CWA 216899 (06/18/2025)
IRIS benefits backdated due to delay of Fiscal Employer Agency switch

The attached proposed decision of the Administrative Law Judge dated May 13, 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 31, 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 April 16, 2025, by telephone.

The issues for determination are (1) whether Petitioner was correctly involuntarily disenrolled from the IRIS program and (2) whether Petitioner is entitled to backdated IRIS enrollment.

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: Kris Knecht, Rock County; Jennifer Madera, TMG
Bureau of Long-Term Support
PO Box 7851
Madison, WI 53707-7851

ADMINISTRATIVE LAW JUDGE:
Wendy I. Smith
Division of Hearings and Appeals

Findings of Fact

1. Petitioner is a resident of Walworth County and a participant in the IRIS program since 2014. Her current IRIS consultant agency is TMG. Her Fiscal Employer Agent (FEA) was previously iLife and is now GT Independence.
2. In a notice dated August 12, 2024, Petitioner was advised that a renewal must be completed by September 17, 2024, in order to continue receiving healthcare benefits. On August 27, 2024, Petitioner’s authorized representative contacted the agency to complete the required healthcare renewal.
3. In a notice dated August 28, 2024, and sent to Petitioner’s guardian — the agency requested that Petitioner submit documented proof of her assets — with a due date of September 16, 2024. Petitioner was advised that a failure to submit the required documents by the deadline could result in benefits being denied, decreased, or ended. This notice was mailed to Petitioner’s authorized representative at her address of record.
4. Petitioner did not submit the required documentation by the deadline.
5. In a notice dated September 17, 2025, the agency advised Petitioner that her MA benefits would end as of October 1, 2024, because she did not supply the required verification information by the stated deadline.
6. The IRIS program received information that Petitioner was scheduled for MA termination at the end of September. Petitioner was then automatically disenrolled from the IRIS program as of September 30, 2024.
7. Petitioner provided partial documentation on September 17, 2024, but this was missing complete asset information about Petitioner’s remaining accounts. Another notice was issued on September 17, 2024, advising that benefits remained closed because of the missing checking account information.
8. On October 14, 2024, the agency received all necessary verification documentation from Petitioner and her MA case was reopened on October 23, 2024, upon processing.
9. In a notice dated October 24, 2024, Petitioner was advised that she was enrolled to receive MA benefits in the Community Waivers program effective as of October 1, 2024.
10. Because Petitioner had been disenrolled from IRIS, Petitioner was referred by the ADRC to the IRIS program on October 25, 2024. TMG confirmed that she was eligible for expedited enrollment on October 25, 2024.
11. During processing of the reenrollment, Petitioner was required to switch from her prior FEA (iLife) to a new FEA (GT Independence) due to a sanction imposed against iLife that prohibited new enrollments. On October 25, 2024, TMG created a work request to establish Petitioner with GT Independence as her FEA.
12. In order to establish her new FEA, Petitioner’s guardian and Petitioner’s employee were required to submit paperwork with GT Independence. GT’s first attempt to contact the guardian was documented as occurring on November 22, 2024, nearly a month after the work request. GT documented that it confirmed receipt of all required paperwork on December 6, 2024.
13. Both Petitioner’s guardian and Petitioner’s care provider, —, were communicative and cooperative with the reenrollment process with Petitioner’s IRIS Consultant.
14. Petitioner was reenrolled in IRIS as of December 17, 2024.
15. Typically, the IRIS expedited reenrollment process takes a few days to complete. In the case of Petitioner, the process took a much longer time than expected—from October 25, 2024 (the date she was referred by the ADRC) until December 17, 2024, the date she was confirmed reenrolled.
16. Petitioner now appeals to the Division of Hearings and Appeals.

Discussion

The Include, Respect, I Self-Direct (IRIS) program is a Medical Assistance 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.

The IRIS Waiver Application most recently approved by the Centers for Medicare and Medicaid Services (CMS) is available online 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 Medicaid Eligibility Handbook (MEH) describes the Adult Home and Community-Based Waivers and subprograms. See MEH § 28.1, available at http://www.emhandbooks.wisconsin.gov/mehebd/meh.htm#t=home.htm.

