Late renewals can cause a gap in Community Waivers enrollment, though the Department has allowed for an expedited re-enrollment process to minimize this. In this case, the petitioner completed a late renewal and would have used the expedited process, but the ADRC delayed sending its IRIS referral for a month, making him ineligible for expedited re-enrollment at that point. In a decision adopted as final, ALJ John Tedesco concluded the petitioner’s IRIS enrollment should be backdated.
This decision was published with support from the Wisconsin chapter of the National Academy of Elder Law Attorneys and Krause Financial.
The attached proposed decision of the Administrative Law Judge dated June 20, 2025 is hereby adopted as the final order of the Department.
[Request for a rehearing and appeal to court instructions omitted.]Preliminary Recitals
Pursuant to a petition filed on January 2, 2025, 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 May 14, 2025, by telephone.
The issue for determination is whether petitioner’s re-enrollment in IRIS should be backdated to 8/1/24.
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: P. Schreiber – TMG
Bureau of Long-Term Support
PO Box 7851
Madison, WI 53707-7851
ADMINISTRATIVE LAW JUDGE:
John Tedesco
Division of Hearings and Appeals
Findings of Fact
- Petitioner is a resident of Milwaukee County.
- Petitioner was enrolled in IRIS with TMG as his IRIS agency.
- On 7/31/24 the agency terminated petitioner’s Medicaid.
- IRIS was also terminated due to petitioner not having Medicaid.
- On 8/13/24 the petitioner and the agency resolved the financial concern of the agency and MA was reopened back to 8/1/24 without any lapse.
- On 8/20/24 the petitioner contacted the ADRC and requested a processing of expedited reenrollment into IRIS.
- The ADRC did not send a referral to TMG until 9/20/24 at which time it was too late to process an expedited re-enrollment into IRIS/TMG.
- Petitioner’s new enrollment to IRIS/TMG was completed on 10/25/24.
Discussion
The Include, Respect, I Self-Direct (IRIS) program is a Medicaid 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, Medicaid Eligibility Handbook §28.1, et. seq. and 42 C.F.R. §441.300, et. seq.
The IRIS waiver application most recently approved by the Centers for Medicare and Medicaid Services (CMS) is available on-line at https://www.dhs.wisconsin.gov/iris/hcbw.pdf. See Application for 1915(c) HCBS Waiver: WI.0484.R03.00 – Jan 01, 2021. 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), IRIS Work Instructions (available at http://www.dhs.wisconsin.gov/publications/P0/P00708a.pdf), and IRIS Service Definition Manual (available at https://www.dhs.wisconsin.gov/publications/p00708b.pdf).
The Department of Health Services is the state agency that oversees and administers the IRIS program and it contracts with and/or assigns specific operational duties to each of the following: Aging and Disability Resource Centers (“ADRCs”), IRIS consultant agencies (“ICAs”), IRIS fiscal employer agents (“FEAs”), and income maintenance agencies (“IM agencies”).
The facts in this case are not in dispute. Petitioner filed an appeal because he was involuntarily disenrolled from the IRIS program from July 31, 2024 through October 25, 2024, and his providers are therefore unable to be paid for care they provided him during that time period. Respondent contended that Petitioner cannot receive coverage of long-term care services unless he is currently enrolled in the IRIS program. The following IRIS program policy supports that position:
An IRIS participant’s enrollment date refers to the date of activation of the service authorization; therefore, the IRIS program prohibits the payment of providers and/or participant-hired workers prior to the enrollment date.
IRIS Policy Manual, §5.5B.
Respondent explained that Petitioner was involuntarily disenrolled from IRIS because the IM agency temporarily terminated his Medicaid eligibility as of August 1, 2024, due to a finding of financial ineligibility. Petitioner and the agency resolved the issue and petitioner was reopened for Medicaid on 8/13/24 with no gap in coverage.
A result of the Petitioner’s brief closure of MA is that he was also disenrolled from the IRIS program as of 8/1/24.
