As stated in the recent DMS Ops Memo 25-07, the state must maintain Medicaid coverage while completing regularly scheduled renewals as long as the renewal is received before the end of the month the renewal is due. In this case, the petitioner completed his renewal October 30, before the end of his renewal month, but MilES failed to issue a notice continuing eligibility. TMG then disenrolled him from IRIS because a state database indicated he hadn’t completed his renewal. ALJ Teresa Perez concluded the petitioner was entitled to IRIS enrollment beginning November 1, noting: “That a computer system says something does not necessarily make it so.”
See FCP 218663 for a similar case on the same issue.
This decision was published with support from the Wisconsin chapter of the National Academy of Elder Law Attorneys and Krause Financial.
Preliminary Recitals
Pursuant to a petition filed on May 12, 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 25, 2025, by telephone.
The issue for determination is whether Petitioner is entitled to IRIS enrollment from November 1, 2024 through March 20, 2025.
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
Bureau of Long-Term Support
PO Box 7851
Madison, WI 53707-7851
ADMINISTRATIVE LAW JUDGE:
Teresa A. Perez
Division of Hearings and Appeals
Findings of Fact
- Petitioner is a resident of Milwaukee County who has been enrolled in the IRIS Program for several years. TMG is his IRIS Consultant Agency.
- Petitioner’s annual Medicaid renewal was due in October 2024. He completed that renewal on October 30, 2024 and MilES confirmed his ongoing eligibility on that date. (Testimony of L. Griffin.)
- Despite completing his Medicaid renewal on October 30, 2024, MilES mistakenly failed to issue a notice to Petitioner indicating that his Community Waivers was open for the month of November 2024.
- Petitioner was disenrolled from IRIS effective November 1, 2024 because the State’s MMIS database indicated to TMG that he had not completed his Medicaid renewal.
- TMG notified MilES that Petitioner had been disenrolled from IRIS because he failed to complete his Medicaid renewal and MilES then closed Petitioner’s Community Waivers case effective December 1, 2024.
- Petitioner spent the next several months attempting to get re-enrolled in IRIS which finally occurred on March 21, 2025.
- On May 12, 2025, Petitioner filed request for a fair hearing seeking IRIS coverage from November 1, 2025 through March 20, 2025.
Discussion
To participate in IRIS, an individual must meet the financial and non-financial eligibility criteria for one of the following: a “full benefit category of [Elderly, Blind, Disabled] Medicaid,” BadgerCare Plus, Wisconsin Well Woman Medicaid, or Adoption Assistance. Medicaid Eligibility Handbook (MEH) §§1.1.2 and 28.1.5 and IRIS Policy Manual, Addenda: Eligibility, Sec. A.5. SSI-Related Medicaid, SSI Medicaid, Medical Assistance Purchase Plan (MAPP), and Community Waivers are all full benefit Medicaid programs. MEH §1.1.2. If a person becomes ineligible for Medicaid, they become ineligible for IRIS and must be disenrolled. See IRIS Policy Manual, Addenda: Program Enrollment, Sec. D.3.
In this case, Petitioner was automatically disenrolled from IRIS on November 1, 2025 based on an entry in a centralized state database indicating that he had become ineligible for Medicaid. In fact, Petitioner continued to meet Medicaid eligibility requirements continuously and completed his Medicaid renewal by October 30, 2024, the month that his renewal was due. These facts are not in dispute.
As stated in a recently issued publication from the Department of Health Services, “federal rules require states to maintain coverage while completing regularly scheduled renewals as long as the renewal is received before the end of the month the renewal is due.” DMS Operations Memo 25-07. That publication goes on to state, “The member’s existing health care coverage must be maintained while their renewal is being processed by the IM agency. This requirement applies to all renewals received during the renewal month, including renewals received after adverse action but on or before the last business day of the renewal month.” Although the policy announced in that publication is new, the federal rules upon which it is based are not. Moreover, Petitioner, as stated above, did not become ineligible for Medicaid or fail to complete his Medicaid renewal. That a computer system says something does not necessarily make it so. He thus should not have been disenrolled from IRIS.
I am therefore remanding this matter to order that Petitioner be re-enrolled in IRIS from November 1, 2024 through March 20, 2025.
Conclusions of Law
Petitioner is entitled to IRIS enrollment from November 1, 2024 through March 20, 2025 because he was eligible for full benefit Medicaid throughout that time period and because he had provided all necessary verification to prove that prior to November 1, 2024.
THEREFORE, it is
Ordered
That this matter is remanded to the agency with instructions to: (1) reinstate the petitioner’s IRIS benefits as of November 1, 2024, and (2) send written confirmation to Petitioner that it has done so. These actions shall be completed within 10 days of the date of this order.
[Request for a rehearing and appeal to court instructions omitted.]
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