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).

To be eligible to participate in IRIS, participants must meet specific criteria, including being functionally eligible, as well as both financially and non-financially eligible for Medicaid. Policy P-03515, IRIS Eligibility Policy, Section A, available at https://www.dhs.wisconsin.gov/publications/p03515.pdf and directly linked from the IRIS Policy Manual.

IRIS policy specifies that a person is required to complete an annual renewal or be subject to involuntary disenrollment:

ii. Medicaid Eligibility Renewal

Once enrolled in BadgerCare Plus or Medicaid, a renewal must be completed at least once each year. The IM agency will mail a letter to the participant the month before the renewal is due. The renewal is conducted by the IM agency and can be done online at access.wi.gov, by phone, by mail, by fax, or in person. The renewal ensures the participant continues to meet all program rules and is receiving appropriate benefits. If continued financial eligibility for Medicaid is not confirmed, then the participant becomes ineligible for the program and will be disenrolled (see Enrollment—Disenrollment and Suspensions).

Id. at Section B.1.ii (emphasis added); see also IRIS Waiver Application, pp. 201-02.

In this case, Petitioner’s guardian initiated a renewal of Petitioner’s MA benefits, but did not respond timely to a request for asset documentation to verify Petitioner’s continued financial eligibility for Medicaid and Community Waivers. When Petitioner did not submit the required information by the deadline, her MA benefits were processed to close as of October 1, 2024. Through an automated process, Petitioner was then disenrolled from the IRIS program due to ineligibility for Medicaid as of October 1, 2024. The untimely verification was rectified when the IM agency processed Petitioner’s documentation on October 23, 2024, and the IM agency was able to retroactively renew Petitioner in Community Waivers with no gap in coverage. However, because Petitioner was disenrolled from IRIS, she was re-referred to IRIS to go through the IRIS enrollment process again. She was not enrolled in IRIS until December 17, 2024, resulting in a 77-day gap in enrollment in IRIS.

Petitioner’s guardian testified that she was told by someone at IRIS that Petitioner’s benefits could be “backpaid” for any gap in IRIS enrollment. Unlike with Medicaid eligibility backdating, IRIS disenrollment requires reenrollment:

Disenrollment Due to Late Renewal of Medicaid

If a member does not complete their Medicaid renewal in a timely fashion, Medicaid will end on the last day of the month in which the renewal was due. If the Medicaid renewal is completed and participant is found eligible within 3 calendar months following the renewal month, ForwardHealth interChange will auto-reenroll the member. Auto-reenroll is not applicable to IRIS participants. IRIS participants will be required to re-enroll into IRIS after Medicaid is re-establish.

Policy P-02997, Department of Health Services’ Adult Long-Term Care Programs Enrollment and Disenrollment Resource Guide at pp. 24-25, available at https://www.dhs.wisconsin.gov/publications/p02997.pdf (emphasis added). The IRIS program prohibits the payment of providers and/or participant-hired workers prior to the enrollment date. See IRIS Policy Manual § 5.5B. Thus, the IRIS program does not backdate eligibility, and prior participants may experience a gap in IRIS coverage when attempting to re-enroll.

The IRIS program does have an “expedited” reenrollment process for circumstances like Petitioner’s:

b. Expedited Re-enrollment Process

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 re-enrollment, the participant’s most recently active plan must successfully address their health and safety.

Policy P-03547, IRIS Program Enrollment Policy, Section B.1.b at pp. 10-11, available at https://www.dhs.wisconsin.gov/publications/p03547.pdf (emphasis added).

Petitioner and her guardian were advised of the need to timely complete a renewal. Petitioner’s guardian testified that there was a transition in guardians for Petitioner which resulted in the new guardian having trouble accessing information. However, no evidence was presented that the renewal notices and verification requests were not properly sent to Petitioner’s correct address of record. Petitioner’s guardian received the renewal notices and responded to those notices but provided incomplete verification documents by the required deadline. I can find no error in the original termination of healthcare benefits due to failure to renew timely. Nor is there any injury as to the Community Waivers eligibility as the IM agency was able to retroactively deem Petitioner eligible with no interruption.

