CWA 215749 (05/16/2025)
Medicaid notices must explain right to appeal

Preliminary Recitals

Pursuant to a petition filed on September 19, 2024, 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 April 24, 2025, by telephone. The hearing was rescheduled at the request of the petitioner’s representative on November 13, 2024; December 18, 2024; January 23, 2025; February 26, 2025; March 12, 2025; April 8, 2025; and April 15, 2025.

The issue for determination is whether the respondent appropriately disenrolled the petitioner from the IRIS program as of August 1, 2024.

There appeared at that time the following persons:

PARTIES IN INTEREST:

Petitioner:
—

Respondent:
Department of Health Services
1 West Wilson Street, Room 651
Madison, WI 53703
By: TMG
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. He was enrolled in IRIS, with TMG his IRIS consultant agency.
2. On July 3, 2024, a letter titled, Wisconsin Long-Term Care Program Disenrollment Notice was issued to the petitioner. It indicated his “long-term care program enrollment has ended or is scheduled to end due to no Medicaid Eligibility.” It indicated his IRIS enrollment was scheduled to end July 31, 2024. It also indicated that he would “receive a separate notice that explains why your benefits are ending. The notice explains how you can ask for a fair hearing if you don’t agree with the decision.”
3. On July 21, 2024, a letter titled, Wisconsin Long-Term Care Program Disenrollment Notice was issued to the petitioner. It indicated his “long-term care program enrollment has ended or is scheduled to end due to no Medicaid Eligibility.” It indicated his IRIS enrollment was scheduled to end July 31, 2024. It also indicted that he would “receive a separate notice that explains why your benefits are ending. The notice explains how you can ask for a fair hearing if you don’t agree with the decision.”
4. On August 4, 2024, a letter titled, Wisconsin Long-Term Care Program Disenrollment Notice was issued to the petitioner. It indicated his “long-term care program enrollment has ended or is scheduled to end due to no Medicaid Eligibility.” It indicated his IRIS enrollment was scheduled to end July 31, 2024. It also indicted that he would “receive a separate notice that explains why your benefits are ending. The notice explains how you can ask for a fair hearing if you don’t agree with the decision.”
5. The letters reflected in Findings of Fact 2, 3, and 4 did not explain the process or deadline to request a fair hearing to contest the IRIS disenrollment.
6. The petitioner was disenrolled for IRIS as of August 1, 2024.
7. On September 19, 2024, the petitioner filed an appeal with the Division of Hearings and Appeals.
8. The petitioner was re-enrolled in IRIS as of November 15, 2024.

Discussion

The petitioner was disenrolled from IRIS as of August 1, 2024. The petitioner filed an appeal seeking to contest that disenrollment.

IRIS policy requires participants be notified of the decision to involuntarily disenroll them from the IRIS program. Application for 1915(c) HCBS Waiver: WI.0484.R03.00 (January 1, 2021) (“IRIS Waiver”), pg. 202 of 274, found online at: https://www.dhs.wisconsin.gov/iris/hcbw.pdf; see also IRIS Policy Manual, § 11.2 (04/2024) (requiring a notice of action be issued when a participant is deemed functionally or financially ineligible for IRIS). The notice is to inform of the disenrollment decision and provide information on how to engage the State Fair Hearing process. Id. The IRIS Policy Manual also indicates, “Information concerning procedures for exercising the participant’s right to an appeal process accompanies the NOA.” IRIS Policy Manul, § 11.2.

The notice of action is required to comply with 42 CFR §431.210. See IRIS Waiver, pg. 206. This requires the following:

(a) A statement of what action the agency … intends to take and the effective date of such action;

(b) A clear statement of the specific reasons supporting the intended action;

(c) The specific regulations that support, or the change in Federal or State law that requires, the action;

(d) An explanation of—

(1) The individual’s right to request a local evidentiary hearing if one is available, or a State agency hearing; or

(2) In cases of an action based on a change in law, the circumstances under which a hearing will be granted; and

(e) An explanation of the circumstances under which Medicaid is continued if a hearing is requested.

42 C.F.R. § 431.210. Federal regulations also require the notice of action be sent at least 10 days prior to date of action. 42 C.F.R. § 431.211.

The record before me does not contain a notice of action addressing petitioner’s IRIS disenrollment of July 31, 2024 that complies with the above-cited federal regulations.

The “Wisconsin Long-Term Care Program Disenrollment Notice” issued on July 3, 2024, July 21, 2024, and August 4, 2024, do not meet the requirements of 42 CFR §431.210 or the IRIS Waiver in order to act as the formal notice of action of IRIS disenrollment. This is because it does not apprise the petitioner of the process and deadline to contest the IRIS disenrollment determination. Nor does it apprise of the circumstances under which the IRIS benefits may be continued if an appeal is filed. In fact, those “notices” indicate that a separate notice would be sent informing of the reason for the disenrollment AND explaining how the petitioner could ask for a fair hearing. The record before me does not contain that separate notice.

At hearing, it was noted by the IM agency that no notice of action informing of IRIS disenrollment was issued as the IM agency had not been informed that petitioner was being disenrolled from IRIS.

As it was not shown an appropriate notice of action regarding IRIS disenrollment was issued to the petitioner, I find that he was incorrectly disenrolled from the IRIS program. I am remanding this matter to the respondent to reinstate IRIS benefits retroactive to August 1, 2024.

Finally, the petitioner’s representative was seeking to be reimbursed for out-of-pocket expenses associated with supportive home care and/or personal care services provided to the petitioner between August 1, 2024 (date of IRIS disenrollment) and November 15, 2024 (date of IRIS re-enrollment). That issue is not ripe for consideration as it must first be submitted to the IRIS program for consideration. If reimbursement is denied, then the issue would be ripe for consideration on appeal.

Conclusions of Law

It was not shown that the petitioner was appropriately disenrolled from the IRIS program as of August 1, 2024.

THEREFORE, it is

Ordered

That this matter is remanded to the Department/ Respondent with instructions to rescind the IRIS disenrollment and reinstate benefits retroactive to August 1, 2024. This action shall be completed within 10 days of the date of this Decision.

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