CWA 216814 (06/18/2025)
IRIS benefits not backdated when primary cause of delay was Fiscal Employer Agency switch

The attached proposed decision of the hearing examiner dated April 11, 2025, is modified as follows and, as such, is hereby adopted as the final order of the Department.

Preliminary Recitals

Pursuant to a petition filed on January 28, 2025, under Wis. Admin. Code § HA 3.03, to review a decision by the Bureau of Long-Term Support (the agency) regarding Medical Assistance (MA), specifically the IRIS program, a telephonic hearing was held on March 13, 2025, by telephone.

The issue for determination is whether petitioner’s IRIS enrollment date should be revised.

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: Theresa Sommerfeldt
Bureau of Long-Term Support
PO Box 7851
Madison, WI 53707-7851

ADMINISTRATIVE LAW JUDGE:
Kelly Cochrane
Division of Hearings and Appeals

Findings of Fact

1. Petitioner is a resident of Waupaca County and has been enrolled in the IRIS program.
2. On November 11, 2024 the income maintenance (IM) agency issued a notice of MA renewal to petitioner stating the renewal should be completed by December 18, 2024 to prevent a disruption in benefits. Petitioner was required to renew his Community Waivers/MA eligibility (and IRIS enrollment) by December 31, 2024.
3. Petitioner submitted his MA renewal on November 11, 2024.
4. On November 15, 2024 the IM agency processed the renewal and sent a verification request for the cash value of a life insurance policy (LIP) that had been reported in the renewal.
5. On December 10, 2024 the IM agency issued a notice to petitioner stating his MA benefits would end December 31, 2024 due failing to verify the LIP.
6. On December 13, 2024 and December 23, 2024 petitioner followed up with the Income Maintenance Agency to state he was not the listed owner of the LIP and was having difficulty getting verification when he was not the owner.
7. On December 16, 2024 petitioner’s IRIS Consultant (IC) discussed the importance of timely completing the renewal and providing verifications with the petitioner.
8. On December 22, 2024 a Wisconsin Long-Term Care Program Disenrollment Notice was issued to the petitioner by the Division of Medicaid Services (DMS). The notice stated that his long-term care program enrollment “has ended or is scheduled to end due to No Medicaid Eligibility.” The notice directed that the petitioner’s IRIS enrollment had ended or is scheduled to end on December 31, 2024.
9. On January 5, 2024 a Wisconsin Long-Term Care Program Disenrollment Notice was issued to the petitioner by the DMS. The notice stated that his long-term care program enrollment “has ended or is scheduled to end due to No Medicaid Eligibility.” The notice directed that the petitioner’s IRIS enrollment had ended or is scheduled to end on December 31, 2024.
10. On January 2, 2025 petitioner provided the requested verification into the agency.
11. On January 3, 2025 the agency processed the verification and opened Community Waivers/MA to effective January 1, 2025.
12. On January 6, 2025 the IM agency issued a notice to petitioner advising his MA/Community Waivers was open effective January 1, 2025.
13. On January 10, 2025 TMG received an IRIS referral from the ADRC for petitioner.
14. TMG began an expedited re-enrollment after receiving the referral but due to delays with having to choose a new Fiscal Employer Agency (FEA) in that process, his enrollment into IRIS was not confirmed until March 11, 2025.

Discussion

The IRIS program is a MA long term care waiver program that serves elderly individuals and adults with physical and developmental disabilities. The IRIS program was developed pursuant to an MA waiver obtained by the State of Wisconsin, pursuant to section 1915(c) of the Social Security Act. The federal government has promulgated 42 C.F.R. § 441.300 – .310 to provide general guidance for this program. Those regulations require that the agency’s agent must assess the participant’s needs and preferences (including health status) as a condition of IRIS participation. Id., § 441.301(c)(2). IRIS is an alternative to Family Care, Partnership, and PACE—all of which are managed long term care waiver programs in Wisconsin. The IRIS program 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, (available online at http://www.dhs.wisconsin.gov/publications/P0/P00708.pdf),

The IRIS waiver application (Waiver) most recently approved by the Centers for Medicare and Medicaid Services (CMS) is available online at https://www.dhs.wisconsin.gov/iris/hcbw.pdf. State policies governing administration of the IRIS program are included in the IRIS Policy Manual, 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 (DHS) 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”), FEAs, and IM agencies.