As for the IRIS disenrollment, a representative for TMG testified about Petitioner’s re-enrollment through the “expedited process” explained above. Per her testimony, typically this expedited process takes a “few days.” In this case, the process resulted in a notable gap in enrollment—from October 1, 2024, through December 16, 2024, during which Petitioner’s employees are currently ineligible for payment. The record shows that Petitioner was referred by the ADRC for reenrollment shortly after her healthcare benefits were reopened on October 25, 2024. On that same day, TMG was able to verify Petitioner’s eligibility for expedited enrollment and requested that GT Independence initiate FEA enrollment. TMG’s representative testified that the delay in enrollment was caused during this FEA process as GT attempted to complete new paperwork with Petitioner’s guardian and Petitioner’s employee. Additional processing time was required due to a Corrective Action Plan sanction imposed on iLife which prevented new enrollments. Per TMG, it was not able to proceed with reenrollment until there was at least one approved service on Petitioner’s plan, an action that is performed by the new FEA.

No representative from GT Independence appeared at the hearing. A sparse timeline of actions allegedly created by GT Independence was produced as an exhibit by TMG. This time line confirms referral to GT on October 25, 2024, but then no documented action until November 22, 2024, when GT attempted to contact Petitioner’s guardian to complete an enrollment packet. The notes state that the representative could not contact the guardian due to having the wrong phone number. This note also states that iLife could not forward enrollment documents. The next update in this timeline is not until December 3, 2024, when employer paperwork was received. There was another unexplained gap in the timeline until December 17, 2024, when an IRIS start date was given.

The notes provided do not explain why a month elapsed from when Petitioner’s case was sent to GT and the first update. It is unclear why GT did not have Petitioner’s contact information or what actions it took to obtain the correct contact information. There is no explanation for the delay between when Petitioner’s paperwork was complete on December 3, 2024, and the eventual start date two weeks later.

It is a well-established principle that a moving party generally has the burden of proof, especially in administrative proceedings. State v. Hanson, 295 N.W.2d 209, 98 Wis. 2d 80 (Wis. App. 1980). Petitioner’s guardian complains that the expedited reenrollment took too long. Petitioner’s guardian testified that she was in contact with her IRIS Consultant to complete enrollment but, due to being new at guardianship, did not understand the process and needed assistance. Her testimony was sincere that she was trying her best to complete what was required. Testimony from Petitioner’s care provider, Lola Adeniyi, corroborates Petitioner’s argument. Ms. Adeniyi testified that she had to proactively contact TMG repeatedly in November to get a status update and was eager to complete the requirements so that she could receive payment.

Based on the record before me, the evidence supports the assertion that once Petitioner’s guardian completed the late renewal, she and the care provider completed the tasks required to get Petitioner reenrolled. No evidence was presented that Petitioner, or the provider was at fault for any delay. More importantly, there was no evidence presented to justify the unreasonably lengthy FEA delays. Therefore, I find that Petitioner has met her burden to establish that she is entitled to a backdated enrollment.

Had Petitioner been able to reenroll with iLife as her FEA, Petitioner likely would have been reenrolled on October 25, 2024, when she was referred to IRIS or within a few days of that date. A 77-day processing period is unreasonable without evidence that Petitioner was at fault for the delay. The record supports adjusting Petitioner’s IRIS enrollment to October 25, 2024.

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. 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). While these cases address the Family Care program, I find the reasoning to be generally applicable to the IRIS program as well. However, per the opinion of the Department, the Division of Hearings and Appeals does not have the authority to adjust an IRIS enrollment date under the expedited reenrollment 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).

As such, this decision is issued PROPOSED, subject to the final approval of the Department.

Conclusions of Law

Petitioner’s enrollment date for the IRIS program should be adjusted to October 25, 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 October 25, 2024.