CWA 219262 (12/29/2025)
IRIS participant disenrolled for living in a motel

Preliminary Recitals

Pursuant to a petition filed on July 21, 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 November 4, 2025, by telephone. Hearings scheduled for September 4, 2025 and September 30, 2024, were rescheduled at petitioner’s request.

The hearing record was held open for two weeks to provide the parties an opportunity to submit additional evidence. As of the issuance of this decision, the Division of Hearings and Appeals has not received any further evidence from either party.

The issue for determination is whether the respondent correctly disenrolled petitioner from the IRIS program.

There appeared at that time the following persons:

PARTIES IN INTEREST:

Petitioner:
—

Respondent:
Department of Health Services
201 E. Washington Ave.
Madison, WI 53703
By: Advocates4U, an IRIS consultant agency
Bureau of Long-Term Support
PO Box 7851
Madison, WI 53707-7851

ADMINISTRATIVE LAW JUDGE:
Jason M. Grace
Division of Hearings and Appeals

Findings of Fact

1. It is believed that Petitioner is a resident of Jefferson County. He is enrolled in the IRIS program.
2. A Long Term Care Functional Screen (LTCFS) was completed with petitioner on or about November 22, 2024. It indicates that he has medical diagnoses that include diabetes, coronary atherosclerosis, osteoarthritis, chronic low back pain, dementia, sleep apnea, asthma, anxiety, PTSD, bipolar, depression, schizophrenia, torn rotator cuff, and non-Hodgkin’s lymphoma.
3. The LTCFS also indicates that petitioner needs assistance with the Activities of Daily Living of Bathing, Dressing, Mobility, Toileting, and Transfers. He further needs assistance with Instrumental Activities of Daily Living of Meal Preparation, Medication Administration/Management, Money Management, Laundry/Chores, and Transportation. It also notes that due “to physical impairments the participant requires overnight assistance with mobility, transferring and toileting tasks. In the event of an emergency due to cognitive and physical impairments, he would require assistance with ensuring he responds appropriately to emergency situations.” He was found to need a nursing home level of care and fell within the target groups of physical disability, Alzheimer’s disease or other irreversible dementia, and severe and persistent mental illness.
4. Petitioner’s IRIS services include supportive home care. He is also enrolled in the IRIS self-directed personal care program.
5. On or about February 25, 2025, the petitioner transferred to Advocates4U as his IRIS consultant agency. At that time, the petitioner was living in a motel.
6. On March 24, 2025, petitioner signed an IRIS Participant Education Manual: Acknowledgement. He acknowledged receiving and reviewing sections of the IRIS Participant Education Manual with his IRIS Consultant that included Self-Direction Responsibilities, Monitoring My Budget and Building My Plan, Preventing Budget Mismanagement and Fraud, Conflicts of Interest, Reporting Critical Incidents, Restrictive Measures, Annual Health Care Information, Background Check Policy, 40-Hours Health and Safety Rules, Participant-Hired Worker Training, Notice of Action and Fair Hearing Requests, and Complaints and Grievances.
7. On or about April 25, 2025, the petitioner signed an IRIS Program Risk Agreement related to living in an ineligible living setting for the IRIS program. The agreement contained the following information, in part:
   

   — is residing in a motel in — WI on a week to week arrangements. ICA is unable to ensure his health and safety because he is residing in temporary housing. ICA is unable to ensure his cares are being met, or his equipment is being utilized. Negative Outcome: Per the Department of Health & Human Services policy (DHS), — has a 90-day threshold residing in a temporary living arrangement at the Motel, which does not qualify as acceptable permanent housing by the DHS. — must have a month-to-month lease agreement by 6/14/2025 to present a copy of the lease for documentation to the ICA to prevent the involuntary disenrollment. After 90 days or by ( 6/14/25 ), — will be subject to Involuntary disenrollment from the IRIS program.

   …

   — has been having some challenges with finding permanent housing and would benefit from housing counseling and resources to assist him with finding a permanent address.

