CWA 217818 (06/17/2025)
IRIS enrollment denied for past unpaid cost share

Preliminary Recitals

Pursuant to a petition filed on April 9, 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 14, 2025, by telephone.

The issue for determination is whether the respondent was authorized to deny the petitioner’s request for enrollment in the IRIS program due to non-payment of an outstanding cost share balance stemming from his previous enrollment in the 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: Stacy Green (IM) and Susan Rother (ICA)
Milwaukee Enrollment Services
1220 W Vliet St
Milwaukee, WI 53205

ADMINISTRATIVE LAW JUDGE:
Jason M. Grace
Division of Hearings and Appeals

Findings of Fact

1. Petitioner (CARES # —) is a resident of Milwaukee County. He enrolled in the IRIS program in February 13, 2022.
2. On June 10, 2024, notice was issued to the petitioner that his enrollment in Community Waivers (i.e., IRIS) would end as of July 1, 2024, for failing to pay his monthly cost share. The notice set forth the right, process, and deadline to file an appeal to contest that action. The deadline was August 16, 2024.
3. The petitioner did not file an appeal of the June 10, 2024 action, and he was disenrolled from the IRIS program as of July 1, 2024.
4. On December 27, 2024, notice was issued to the petitioner that he was not enrolled in Community Waivers as he had not paid his cost share. The notice set forth the right, process, and deadline to file an appeal to contest that action. The deadline was February 11, 2025.
5. On February 5, 2025, notice was issued to the petitioner indicating he was enrolled in Nursing Home Long Term Care as of January 1, 2025.
6. On or about February 18, 2025, petitioner applied for MAPP. At some later point the petitioner requested enrollment in the IRIS program.
7. The petitioner has cost share arrears of over $7,000.00. This stems from his non-payment of a Community Waivers cost share when he was previously enrolled in the IRIS program.
8. The petitioner is not able to pay his cost share arrears.
9. On March 7, 2025, notice was issued to the petitioner indicating he was enrolled in MAPP as of April 1, 2025. It also notified that he was denied enrollment into Community Waivers as he had not paid his monthly cost share. The notice set forth the right, process, and deadline to file an appeal to contest that action. The deadline was May 19, 2025.
10. On April 9, 2025, the petitioner filed an appeal contesting the March 7, 2025 notice of action denying him enrollment in IRIS.

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 Department of Health Services (Department) 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, IRIS consultant agencies, IRIS fiscal employer agents, and income maintenance agencies (IM).

The issue in this case is whether the respondent was authorized to deny the petitioner’s request for enrollment in the IRIS program due to non-payment of cost share arrears stemming from his previous enrollment in the program. He was disenrolled from the IRIS program in June 2024 for failing to pay his cost share. His cost share arrears are over $7,000.00.

The IRIS Waiver authorizes the program to involuntarily disenroll an IRIS member for falling into cost share arrears. 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; see also IRIS Policy and Procedure, P-03547 (09/2024), pgs. 26-27, found online at https://www.dhs.wisconsin.gov/publications/p03547.pdf. The Medicaid Eligibility Handbook (MEH), indicates that “Nonpayment of a Home and Community-Based Waivers cost share will result in nonfinancial ineligibility for an adult age 19 or older…” MEH, § 11.1. And IRIS policy provides the following:

3. Referral Withdrawals

After a prospective participant is referred to the [IRIS] program, a referral withdrawal can be initiated anytime during the referral period. There are two types of referral withdrawals that can occur: a “participant requested withdrawal” or a “program requested withdrawal.”

…

b. Program Requested Withdrawal

Program requested withdrawals occur when a referred participant’s ICA determines that the participant is no longer in compliance with program enrollment criteria or is otherwise not eligible to enroll into the program. During a program requested withdrawal, the ICA refers the participant back to their ADRC or Tribal ADRS for enrollment counseling. The ICA provides a written notice of referral withdrawal to the referred participant, as well as a Notice of Action (NOA). Program requested withdrawals occur for the following reasons:

…

v. Unwilling or Unable to Remediate: This reason is used when a newly referred or re-referred participant is unwilling or unable to remediate existing concerns. When this reason is used, the ICA must seek approval from the Department before withdrawing the referral utilizing the IRIS Denial of Enrollment Request (F-01319B). This reason for withdrawal includes when:

1. 1. There are unpaid cost share arrears and/or unresolved repayment agreements that the referred participant refuses to pay in full prior to enrollment.
   2. There is documented history of ongoing budget mismanagement and/or credible allegations of fraud that the referred participant is unwilling or unable to resolve.
   3. There are significant unresolved health and safety concerns.

…

IRIS Policy and Procedure, P-03547 (09/2024), pg. 8 (emphasis added).

Based on the foregoing, I find that the respondent was authorized to deny petitioner’s request for re-enrollment in the IRIS program due to his cost share arears of over $7,000.00 and his inability or refusal to remediate that issue by paying them off prior to enrollment.

Conclusions of Law

The respondent was authorized to deny the petitioner’s request for enrollment in the IRIS program due to non-payment of an outstanding cost share balance stemming from his previous enrollment in the program.

THEREFORE, it is

Ordered

That petitioner’s appeal is dismissed.

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