CWA 217567 (06/06/2025)
IRIS disenrollment improper when ICA failed to provide sufficient information at renewal

Preliminary Recitals

Pursuant to a petition filed on March 19, 2025, under Wis. Admin. Code § HA 3.03, to review a decision by the Milwaukee Enrollment Services regarding Medical Assistance (MA), a hearing was held on May 7, 2025, by telephone.

The issue for determination is whether Respondent correctly disenrolled Petitioner from IRIS on January 31, 2025.

There appeared at that time the following persons:

PARTIES IN INTEREST:

Petitioner:
—

Petitioner’s Representative:
Attorney Mary Colleen Bradley
Disability Rights Wisconsin
1502 W Broadway
Monona, WI 53713

Respondent:
Department of Health Services
1 West Wilson Street, Room 651
Madison, WI 53703
By: Lyeisha Griffin
Milwaukee Enrollment Services
1220 W Vliet St
Milwaukee, WI 53205

ADMINISTRATIVE LAW JUDGE:
Teresa A. Perez
Division of Hearings and Appeals

Findings of Fact

1. Petitioner (CARES # —) is a resident of Milwaukee County.
2. On December 16, 2024, Milwaukee Enrollment Services (MilES) sent Petitioner a letter notifying him that he must complete an annual renewal to keep getting his Medicaid benefits and that if he “failed to act by January 16, 2025,” his “Medicaid” benefits could end on January 31, 2025 or he could have a “delay or gap in coverage.”
3. On January 4, 2025, January 19, 2025, and February 2, 2025, the Department of Health Services issued notices to Petitioner stating that his IRIS enrollment “has ended or is scheduled to end on: JANUARY 31, 2025” due to “no Medicaid Eligibility.” The notices further stated that Petitioner would receive a separate notice with additional information regarding the reason his benefits were ending and his right to file an appeal.
4. In accordance with the instructions he received from MilES in the letter sent on December 16, 2024, Petitioner contacted MilES to complete his Medicaid renewal on January 13, 2025 and again on January 14, 2025. Both of those contacts were prior to the “adverse action date.” Petitioner was prompted to leave message each time. MilES did not return those calls.
5. By notice dated January 17, 2025, MilES informed Petitioner that his “Community Waivers” would end February 1, 2025 because his renewal had not been completed.
6. On January 17, 2025, which was after the “adverse action date,” Petitioner called MilES a third time and was able to complete his renewal interview; however, he was informed that he would need to send in verification of certain items and his spouse’s signature.
7. On January 20, 2025, MilES issued a notice to Petitioner instructing him that to get or keep his Community Waivers and Medicaid, he must submit certain documents to verify his financial eligibility as well as a spousal signature by February 10, 2025. Petitioner submitted all requested information by February 5, 2025.
8. On January 22, 2025, Petitioner’s IRIS Consultant (IC) advised Petitioner that his Medical Assistance coverage was scheduled to end on January 31, 2025. Petitioner informed her that MilES “had extended it until February 10, 2025.” The IC stressed the importance of meeting that deadline.
9. Petitioner’s IC informed Petitioner of the importance of completing his Medicaid renewal to maintain IRIS enrollment on multiple occasions in January 2025 but did not advise Petitioner that by not completing the renewal process, including the provision of required verification, by the “adverse action date,” that he risked losing Medicaid temporarily which would, in turn, likely cause him to be disenrolled from IRIS as of January 31, 2025 and that if he did not complete the renewal process until February 1, 2025 or later (despite his understanding that his deadline had been extended until February 10, 2025), he would definitely be disenrolled from IRIS. Nor did the IC advise him that he should file a request for fair hearing in response to the January 17, 2025 MilES notice to prevent losing Medicaid temporarily and to prevent consequent IRIS disenrollment.
10. By notice dated February 11, 2025, MilES informed Petitioner that his renewal was completed and that he was enrolled in Community Waivers as of February 1, 2025. On the same date, MilES informed Petitioner by telephone that his Community Waivers was open and ongoing with no gap in coverage.
11. Petitioner was, in fact, automatically disenrolled from IRIS on February 1, 2025 because MMIS, a State database, showed a February 1, 2025 end date for Medicaid. Petitioner was not re-enrolled until April 23, 2025. Because Petitioner had been advised by MilES that he had continuous Community Waivers coverage, he did not realize he had been disenrolled until he later learned that his caregiver was no longer being paid.

