IRIS enrollment dates may be revised if the agency is the cause of a wrongful termination of IRIS enrollment. In this case, the agency called the petitioner before her renewal deadline but she declined to do the renewal over the phone. She claimed at hearing to have submitted her renewal paperwork in person to Milwaukee Enrollment Services the day before the deadline, but the documents were not processed and a signature was not provided until after the deadline. ALJ John Tedesco concluded the agency had not erred and the termination of the petitioner’s IRIS due to missing the renewal deadline was correct.
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 14, 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 IRIS enrollment should be backdated to cover the period from 6/1/25 to 7/13/25.
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.
- The petitioner was enrolled in IRIS.
- On April 15, 2025 the agency sent a notice to petitioner informing her that her Medicaid was required to have a completed renewal by May 16, 2025.
- On May 13, 2025 the agency called petitioner to renew her Medicaid. She declined stating she would mail in a written renewal.
- The renewal was not completed by May 16, 2025.
- Petitioner’s Medicaid coverage closed on May 16, 2025 adverse action date because renewal was not complete. Notice of MA closure was sent.
- IRIS was closed due to Medicaid having closed.
- Petitioner completed a telephone renewal of her Medicaid on May 29, 2025.
- IRIS was re-opened as of July 13, 2025.
Discussion
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 his IRIS eligibility, ended at the end of December 2024 for failing to timely complete his annual review. The agency can backdate MA eligibility under separate MA policy, and that was done.
Iris enrollment dates may be revised if the agency is the cause of a wrongful termination of IRIS enrollment. See, e.g. In Re —, DHA Case Number CWA-216814 (Final Decision June 18, 2025). In this case I am entirely unpersuaded that the error of disenrollment or re-enrollment delay was caused by any agency. The cause of the problem here was petitioner’s. Petitioner was notified by mailing on April 15, 2025 that her renewal was due to be completed by May 16, 2025. The notice clearly stated “benefits could end on May 31, 2025…even if they get benefits back after losing them, there could be a time when they are not covered.” The agency even called petitioner on the phone on May 13, 2025 to ask her to complete her renewal on the phone at that time. Petitioner or her representative declined to do so.
Petitioner stated at hearing that she went in-person to Milwaukee Enrollment Services and submitted all needed documentation for the renewal on May 15, 2025. She explained that she believed this renewal was completed. The county did not have a record of a visit on May 15. It may be that petitioner only dropped off documents to be processed as some documents were processed on May 21 and May 28. The final telephonic signature, a requirement of a completed renewal, for the renewal occurred on May 29, 2025. That is the date of the completed renewal.
Because Medicaid had not been renewed by May 16 the Medicaid case was closed with an effective date of May 31, 2025.
On May 29, 2025, petitioner contacted the agency by phone to complete the renewal. This followed the adverse action date when the agency acted to close the Medicaid case. The agency can backdate MA eligibility under separate MA policy, and that was done to make sure there was not break in Medicaid coverage. See MEH §§ 2.8.2, 3.1.6, and 3.1.6.2. The IRIS program’s policy is different, however. The IRIS program prohibits the payment of providers and/or participant-hired workers prior to the enrollment date. See IRIS Policy Manual, § 2.0 (https://www.dhs.wisconsin.gov/publications/p03515.pdf). IRIS policy also provides that if a renewal is completed within 30 days of closure, it can be processed as an “expedited re-enrollment”, which occurred. Even with expedited re-enrollment the new enrollment was not completed until July 13, 2025.
This was not agency error. Petitioner should have completed the renewal before the May 16 deadline she was provided in the April 15, 2025 notice. That is why the notice was sent in April. The agency called her to do the renewal but petitioner chose not to. It is misplaced to now argue that the agency erred.
Conclusions of Law
Petitioner failed to prove that she was wrongfully terminated from IRIS due to agency error.
THEREFORE, it is
Ordered
That this appeal is dismissed.
[Request for a rehearing and appeal to court instructions omitted.]
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