   …

   Options: — does not want to reside in a motel or hotel. He prefers an apartment arrangement in Dane, Walworth or Rock County. IC provided varies housing resources that includes: low income resources, housing resource guide for Rock County, given hand to hand to —. IC also emailed a 2 page —, rental units list to —. Additionally, the contact (ph: 211) assistance for local housing resource; Community Action INC. (ph: 608- 313-1333), provides housing stability and services for low-income households.

   …

   — informed IC that he will search for stable housing for an apartment out in the community. — shared with IC that he has a rental unit in mind that he will follow up by the end of next week. — understands he needs to find an apartment by 6/14/2025. He shared the resources that he is trying to find an apartment. …

8. By notice dated July 4, 2025, petitioner was informed that his IRIS enrollment was being terminated, effective July 22, 2025. It was indicated the basis for the action was that he did not reside in an eligible living arrangement to maintain IRIS enrollment. The notice further provided the following information:
   

   On 3/24/2025, your IRIS Consultant met with you and completed a Risk Agreement, which outlined the risk of involuntary disenrollment if you were unable to find permanent housing before reaching ninety days from that date. Additionally, your IRIS Consultant provided you with housing assistance information for three different low-income housing units and programs in the counties surrounding Rock County. As of 07/07/2025, you have not found permanent housing. Therefore, you are being disenrolled due to an ineligible living setting.

   Per the IRIS Policy P-03547 Section 2.a.iv , “Moved to an Ineligible Setting: The ICA selects this reason when the participant has moved into or was admitted to an ineligible living arrangement or residence. If a participant is temporarily admitted to or residing in a nursing home, hospital, community-based residential facility (CBRF), or rehabilitation facility for 90 days or more, the ICA should follow the suspension requirements and steps described in section C.2 of this policy prior to pursuing disenrollment. If that residence reaches 90 days or is not expected to be temporary, the ICA refers the participant for disenrollment utilizing this reason.”

9. The petitioner filed an appeal with the Division of Hearings and Appeals.

Discussion

The IRIS program is a Medical Assistance long term care waiver program that serves elderly individuals and adults with physical and developmental disabilities. IRIS is an alternative to Family Care, Partnership, and PACE—all of which are managed long term care waiver programs. The IRIS program, in contrast, is designed to allow participants to direct their own care and to hire and direct their own workers. See IRIS Policy Manual §1. (available at https://www.dhs.wisconsin.gov/publications/p0/p00708.pdf.

The issue in this case is whether the respondent was authorized to disenroll the petitioner from the IRIS program due to living in an ineligible living setting. At the time of the issuance of the notice of action, petitioner had been living in a motel on a week-to-week basis for over 90 days and he had already signed a Risk Agreement indicating that he would be involuntarily disenrolled from the IRIS program if he did not find permanent housing by June 14, 2025.

The hearing record was held open for two weeks to provide the parties an opportunity to submit additional evidence. As of the issuance of this decision, the Division of Hearings and Appeals has not received any further evidence from either party.

Eligible community living arrangements for the IRIS program include:

1. Permanent Eligible Living Arrangements…
   2. Physical Disability (PD) and Frail Elder (FE) Target Groups
      Eligible living arrangements for participants with a PD or are FE include:
      • House, apartment, condominium, or other private residence
      • Rooming or boarding house
      • Certified Adult Family Home (1-2 bed)
      • Licensed Adult Family Home (3-4 beds)
      • Certified Residential Care Apartment Complex (RCAC)
2. Temporary Living Arrangements
   Participants not residing in one of the eligible settings listed above when they apply may still seek enrollment in the IRIS program. In transitional situations, a participant may reside in a hotel, motel, homeless shelter, or other type of transitional housing. However, final enrollment cannot be established, and IRIS program services may not begin, until the person lives in an eligible setting.
3. Short Term Institutional Stays
   Institutional settings include hospitals, nursing facilities, or other long-term care institutions. An IRIS program participant’s permanent residence or living arrangement doesn’t change if they are admitted to an institutional setting for short-term acute care or rehabilitative services. They remain eligible for the IRIS program.
4. IRIS program services, however, must be suspended while the participant is in this short-term setting. The participant is required to report any institutional stay to IM within 10 days. Upon request of the participant, the ICA can assist with reporting this change in living arrangement to IM (see Process for Reporting a Change to the IM Agency B.2.b. below).
5. The ICA staff will assist the participant with planning and relocation activities to return to an eligible community living arrangement.
6. A temporary stay that becomes permanent triggers a program requested disenrollment from the IRIS program. This happens because these facilities are ineligible living settings for IRIS participants. A participant who has an institutional stay that extends beyond 90 days following the admission date to the facility must be disenrolled from the IRIS program.
   …

