IRIS benefits may be backdated if agency error causes unreasonable delay. In this case, the petitioner was disenrolled from IRIS for failing to verify her husband’s income, but provided that verification and completed a Medicaid renewal the following month. It then took 77 days before she could get an appointment with the ADRC and another 55 days to complete the new enrollment process. In a final decision modifying ALJ Kate Schilling’s proposed decision, DHS Secretary Kirsten Johnson concluded: “Under these limited circumstances of an agency error resulting in an unreasonable delay during the ‘unwinding period’ of fall 2024, backdating of IRIS can be an appropriate equitable remedy.”
The final decision is published below. See the attached PDF for ALJ Kate Schilling’s proposed decision.
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 hearing examiner dated April 24, 2025, is modified as follows and, as such, is hereby adopted as the final order of the Department.
Preliminary Recitals
A petition was filed on January 14, 2025, under Wis. Admin. Code § HA 3.03, to review a decision by the Bureau of Long-Term Support regarding Medical Assistance (MA). The hearing was initially scheduled for February 13, 2025; however, the case had been opened as a MAPP and FoodShare appeal rather than an IRIS denial. Therefore, the IRIS Consultant Agency was not in attendance at the hearing to discuss the case. The hearing was rescheduled to February 27, 2025; however, the phones at the Division of Hearings and Appeals were not working at the time and the hearing had to be rescheduled. The hearing was then held on March 18, 2025, by telephone. The hearing record was left open for one week following the hearing so that additional documentation could be submitted.
The issue for determination is whether the petitioner’s enrollment date for IRIS should be adjusted to 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: Theresa Sommerfeldt, TMG
Stacy Green, MILES IM Agency
Bureau of Long-Term Support
PO Box 7851
Madison, WI 53707-7851
ADMINISTRATIVE LAW JUDGE:
Kate J. Schilling
Division of Hearings and Appeals
Findings of Fact
- Petitioner (CARES # —) is a 60 year old resident of Milwaukee County who was enrolled in IRIS and receiving supportive home care assistance.
- On May 13, 2024, the Income Maintenance agency (IM agency) noticed that there was unearned income for the petitioner’s husband in the State Wage Income Collection Agency (SWICA) database that had not been reported.
- On May 14, the IM agency sent out a request for verification of earned income due by June 3, 2024.
- On June 7, 2024, the IM agency sent out another notice stating that it still had not received verification of earned income from the petitioner and her spouse. The notice stated that these verification items were due June 26, 2024.
- On July 17, 2024, the agency sent a notice to the petitioner indicating that her IRIS and Medicaid benefits would end as of August 1, 2024, due to lack of earned income verification.
- On July 20 or 22, 2024 (both dates are cited within the exhibits) the petitioner submitted an employer income verification form; however, it was not signed by the employer; therefore, it was insufficient for purposes of income verification.
- The petitioner’s Medicaid closed on August 1, 2024, due to failure to verify earned income. Since the petitioner was no longer financially eligible for Medicaid, her IRIS benefits closed on August 1, 2024.
- August was the petitioner’s annual renewal for Medicaid; therefore, the Medicaid renewal had to be completed to re-establish Medicaid benefits. On August 30, 2024, the IM agency processed the renewal and income verification submissions, and approved the petitioner’s financial eligibility for Medicaid benefits as of August 1, 2024.
- Due to high volume and staffing shortages with the ADRC, the petitioner was not able to get an appointment with the ADRC staff to re-enroll into IRIS until November 14, 2024. The petitioner selected enrollment with the IRIS Consultant Agency (ICA) and fiscal employer agent (FEA) that she had previously utilized. The ADRC then made the enrollment referrals to the ICA and FEA that same day.
- It took until January 7, 2025, for the petitioner to be officially re-enrolled into IRIS as she had to go through the entire new enrollment and orientation process over again.