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, 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”).

Petitioner filed an appeal because he was involuntarily disenrolled from the IRIS program from February 1, 2025 through April 23, 2025. Respondent, TMG, explained that Petitioner was involuntarily disenrolled from IRIS because he did not timely complete a Medicaid renewal, that his Medicaid case was therefore closed on February 1, 2025 (though it reopened as of February 10, 2025), and that program policy prohibited re-enrollment until a new referral from the aging and disability resource center which TMG did not receive until March 2025. As detailed in the Findings of Fact, Petitioner’s Medicaid / Community Waivers case was ultimately opened and backdated to February 1, 2025 by MilES.

Respondent’s action in involuntarily enrolling Petitioner was consistent with the following recently published IRIS policy:

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).

IRIS Policy and Procedure Publication P-03515 §B.1.ii.

Petitioner argued, in part, that his disenrollment was not proper in light of his IRIS consultant’s failure to timely and appropriately advise him of the need to complete his Medicaid eligibility prior to the income maintenance agency’s “adverse action date” in order to avoid temporary closure of his Medicaid (and consequent disenrollment from IRIS) and the IC’s failure to explain that meeting the February 10, 2025 verification deadline set by MilES was not sufficient to avoid temporary loss of his Medicaid (and consequent disenrollment from IRIS). The IRIS consultant did not participate in the hearing but TMG’s representative at hearing acknowledged that the ICA’s case notes do not reflect that the IRIS Consultant provided that information and that the IRIS Consultant may well not have understood the significance between an extension of a deadline to submit verification and an extension of Medicaid eligibility.

Petitioner contended that in failing to provide that critical information, TMG failed to comply with IRIS policy that states: “To prevent eligibility-related disenrollments where possible, ICAs provide ongoing assistance and education to participants related to program eligibility requirements, including: assisting participants with financial eligibility tasks, such as annual Medicaid eligibility review.” IRIS Policy P-03547 (09/2024) §D.3.a. I concur. I am sympathetic to the difficulty of the task assigned to IRIS consultants. It is not easy for any one individual to fully master all the relevant information (e.g., the relationship of Medicaid eligibility and IRIS enrollment; the different duties assigned to the public and private entities that administer these programs; and the ways in which the computer systems utilized by the State affect eligibility). It is a byzantine and sometimes opaque system. That complexity is, presumably, why IRIS policy requires ICAs to assist IRIS participants in endeavoring to maintain Medicaid eligibility.

Petitioner also noted that in short order, he was sent no fewer than eight notices regarding what he must do to maintain his benefit eligibility. Some of those notices reference Medicaid, some reference Community Waivers, some reference IRIS, some reference two or all three of those programs. The information in those notices was not entirely consistent and did not always reflect the information that Petitioner was provided by program staff. The flurry of inconsistent and/or confusing notices is a reality faced by many benefit recipients. Petitioner here really didn’t stand a chance of understanding how all of those notices and all of the information he was provided fit together without the insight of trained staff. And, the evidence in the record showed that Petitioner endeavored, in good faith and in a timely manner, to comply with the instructions he was provided.

Based on the evidence in the record before me, I find that the IRIS consultant agency did not fulfill its responsibility to provide this petitioner with sufficient information to maintain his Medicaid eligibility and thus avoid IRIS disenrollment—a responsibility that was particularly important in this case.

Conclusions of Law

Petitioner’s disenrollment from IRIS on February 1, 2025 was not proper.

THEREFORE, it is

Ordered

That the matter is remanded to the Department of Health Services and any relevant contractors to take all administrative steps necessary to rescind Petitioner’s February 1, 2025 disenrollment from IRIS and to provide Petitioner with information necessary to submit claims for previously authorized IRIS services that were provided from February 1, 2025 through April 23, 2025. The agencies shall comply with this order within ten days of the date of this decision.

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