Any negative action regarding a person enrolled in Medicaid must be preceded by proper notice that includes appeal rights. In this case, the petitioner lost her SSI eligibility but the agency never sent a notice with appeal rights before terminating her from IRIS. ALJ Brian Schneider concluded the IRIS termination was incorrect because the petitioner did not receive adequate notice beforehand.
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 July 15, 2025, under Wis. Admin. Code, §HA 3.03, to review a decision by TMG to discontinue the Include, Respect, I Self-Direct Program (IRIS), a hearing was held on August 20, 2025, by telephone.
The issue for determination is whether the agency provided adequate notice of the IRIS termination.
PARTIES IN INTEREST:
Petitioner:
—
Petitioner’s Representative:
Atty. Elizabeth Mamerow
Disability Rights Wisconsin
6737 West Washington Street, Suite 3230
Milwaukee, WI 53124
Respondent:
Department of Health Services
1 West Wilson Street, Room 651
Madison, WI 53703
By: Theresa Sommerfield
TMG
2424 Rimrock Rd., Suite 230
Fitchburg, WI 53713
ADMINISTRATIVE LAW JUDGE:
Brian C. Schneider
Division of Hearings and Appeals
Findings of Fact
- Petitioner is a resident of Milwaukee County.
- Petitioner has been eligible for IRIS with TMG as the consulting agency. Her eligibility was based on Medicaid (MA) through the receipt of Supplemental Security Income (SSI). Petitioner’s SSI ended effective April 1, 2025 because she became eligible for Disabled Adult Child (DAC) benefits.
- A notice dated January 15, 2025 informed petitioner about the pending end to SSI and said “We have asked your [county] agency to check if your Medicaid can continue after 4/30/25. You don’t need to do anything at this point… If your Medicaid cannot continue, your agency will send you a letter letting you know your rights and responsibilities.”
- On May 15, 2025, the agency sent petitioner a notice informing her that her long-term care enrollment will end May 31, 2025 due to no Medicaid eligibility. It stated that a separate notice explaining her right to appeal would follow. No such notice was sent.
- IRIS closed effective June 1, 2025. On June 3, 2025, Milwaukee Enrollment Services processed an MA request, and petitioner immediately was found to be eligible for MA effective June 1, 2025. A notice dated June 4, 2025 informed petitioner that MA was open as of May 1, 2025. The notice did not mention long-term care.
- Petitioner discovered that IRIS was closed in July, 2025. A new referral was sent through the ADRC, and IRIS was reopened August 20, 2025.
Discussion
The IRIS program was developed pursuant to a Medical Assistance waiver obtained by the State of Wisconsin, pursuant to section 6087 of the Deficit Reduction Act of 2005 (DRA), and section 1915(c) of the Social Security Act. It is a self-directed personal care program.
As with any negative action in the MA-related realm, the IRIS agency must notify the recipient in writing of a proposed discontinuance. IRIS Policy Manual, §11.1A. The notice must include an explanation of the participant’s “rights and the process with regard to filing an appeal, including their opportunity to indicate on the Request for a State Fair Hearing their desire to continue their services while their appeal is under consideration,” id., language taken directly from the 1915(c) Medicaid Home and Community-Based Services waiver. In this instance the only notice sent to petitioner did not include appeal rights, instead referring to an additional notice that was not issued because petitioner did not have an open case at Milwaukee Enrollment Services. As a result, petitioner did not receive adequate notice of the negative action and did not have the opportunity to request continued benefits. I thus conclude that the disenrollment from IRIS was incorrect.
Conclusions of Law
The termination of IRIS was incorrect because petitioner did not receive adequate notice prior to the action.
THEREFORE, it is
Ordered
That the matter be remanded to TMG with instructions to restore petitioner’s IRIS eligibility and its services effective June 1, 2025. It shall do so within 10 days of this decision.
[Request for a rehearing and appeal to court instructions omitted.]
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