A participant in IRIS may be disenrolled if they lose their Medicaid eligibility after a renewal. In this case, the petitioner completed a FoodShare renewal that the agency mistakenly processed as a Medicaid renewal, even though her Medicaid was not due for a renewal. Noting that there was no evidence the petitioner ever stopped being eligible or was advised in writing of needing to complete an early Medicaid renewal, ALJ Teresa Perez concluded the disenrollment was agency error.
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 28, 2025, under Wis. Admin. Code § HA 3.03, to review a decision by the Department of Health Services to disenroll Petitioner from the IRIS Program, a hearing was held on July 16, 2025, by telephone.
The issue for determination is whether Petitioner was properly disenrolled from IRIS from May 1, 2025 through May 13, 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: Jennifer Madera, TMG
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 (CARES # —) is a resident of Dodge County.
- Petitioner is a resident of Dodge County who has been enrolled in the IRIS Program since September 2013. TMG is Petitioner’s IRIS Consultant Agency.
- Petitioner completed a Medicaid renewal in September 2024.
- The income maintenance (IM) agency informed Petitioner that she must complete a FS renewal in March 2025. Petitioner called the agency on March 14, 2025 to complete that renewal. For unclear reasons, the agency processed that as a renewal of both her Medicaid and her FoodShare.
- During Petitioner’s telephone contact with the agency on March 14, 2025, the agency worker asked Petitioner to confirm the balance of her bank accounts and Petitioner did so. The worker told Petitioner that she would be sent a summary and if everything looked accurate there no further steps that Petitioner would need to complete. However, on March 17, 2025, the agency sent Petitioner a request for verification of her bank accounts.
- On April 20, 2025 and on May 4, 2025, the Department of Health Services sent Petitioner notices informing her that her IRIS enrollment “has ended or is scheduled to end on: April 30, 2025” due to “no Medicaid eligibility.”
- On April 30, 2025, Petitioner submitted the verification requested by the IM agency.
- On May 1, 2025, the IM agency closed Petitioner’s Medicaid case. On May 14, 2025, the IM agency re-opened her Medicaid case and backdated her eligibility to May 1, 2025.
- On May 14, 2025, TMG received a “re-referral” from the ADRC which allowed TMG to re-enroll Petitioner into IRIS on that same date.
- Petitioner filed an appeal seeking IRIS re-enrollment from May 1, 2025 through May 13, 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 §§1.1.2 and 28.1.5. If a person loses full benefit Medicaid eligibility, their IRIS Consultant Agency must disenroll them from the IRIS Program.
The Division of Hearings and Appeals sent a copy of the hearing notice to the IM agency but no representative from the IM agency appeared. A representative from TMG did, however, appear and produced some documentation from the IM agency’s CARES database. Based on the evidence in the hearing record, it is not clear why the IM agency initiated a Medicaid renewal for Petitioner in March 2025 given that she had completed a renewal in September 2024 and Medicaid renewals are generally required only annually. Petitioner apparently had a FoodShare renewal due in March or April 2025 but there is no indication that she asked the agency to complete her Medicaid renewal early. Nevertheless, Petitioner endeavored to comply with the agency’s requests while hospitalized. As she credibly testified, Petitioner confirmed the bank account balances that an agency representative read aloud to her during a telephone renewal interview on March 14, 2025. Despite agreeing with the information that the agency already had on file, presumably from a third party source, the agency followed up by sending a verification request to Petitioner.
Petitioner did not learn of the verification request until April 29, 2025 and then promptly sent in the requested verification the following day; however, it was not processed until on or after May 1, 2025 by which time the Department had already automatically disenrolled her from IRIS.
There is no evidence in the hearing record to suggest that Petitioner ever stopped meeting the eligibility requirements for full-benefit Medicaid nor is there evidence that Petitioner was advised in writing that she must complete an early Medicaid renewal by a particular date.
Based on the evidence available to me, I find that Petitioner’s Medicaid was terminated in error and that as a result, she was disenrolled from IRIS in error from May 1, 2025 through May 13, 2025.
Conclusions of Law
Due to IM agency processing errors, Petitioner was improperly disenrolled from IRIS from May 1, 2025 through May 13, 2025.
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 May 1, 2025 IRIS disenrollment. The Department shall comply with this order within ten days of the date of this decision.
[Request for a rehearing and appeal to court instructions omitted.]
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