CWA 217260 (07/08/2025)
Petitioner disenrolled from IRIS for living in his car, ineligible living arrangement

Preliminary Recitals

Pursuant to a petition filed on February 27, 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 June 11, 2025, by telephone. Hearings scheduled for April 16, 2025 and May 14, 2025 were rescheduled at the request of the petitioner and/or his representative.

The issue for determination is whether the respondent was authorized to involuntarily disenroll the petitioner from the IRIS program.

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: Melanie Malm
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 Jefferson County. He is enrolled in the IRIS program, with TMG his IRIS consultant agency.
2. The petitioner’s most recent Long-Term Care Functional Screen (LTCFS) indicates he belongs to the Frail Elder target group. He has diagnoses that include Small Bowel Obstruction; Constipation; Gastritis, unspecified without bleeding; Peptic Ulcer Disease; Diarrhea of Presumed Infections Origin; Gastrointestinal hemorrhage, Hyperlipidemia; Vitamin D Deficiency; Anemia; Paroxysmal Supraventricular Tachycardia; Chronic Diastolic Congestive Heart Failure; Raynaud’s Syndrome; Hypertension; Osteoarthrosis; Kyphosis; Age-related Osteoporosis with current pathological fracture with routine healing; Back Pain; Pain in Joint (shoulder region); Spinal Stenosis of lumbar region without neurogenic claudication; Lumbar Disc Disease; Lewy Body Dementia; Chronic Obstructive Pulmonary Disease; Obstructive Sleep Apnea; Restrictive Lung Disease; Elevated Diaphragm; Paralyzed Hemidiaphragm, Mild Intermittent Asthma without complication; Stage 3 Chronic Renal Failure; Depression; Agerelated Cataract of Both Eyes; Iron Malabsorption; and Acute Vascular Insufficiency of Intestine.
3. The LTCFS also indicates the petitioner requires assistance with 5 Activities of Daily Living (ADLs), including bathing, dressing, mobility in home, toileting, and transferring. It also indicates he needs assistance with 5 Instrumental Activities of Daily Living (IADLs), including meal prep, medication administration/management, money management, laundry/chores, and transportation. It further indicates he requires assistance with overnight cares and range of motion.
4. The petitioner’s Individual Support and Services Plan (ISSP) consists of Supportive Home Care and Community Transportation.
5. The petitioner is unhoused and has been living in his vehicle with his wife since May 2024. This was reported to TMG in May 2024.
6. On February 11, 2025, TMG informed the petitioner that he would be disenrolled from the IRIS program since he has been living in an ineligible living setting for more than 90 days.
7. On February 20, 2024, notice was issued to the petitioner indicating he was being involuntarily disenrolled from the IRIS program, effective March 7, 2025. The basis for the disenrollment was that he did not reside in an eligible living arrangement for IRIS for over 90 days and there was no plan for transitional housing.
8. On February 27, 2025, the petitioner filed an appeal contesting his IRIS disenrollment. His IRIS benefits were ordered to continue until a decision was issued by the DHA.

Discussion

The 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. See IRIS Policy Manual §1. (available at https://www.dhs.wisconsin.gov/publications/p0/p00708.pdf).

The issue in this case is whether the respondent was authorized to disenroll the petitioner from the IRIS program due to living in an ineligible living setting. He is unhoused and has been living in his vehicle for over 90 days, with no established plan to transition to an IRIS eligible living setting.

The IRIS Waiver authorizes the respondent to involuntarily disenroll an IRIS member for “movement to an ineligible living setting.” See Application for 1915(c) HCBS Waiver: WI.0484.R03.00 – Jan 01, 2021 (IRIS Waiver), pg. 202 of 274, found online at https://www.dhs.wisconsin.gov/iris/hcbw.pdf. Eligible IRIS living settings for the Frail Elder target group include:

i) Permanent Eligible Living Arrangements

…

2) Physical Disability (PD) and Frail Elder (FE) Target Groups

Eligible living arrangements for participants with a PD or are FE include:

• • House, apartment, condominium, or other private residence
  • Rooming or boarding house
  • Certified Adult Family Home (1-2 bed)
  • Licensed Adult Family Home (3-4 beds)
  • Certified Residential Care Apartment Complex (RCAC)

ii) Temporary Living Arrangements

Participants not residing in one of the eligible settings listed above when they apply may still seek enrollment in the IRIS program. In transitional situations, a participant may reside in a hotel, motel, homeless shelter, or other type of transitional housing. However, final enrollment cannot be established, and IRIS program services may not begin, until the person lives in an eligible setting.

iii) Short Term Institutional Stays

Institutional settings include hospitals, nursing facilities, or other long-term care institutions. An IRIS program participant’s permanent residence or living arrangement doesn’t change if they are admitted to an institutional setting for short-term acute care or rehabilitative services. They remain eligible for the IRIS program.

IRIS program services, however, must be suspended while the participant is in this short-term setting. The participant is required to report any institutional stay to IM within 10 days. Upon request of the participant, the ICA can assist with reporting this change in living arrangement to IM (see Process for Reporting a Change to the IM Agency B.2.b. below).

The ICA staff will assist the participant with planning and relocation activities to return to an eligible community living arrangement.

A temporary stay that becomes permanent triggers a program requested disenrollment from the IRIS program. This happens because these facilities are ineligible living settings for IRIS participants. A participant who has an institutional stay that extends beyond 90 days following the admission date to the facility must be disenrolled from the IRIS program.

IRIS Policy and Procedure, P-03547 (09/2024), pgs. 3-4; See also IRIS Policy and Procedure, P-03515 (09/2023), pgs. 3-4.

IRIS policy clarifications communicated to the ICAs by the Department indicate that unhoused/homeless individuals will be treated the same as individuals residing in assisted living or another ineligible living setting and that after 90 days they will be referred for disenrollment. See TMG Exhibits, pgs. F19-F20. As of June 19, 2024, it was indicated that:

[][p]participants without permanent housing within 90 days of the identified temporary living arrangement should be referred for disenrollment for ineligible living arrangement. If a participant has a documented permanent housing plan with an established start and end date, they may be eligible to remain enrolled in IRIS.

Id.

The petitioner had been living in his vehicle for nine months prior to the issuance of the notice of involuntarily IRIS disenrollment. That living setting continues as of the date of the hearing. Based on the record, I find the respondent was authorized to disenroll the petitioner from the IRIS program as he had been living in an ineligible setting for more than 90 days and did not have a plan established to transition to an IRIS eligible living setting.

As noted by the respondent at hearing, this does not disqualify petitioner from enrolling in other long-term care programs wherein a care manger would be responsible for assisting him in locating permanent housing. He should contact the ADRC for further assistance and counseling.

Conclusions of Law

The respondent was authorized to disenroll the petitioner from the IRIS program as he had been living in an ineligible living setting for more than 90 days.

THEREFORE, it is

Ordered

That petitioner’s appeal is dismissed.

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