IRIS vs Family Care: A Guide for Home Care Agencies
IRIS vs Family Care for Wisconsin supportive home care agencies: who approves hours, the $6.38 MCO minimum rate, how FEAs pay claims, and enrollment rules.
Resources
IRIS vs Family Care at a Glance
Sagar Kumar, COO and Co-Founder, Verveware
IRIS vs Family Care comes down to who controls the money. In Family Care, a managed care organization (MCO) authorizes and pays for supportive home care (SHC); in IRIS, the participant directs a budget and a fiscal employer agent (FEA) pays you. For a Wisconsin homecare agency, the service and codes are the same, but approvals, rates and claims are not.
Family Care (and Partnership): managed care. The Wisconsin Department of Health Services (DHS) pays each MCO monthly for every member, and the MCO keeps a network of long-term care providers (DHS Family Care).
IRIS (Include, Respect, I Self-Direct): self-direction. The participant chooses and manages providers within a budget, with help from an IRIS consultant agency and an FEA (DHS IRIS).
Supportive home care is covered in both.
Who Authorizes the Work
In Family Care, the MCO care team must approve every service before the member receives it. It can approve a service only if it's in the benefit package, supports the member's outcomes and is the most cost-effective option (DHS Family Care benefits). Deliver and bill only the units on the MCO's authorization.
In IRIS, the participant chooses your agency. DHS requires a written participant-provider service agreement for agency services (except chore-only SHC) covering scope, compensation, the amount of service authorized, training documentation, emergency and back-up plans, billing and termination (P-03071). The service also has to appear on the participant's Individual Support and Service Plan (ISSP).
How Rates Are Set
Family Care MCOs must follow DHS's minimum fee schedule, in effect since October 1, 2024 (ForwardHealth). For MCO-directed agency SHC, the 2026 MCO contract requires at least $6.38 per 15-minute unit or $25.52 per hour. When it checks the minimum, DHS divides time spent with more than one member at once by the number of members present (2026 contract). MCOs still must negotiate and pay above the minimum when a member's needs call for it.
The minimum fee schedule doesn't apply to IRIS. Participants negotiate rates with you within their budget (DHS FAQ), and they can't authorize claims beyond it (IRIS Policy Manual).
How You Get Paid
Family Care
You bill the MCO, or its third-party administrator, using the method your provider agreement sets. Unless you agreed to later payment, MCOs must pay or deny 90% of clean claims within 30 days, 99% within 90 days and all within 180 days (2026 contract).
IRIS
Agency claims go straight to the participant's FEA with the participant ID, provider ID, service code, modifier, units, rate, date of service and authorization period. The FEA checks each claim against the ISSP. Units above the authorization are pended; services not on the ISSP are denied. Approved claims are paid by electronic funds transfer (IRIS Policy Manual).
Before any payment, you must sign Wisconsin Medicaid provider agreement F-00180C and return it to the FEA. Complete only the packet for the FEA the participant chose (ForwardHealth IRIS provider page).
Rules That Apply in Both Programs
Medicaid enrollment. Every HCBS provider in Family Care, Partnership, PACE and IRIS had to apply on the ForwardHealth Portal by December 31, 2025. Without approval by March 31, 2026, providers can't be paid for dates of service from April 1, 2026, and contracts with MCOs or IRIS participants, and IRIS authorizations, are cancelled (LTC 2025-03). SHC agencies with an EVV-only Medicaid ID revalidate and keep the same ID. If you aren't enrolled yet, apply now through the ForwardHealth Portal; our Wisconsin startup guide covers the basics.
EVV. S5125 and S5126 require EVV in Family Care, Partnership and IRIS (DHS EVV codes). DHS doesn't require it for live-in workers, but MCOs and agencies can, and the live-in worker must still be identified to the program (DHS EVV FAQ). See our Sandata alternative in Wisconsin guide.
Training standards. Family Care SHC follows P-01602; IRIS follows P-03071.
IRIS vs Family Care FAQ
What Is the Difference Between IRIS and Family Care for Home Care Agencies?
Family Care is managed care; IRIS is self-directed. In Family Care, an MCO authorizes services, contracts with your agency, pays at least DHS's minimum fee schedule and processes your claims. In IRIS, the participant chooses your agency and negotiates the rate within their budget, and their fiscal employer agent pays claims that match the plan.
Does Wisconsin's Minimum Fee Schedule Apply to IRIS?
No. DHS's minimum fee schedule sets the lowest rates Family Care, Partnership and PACE MCOs can pay for supportive home care, starting October 1, 2024. It doesn't apply to IRIS, where participants negotiate rates with providers within their individual budget.
Do Supportive Home Care Agencies Have to Enroll With Wisconsin Medicaid?
Yes. Providers of adult long-term care waiver services in Family Care, Partnership, PACE and IRIS must be enrolled through the ForwardHealth Portal to be paid by an MCO or IRIS fiscal employer agent. Agencies that only had an EVV-only Medicaid ID revalidate and keep the same ID.
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