Any negative action regarding a person enrolled in Medicaid must be preceded by proper notice. In this case, the petitioner lost her SSI eligibility but the agency never sent a notice 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 March 21, 2025, under Wis. Admin. Code, §HA 3.03, to review a decision by the Bureau of Long-Term Support to discontinue the Include, Respect, I Self-Direct program (IRIS), a hearing was held on September 10, 2025, by telephone. The hearing was delayed for four months because the petitioner did not receive a letter requesting more information from the Division of Hearings and Appeals.
The issue for determination is whether the agency provided adequate notice of the IRIS termination.
PARTIES IN INTEREST:
Petitioner:
—
Respondent:
Department of Health Services
1 West Wilson Street, Room 651
Madison, WI 53703
By: Jennifer Madera
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 Dane County.
- Petitioner has been eligible for IRIS with TMG as the consulting agency. Her eligibility was based on receipt of Supplemental Security Income (SSI).
- Petitioner’s SSI ended in January, 2025 when she started to receive regular social security payments. MA thus closed for petitioner as of February 1, 2025 because she had to apply for a different type of MA at the county agency.
- Petitioner’s guardian became aware of the MA action in early March, 2025. An MA application was filed on March 7, and soon after MA was granted effective March 1, 2025.
- IRIS closed effective March 1, 2025 concurrently with the SSI-based MA ending. No notice of the IRIS discontinuance was sent before IRIS closed.
- Petitioner’s guardian discovered that IRIS was closed in early March, 2025. A new referral was sent through the ADRC, and petitioner was re-enrolled in IRIS on March 27, 2025, leaving a 26 day gap in coverage.
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 no notice including appeal rights was sent to petitioner prior to IRIS closing. 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 March 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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