit, but also preserves them as inheritance by protecting them from Medicaid’s estate recovery program. There are many other options when the applicant has assets exceeding the limit.

Inadequate planning or improperly implementing a Medicaid planning strategy can result in a denial or delay of Medicaid benefits. Professional Medicaid planners are educated in the planning strategies available in the state of Wisconsin to meet Medicaid’s financial eligibility criteria without jeopardizing Medicaid eligibility. While there are a variety of planning strategies, some do violate Medicaid’s 60-month look back rule, and therefore, should be implemented well in advance of the need for long-term care. However, there are some workarounds, like the Modern Half-a-Loaf Strategy, and Medicaid planners are aware of them. For all of these reasons, it is highly suggested one consult a Medicaid planner for assistance in qualifying for Medicaid when over the income and / or asset limit(s). Find a Medicaid planner.

 

How to Apply for the Wisconsin’s IRIS Medicaid Waiver

Before You Apply

Prior to submitting an application for IRIS, applicants need to ensure they meet the eligibility criteria. Applying when over the income and / or asset limit(s) will be cause for denial of benefits. The American Council on Aging offers a free Medicaid eligibility test to determine if one might meet Medicaid’s eligibility criteria. Take the Medicaid eligibility test.

As part of the application process, applicants will need to gather documentation for submission. Examples include copies of Social Security and Medicare cards, bank statements up to 60-months prior to application, proof of income, and copies of life insurance policies, property deeds, and pre-need burial contracts. Unfortunately, a common reason applications are held up is required documentation is missing or not submitted in a timely manner.

Since the IRIS Waiver is not an entitlement program, there may be a waitlist for program participation. The waiver is approved for a maximum of approximately 29,376 beneficiaries each year.

 

Application Process

To apply for the IRIS Medicaid Waiver, persons should contact their local Aging and Disability Resource Center (ADRC). Contact information can be found here. As part of the application process, an in-person functional needs assessment will be completed.

For additional information about IRIS, click here. The Division of Long Term Care (DLTC) within the Wisconsin Department of Health Services (DHS) administers the WI IRIS Medicaid Waiver.

 

Approval Process & Timing

The WI Medicaid application process can take up to 3 months, or even longer, from the beginning of the application process through the receipt of the determination letter indicating approval or denial. Generally, it takes one several weeks to complete the application and gather all of the supportive documentation. If the application is not properly completed, or required documentation is missing, the application process will be delayed even further. In most cases, it takes between 45 and 90 days for the Medicaid agency to review and approve or deny one’s application. Based on law, Medicaid offices have up to 45 days to complete this process (up to 90 days for disability applications). However, despite the law, applications are sometimes delayed even further. Furthermore, as wait-lists may exist, approved applicants may spend many months waiting to receive benefits.

Determine Your Medicaid Eligibility

Get Help Qualifying for Medicaid