To participate in the IRIS program, individuals must be 18 years of age or older, meet the nursing home level of care, and meet the financial and non-financial eligibility criteria for one of the following: a fullbenefit category of Elderly Blind or Disabled (EBD) MA, BadgerCare Plus, Wisconsin Well Woman Medicaid, Adoption Assistance or Foster Care Medicaid. See MEH § 28.1.5. As part of determining ongoing eligibility, all IRIS participants must complete an annual functional and financial eligibility review. Failure to maintain that eligibility may result in disenrollment. See IRIS Policy Manual, § 2.0 (https://www.dhs.wisconsin.gov/publications/p03515.pdf). The agency has the right to disenroll members from IRIS for losing their financial eligibility. See IRIS Waiver, p. 202; IRIS Work Instructions, Ch. 7 (https://www.dhs.wisconsin.gov/publications/p03515.pdf).

In this case, the petitioner’s MA, and therefore his IRIS eligibility, ended at the end of December 2024 for failing to timely complete his annual review. The agency can backdate MA eligibility under separate MA policy, and that was done. See Finding of Fact #12; see also MEH §§ 2.8.2, 3.1.6, and 3.1.6.2. The IRIS program’s policy is different, however. The IRIS program prohibits the payment of providers and/or participant-hired workers prior to the enrollment date. See IRIS Policy Manual, § 2.0 (https://www.dhs.wisconsin.gov/publications/p03515.pdf). IRIS policy also provides that if a renewal is completed within 30 days of closure, it can be processed as an “expedited re-enrollment”, which occurred. See Exhibit I.

The preponderance of the evidence shows that there was agency error in terminating his Community Waivers/MA as of December 31, 2024. It is clear that petitioner reported a LIP on his renewal in November. Because he reported it, the IM agency correctly requested verification of that as a possible available asset. See MEH § 20.3.5. When he got the notice saying his MA was ending for failing to verify the LIP, he went to the agency to discuss it. Admittedly, he now knows he did not have to report that as an asset because he is not the owner of the LIP. It is in fact a term life insurance policy on him but owned by another person (his ex-wife/PK) to cover his funeral/burial expenses. He explained this to an agency worker on December 13. He then called the agency on December 23 with PK on the phone and they again explained the same facts and that they were having difficulty getting the verification from the insurance company in a timely manner. It was apparently then that the worker on the 23rd, took in their information, but needed to confirm any action with a lead worker. Case Comments reflect that the lead worker then decided that the verification was indeed necessary and requested verification again, however that was due after the deadline of the 31st.

When verifying information, the MA recipient has the primary responsibility for providing verification. See MEH § 20.5. However, MA policy also provides:

Do not deny eligibility when the member does not have the ability to produce verification. Assist the member in obtaining verification if he or she has difficulty in obtaining it.

Use the best information available to process the application or change within the time limit and issue benefits when the following two conditions exist:

1. The member does not have the power to produce verification, and
2. Information is not obtainable timely even with your assistance.

In this situation, seek verification later. When you have received the verification, you may need to adjust or recoup benefits based on the new information. Explain this to the member when requesting verification.

Id. (emphasis added).

Petitioner testified that he had been confused about having to report the LIP but was simply trying to be honest. He then tried to correct his reporting error by going into the agency and calling the agency to explain that he did not own the asset. Under these facts, it is clear petitioner had attempted to provide the best evidence of the LIP and advised the agency he was having difficulty getting the verification in a timely manner.

Turning to the question of whether an agency error then caused an unreasonable delay in IRIS reenrollment, there was no dispute that the re-enrollment process was delayed due to the required switch in petitioner’s FEA. The DHS has placed a cap on iLife referrals, which was petitioner’s FEA. This required petitioner to choose another FEA and complete enrollment. Placing a cap on iLife referrals is not alleged or demonstrated to be an agency error.

Petitioner argues that under the facts of this case, his IRIS enrollment date should be revised from March 11, 2025 to January 1, 2025. I agree that the preponderance of the evidence shows there were issues caused by agency error that caused his Community Waivers/MA to end on December 31, 2024. However, the record does not show that agency errors caused an unreasonable delay in re-enrolling him. Requiring a new FEA is not an agency error when the cap on the original FEA is not an error.

Conclusions of Law

Petitioner is not eligible to receive backdated IRIS benefits for a period of time preceding enrollment.

THEREFORE, it is

Ordered

That the appeal is denied.

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