IRIS Policy and Procedure, P-03515 (09/2023), pgs. 3-4.

IRIS policy indicates that person must be living in a permanent living arrangement in order to receive IRIS services. Id. Petitioner’s living arrangement of a motel does not meet that definition. Id. An individual living in a temporary living arrangement such as a motel is allowed to apply for IRIS enrollment but final enrollment is not established and they cannot receive IRIS services until they move into an eligible setting. Id. The record before does not support the petitioner’s claim that he has moved into such an eligible setting.

The IRIS Waiver authorizes the respondent to involuntarily disenroll an IRIS member for “movement to an ineligible living setting.” See Application for 1915(c) HCBS Waiver: WI.0484.R03.00 – Jan 01, 2021 (IRIS Waiver), pg. 202 of 274, found online at https://www.dhs.wisconsin.gov/iris/hcbw.pdf; and see IRIS Policy and Procedure, P-03547 (09/2024), pg. 25. IRIS policy provides the following:

…The ICA selects this reason [Moved to an Ineligible Setting] when the participant has moved into or was admitted to an ineligible living arrangement or residence. If a participant is temporarily admitted to or residing in a nursing home, hospital, community-based residential facility (CBRF), or rehabilitation facility for 90 days or more, the ICA should follow the suspension requirements and steps described in section C.2 of this policy prior to pursuing disenrollment. If that residence reaches 90 days or is not expected to be temporary, the ICA refers the participant for disenrollment utilizing this reason.

This disenrollment reason includes if the participant has been incarcerated or admitted to an IMD for 24 hours. When a participant is being disenrolled for an incarceration or IMD admission, the ICA does not need to request the disenrollment from the Department to initiate the disenrollment process. Additionally, after the disenrollment has been initiated, they do not need to issue an NOA to the participant regarding the disenrollment. If a participant is released prior to the ICA being notified of the incarceration or IMD admission, see section C.2 above for the policy regarding retroactive suspensions.

Note: IMD admissions requiring disenrollment are only applicable to participants aged 21-64 (those 20 and under or 65 and older do not apply).

1. Remediation/Documentation Required: The ICA must provide documentation regarding the participant’s decision, incarceration date, or admission date.

IRIS Policy and Procedure, P-03547 (09/2024), pg. 25.

The respondent lived in an ineligible living setting for IRIS services from at least February 25, 2025 until July 4, 2025 (the date of the notice of action). This is over 4 months. On April 25, 2025, the respondent provided him a risk agreement that notified him he was in an ineligible living setting and that he would be involuntarily disenrolled from IRIS if that did not change by June 14, 2025. His ICA provided him housing assistance. Petitioner’s claim at hearing that he had subsequently moved to an IRIS eligible living setting was not supported. As petitioner remained in what the IRIS program deems to be an ineligible living setting, the respondent was authorized by IRIS policy to involuntarily disenroll him from the program. As such, I must uphold the disenrollment.

Finally, as noted by the respondent, this does not disqualify petitioner from enrolling in other long-term care programs wherein a care manger would be responsible for assisting him in locating permanent housing. He should contact the ADRC for further assistance and counseling.

Conclusions of Law

The respondent was authorized to disenroll the petitioner from the IRIS program as he had been living in an ineligible living setting for more than 90 days.

THEREFORE, it is

Ordered

That petitioner’s appeal is dismissed.

[Request for a rehearing and appeal to court instructions omitted.]