- The petitioner filed an appeal with the Division of Hearings and Appeals on January 14, 2025, to obtain backdated IRIS benefits for the period of time from August 1, 2024 through January 6, 2025.
Discussion
The IRIS program is a Medical Assistance (MA) home and community-based long term care waiver program authorized under § 1915(c) of the Social Security Act. The program permits a state to furnish an array of home and community-based services that assist Medicaid beneficiaries to live in the community and avoid institutionalization. The State has broad discretion to design its waiver program to address the needs of the waivers target population. The waiver approved by the Centers for Medicare and Medicaid Services (CMS) which provides the program’s authority is available at https://www.dhs.wisconsin.gov/iris/hcbw.pdf. State policies governing administration of the IRIS program are included in the IRIS Policy Manual (available at https://www.dhs.wisconsin.gov/publications/p0/p00708.pdf).
The petitioner lost Medicaid financial eligibility as of August 1, 2024, due to a failure to verify earned income in the household. The petitioner seemingly does not dispute that this verification item was outstanding at the end of July 2024 or that it took until August 30, 2024 to re-establish Medicaid financial eligibility. The Income Maintenance agency (IM agency) backdated Medicaid card services (non-long term care eligibility) to August 1, 2024, pursuant to policy in the Medicaid Eligibility Handbook (MEH) §2.8.2.
The IM agency approved the petitioner’s financial eligibility for Medicaid on August 30, 2024. It is unknown when the IM agency made the referral to the Aging and Disability Resource Center (ADRC); this information is not provided by the record. The case was processed by the ADRC as a new enrollment for IRIS.
Due to high volume, staffing shortages, and scheduling delays with the county ADRC, the petitioner was not able to get an appointment until November 14, 2024. This was 77 days after Medicaid financial eligibility had been established by the IM agency. The case record does not contain any explanation for this timeframe and contains no documentation that would support a conclusion that the delay is attributable to any cause other than agency error. On November 14, 2024, the petitioner met with the ADRC options counselor and requested enrollment into the IRIS program with TMG as the IRIS Consultant Agency (ICA) and Acumen as the fiscal employer agent (FEA). It took until January 7, 2025, for the petitioner’s IRIS enrollment to officially start as the IRIS agencies had to create a new service plan, complete the new participant orientation, sign all new paperwork, and rehire supportive home care workers.
At the hearing, the petitioner requested backdated IRIS benefits to August 1, 2024, so that her caregiver who provided supportive home care services between August 1, 2024 and January 6, 2025, can be paid for the hours they provided care. While Medicaid card services can be backdated, IRIS benefits generally cannot. We are beyond the appeal timeframe for the Division of Hearings and Appeals to review the disenrollment action that occurred on August 1, 2024 which had an appeal deadline of September 16, 2024. The petitioner did timely appeal the notice dated November 14, 2024, which indicated that her community waivers would start as of December 1, 2024.
When a person has been determined functionally and financially eligible for publicly funded long-term care, the ADRC staff must act promptly to provide information regarding enrollment into Family Care or IRIS.
In this case, it took 77 days for the petitioner to get an appointment with the ADRC and 55 days thereafter for her IRIS benefits to start. This ALJ determines this to constitute an agency error in this case. Under these limited circumstances of an agency error resulting in an unreasonable delay during the ‘unwinding period’ of fall 2024, backdating of IRIS can be an appropriate equitable remedy. For these reasons, an adjusted IRIS start date of November 1, 2024, is appropriate.
Conclusions of Law
The petitioner’s IRIS start date should be adjusted to November 1, 2024.
THEREFORE, it is
Ordered
That the agency shall, within 10 days of the date of the Final Decision, take all necessary administrative steps to revise the petitioner’s IRIS enrollment date to November 1, 2024.
[Request for a rehearing and appeal to court instructions omitted.]
If you found this decision useful, sign up for my email newsletter. You’ll get summaries of newly published decisions and a PDF of useful information on estate recovery.