When a person’s eligibility for SSI ends, agency policy is to automatically run Medicaid eligibility under other criteria. In this case, the petitioner’s SSI ended and she even received a notice saying she didn’t need to do anything and her Medicaid would continue, but the agency failed to run eligibility and she was disenrolled from Medicaid and IRIS. ALJ John Tedesco concluded the disenrollment was in error and enrollment should be reinstated to avoid any gap in coverage.
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 July 15, 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 August 27, 2025, by telephone.
The issue for determination is whether petitioner’s IRIS enrollment date should be revised.
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: K. Oberg – MILES
Bureau of Long-Term Support
PO Box 7851
Madison, WI 53707-7851
ADMINISTRATIVE LAW JUDGE:
John Tedesco
Division of Hearings and Appeals
Findings of Fact
- Petitioner is a resident of Milwaukee County.
- Petitioner was enrolled in Medicaid as a result of her eligibility for SSI.
- Petitioner lost SSI eligibility as of April 30, 2025.
- The county agency closed petitioner’s Medicaid eligibility on April 30, 2025.
- Petitioner’s IRIS enrollment was also closed as a result of her Medicaid closing.
- On May 6, 2025, the petitioner visited the county agency and applied for Medicaid. Her Medicaid eligibility was determined and she was opened as of May 1, 2025 with no lapse.
- In May 2025, petitioner applied for IRIS re-enrollment with the ADRC.
- On August 1, 2025 TMG, the IRIS agency, received a referral from the ADRC.
- Petitioner was re-enrolled in IRIS effective August 8, 2025.
Discussion
The IRIS program is a MA long term care waiver program that serves elderly individuals and adults with physical and developmental disabilities. The IRIS program was developed pursuant to an MA waiver obtained by the State of Wisconsin, pursuant to section 1915(c) of the Social Security Act. The federal government has promulgated 42 C.F.R. § 441.300 – .310 to provide general guidance for this program. Those regulations require that the agency’s agent must assess the participant’s needs and preferences (including health status) as a condition of IRIS participation. Id., § 441.301(c)(2). IRIS is an alternative to Family Care, Partnership, and PACE—all of which are managed long term care waiver programs in Wisconsin. The IRIS program 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, (available online at http://www.dhs.wisconsin.gov/publications/P0/P00708.pdf).
The IRIS waiver application (Waiver) most recently approved by the Centers for Medicare and Medicaid Services (CMS) is available online at https://www.dhs.wisconsin.gov/iris/hcbw.pdf. State policies governing administration of the IRIS program are included in the IRIS Policy Manual, 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 (DHS) 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”), FEAs, and IM agencies.
To participate in the IRIS program, individuals must be 18 years of age or older, meet the nursing home level of care, and meet the financial and non-financial eligibility criteria for one of the following: a full-benefit category of Elderly Blind or Disabled (EBD) MA, BadgerCare Plus, Wisconsin Well Woman Medicaid, Adoption Assistance or Foster Care Medicaid. See MEH § 28.1.5. As part of determining ongoing eligibility, all IRIS participants must complete an annual functional and financial eligibility review. Failure to maintain that eligibility may result in disenrollment. See IRIS Policy Manual, § 2.0 (https://www.dhs.wisconsin.gov/publications/p03515.pdf). The agency has the right to disenroll members from IRIS for losing their financial eligibility. See IRIS Waiver, p. 202; IRIS Work Instructions, Ch. 7 (https://www.dhs.wisconsin.gov/publications/p03515.pdf).
In this case, the petitioner’s MA, and therefore her IRIS eligibility, ended at the end of April 2025. The agency representative testified that this termination was error by the agency. The agency explained that because petitioner’s SSI ended the agency policy instructed that the agency was to automatically run petitioner’s eligibility for Medicaid under other eligibility criteria. The agency even testified that a notice was sent to petitioner informing her that she need do nothing and that her Medicaid would continue. The agency stated that it did not redetermine Medicaid eligibility and that this was the critical error by the agency that caused the issues in this appeal. Instead, the agency simply closed Medicaid as of April 30, 2025.
The agency realized its error, however, when petitioner showed up at the agency office on May 6, 2025. The agency can change the MA eligibility under separate MA policy, and that was done. See MEH §§ 2.8.2, 3.1.6, and 3.1.6.2. The IRIS program’s policy is different, however. IRIS policy also provides that if a renewal is completed within 30 days of closure, it can be processed as an “expedited re-enrollment.” But an expedited re-enrollment was apparently not completed here because despite petitioner contacting the ADRC in May to re-initiate IRIS, and even with the IRIS agency contacting the ADRC on June 25 to check on progress, it took until August 8, 2025 for petitioner to be re-enrolled. There was no reason that there should have been a lapse at all.
Petitioner argues that under the facts of this case, her IRIS enrollment date should be revised in order to correct the lapse in her IRIS coverage. Instead of August 8, 2025 the date should be May 1, 2025. I agree that the preponderance of the evidence shows there were issues caused by agency error that caused her Community Waivers/MA to end in error on April 30, 2025,
Conclusions of Law
Petitioner was terminated from IRIS as of May 1, 2025 in error and petitioner’s enrollment date for IRIS should be adjusted from 8/8/25 to 5/1/25 so that there is no lapse in her IRIS coverage.
THEREFORE, it is
Ordered
That, this matter is remanded to the agency with direction to correct the agency’s wrongful termination by revising the petitioner’s IRIS enrollment date to May 1, 2025. This must be completed within 10 days of this Decision.
[Request for a rehearing and appeal to court instructions omitted.]
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