An IRIS member is not automatically re-enrolled in the IRIS program after completing a late Medicaid renewal. In this case, the Petitioner contacted the ADRC on 8/20/24. The ADRC did not meet with petitioner until 9/19/24. By this time, it was too late for the expedited re-enrollment process. Had the ADRC sent a referral to TMG by 8/30/24 then the expedited re-enrollment would have been completed. That did not happen. For a reason unknown at hearing, the ADRC did not provide TMG with an IRIS referral until 9/20/24.
Under IRIS policy, a member may be eligible for an expedited re-enrollment when the member’s disenrollment from the program was effective less than 30 days prior to their new program start date. See IRIS Policy and Procedure Publication P-03547 (09/2024) §B.1.b. The expediated re-enrollment process provides, in relevant part, the following:
The expedited re-enrollment process allows participants who have been disenrolled from the IRIS program, for the reasons indicated below, to be re-enrolled in the program with an abbreviated referral period. The referral process for the participant remains the same as an initial enrollment, meaning that the ADRC or Tribal ADRS must refer the participant to the ICA using the IRIS Authorization Form (F-00075).
This process applies only to participants who are found eligible for the IRIS program again following:
- Release from an incarceration.
- Discharge from an institution for mental disease (IMD) admission.
- Discharge from a suspension that has lasted longer than 90 days.
- Reinstatement of Medicaid eligibility after it had lapsed.
When a participant is re-enrolling in the program, the ICA may reinstate their most recently active IRIS Service Plan (including all orientation, FEA-related, Participant-Hired Worker (PHW) or provider-related, and plan-related documentation) and re-enroll the participant immediately following receipt of their referral when their disenrollment was effective less than 30 days prior to their new program start date. To be eligible for an expedited reenrollment, the participant’s most recently active plan must successfully address their health and safety. …
Id. The Department provided further guidance to TMG clarifying that a participant is eligible for the expedited re-enrollment process if the IRIS participant has been referred to the ICA within 30 days of their previous disenrollment date.
In this case, the ADRC provided TMG an IRIS referral to re-enroll the Petitioner in the program on 9/20/24. The re-enrollment with TMG was completed as of 10/25/24. This unnecessary delay was caused by the ADRC not processing the referral back to TMG as part of an expedited re-enrollment. The ADRC could have processed the referral prior to the expiration of 30 days. Instead, the ADRC took an additional 20 days before the referral was sent.
The Department has been willing to adjust the start date for enrollment of Family Care participants if it determines that agency error caused unreasonable delays despite the general preclusion on backdating enrollment into Family Care, which is a managed care program. See, e.g., In re —, DHA Case No. 205394 (Wis. Div. Hearings & Appeals Sept. 29, 2022) (DHS), In re —, DHA Case No. 207295 (Wis. Div. Hearings & Appeals Sept. 29, 2022) (DHS). However, the Department clarified in a Final Decision that DHA does not have the authority to make a final decision to adjust the enrollment date in the Family Care Program. That is a remedy that only the Department may authorize.
The Department has applied the same reasoning to IRIS cases. See In re —, DHA Case Number MGE-216221 (Final decision by DHS Secretary dated 5/2/25). Backdating of IRIS enrollment in this case is similarly appropriate based on a delay by the ADRC agency in processing the re-enrollment which was unexplained at hearing.
Although this is an IRIS rather than a Family Care matter, in light of the adjusted enrollment date sought, I am issuing this as a proposed decision in line with the above-referenced line of final decisions. I would note that the Department’s Secretary previously indicated in a final decision that DHA does not have the authority to adjust the IRIS enrollment date under the expedited re-enrollment process and that it is a remedy that only the Department may authorize. See —, DHA Case No. 209367 (Wis. Div. Hearings & Appeals Jan. 4, 2024) (DHS).
Conclusions of Law
Petitioner’s enrollment date for IRIS should be adjusted to August 1, 2024.
THEREFORE, it is
Ordered
That, if this proposed decision is adopted as final by the Department Secretary, the agency must, within ten days of the date of the Final Decision, take all necessary administrative steps to revise the Petitioner’s IRIS enrollment date to August 1, 2024.
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