CWA 219333 (10/15/2025)
IRIS re-enrollment denied for unpaid cost share, failed repayment agreement

Preliminary Recitals

Pursuant to a petition filed on July 23, 2025, under Wis. Admin. Code § HA 3.03, to review a decision by First Person Care Consultants regarding IRIS, a hearing was held on September 17, 2025, by telephone. The hearing record was held open until September 24, 2025 to allow Petitioner and Respondent an opportunity to submit documentation regarding the amount of Petitioner’s cost share arrears; specifically, whether Petitioner made a payment in April 2023. Very shortly after the hearing had concluded, Petitioner called the administrative law judge and left a voice mail message explaining that she had reviewed her bank records and that she had concluded that she had not made a payment in April 2023 and that the agency’s representative had been correct on that point. She also apologized for her error. In addition, during that “hold open period”, Respondent submitted a copy of a paycheck dated April 28, 2023 that was made out to Petitioner’s representative. Both Petitioner’s voice mail and the paystub submitted by Respondent were added to the hearing record.

The issues for determination are: (1) whether First Person Care Consultants properly disenrolled Petitioner from IRIS on July 1, 2025, and (2) if so, whether Petitioner is entitled to be re-enrolled.

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: Sue Rothe, First Person Care Consultants
First Person Care Consultants
PO Box 7851
Madison, WI 53707-7851

ADMINISTRATIVE LAW JUDGE:
Teresa A. Perez
Division of Hearings and Appeals

Findings of Fact

1. Petitioner is an 87-year old resident of Milwaukee County who was disenrolled from IRIS effective July 1, 2025.
2. First Person Care Consultants was Petitioner’s most recent IRIS Consultant Agency (“ICA”).
3. In June 2024, the ICA sought to disenroll Petitioner from IRIS after he fell behind on paying his monthly cost share amounts. Petitioner appealed that disenrollment and, on October 8, 2024, Administrative Law Judge Jason Grace issued a decision (DHA Case No. CWA-214294) finding that, although Petitioner had a cost share delinquency, “the respondent errored in involuntary disenrolling the petitioner from the IRIS program based on nonpayment of cost share as he had entered into a repayment plan and was complying with the terms of that plan.”
4. On February 26, 2025, Petitioner signed an updated “IRIS Program Cost Share Repayment Agreement” agreeing to pay $366.94 per month towards the arrears in addition to paying his currently monthly cost share amount. The effective date of that agreement was March 1, 2025.
5. Petitioner’s required payment, under the terms of the February 2025 cost share repayment agreement, was $463.55 for March 2025 ($96.61 monthly cost share + $366.94). He paid $500 on March 6, 2025. Petitioner did not make any payments in the months of April 2025 or May 2025.
6. Petitioner had a Medicaid renewal due by the end of February 2025. He initiated his renewal prior to that deadline.
7. On March 3, 2025, the agency sent Petitioner a written request for both a spousal signature and documentation of assets and income, which were both steps needed to complete the renewal process.
8. Both the due date to comply with the agency’s verification request and Petitioner’s renewal deadline were extended multiple times.
9. Petitioner’s final deadline to comply with the agency’s verification request was April 24, 2025; the agency issued written notice of that deadline on April 15, 2025.
10. Petitioner submitted some but not all requested verification by April 24, 2025.
11. On April 25, 2025, the agency issued a written notice to Petitioner which stated that his Medicaid and Community Waivers eligibility would end as of June 1, 2025 because the agency was still waiting to receive some of the requested verification.
12. Petitioner’s eligibility for Community Waivers lapsed as of June 1, 2025 because he did not satisfy all of the agency’s requests for verification until July 8, 2025.
13. Because Petitioner’s Community Waivers was terminated, Petitioner was disenrolled from IRIS but not until July 1, 2025.
14. After Petitioner’s Community Waivers renewal was completed on July 8, 2025, Petitioner requested re-enrollment in IRIS.
15. Via notice dated July 24, 2025, the ICA advised Petitioner that his request for re-enrollment was denied because he had a $4,193.05 delinquent cost share from his previous enrollment in the IRIS Program. The notice further stated: “A repayment agreement was previously signed on 02/26/2025 during your previous enrollment. You have only made one payment after signing this repayment agreement. [The ICA] spoke with you about paying off your cost share balance in full to proceed forward with your re-enrollment and you stated that you cannot pay off the full repayment amount at this time.”
16. Petitioner filed an appeal with the Division of Hearings and Appeals seeking re-enrollment in IRIS and asked that the re-enrollment be effective July 1, 2025.

Discussion

To participate in IRIS, an individual must meet the financial and non-financial eligibility criteria for one of the following: a “full benefit category of [Elderly, Blind, Disabled] Medicaid”, BadgerCare Plus, Wisconsin Well Woman Medicaid, or Adoption Assistance. Medicaid Eligibility Handbook (MEH) §§1.1.2 and 28.1.5 and IRIS Policy Manual, Addenda: Eligibility, Sec. A.5. SSI-Related Medicaid, SSI Medicaid, Medical Assistance Purchase Plan (MAPP), and Community Waivers are all full benefit Medicaid programs. MEH §1.1.2. If a person becomes ineligible for Medicaid, they become ineligible for IRIS and must be disenrolled. See IRIS Policy Manual, Addenda: Program Enrollment, Sec. D.3.

In this case, the agency explained that Petitioner was disenrolled from IRIS on July 1, 2025 based on the closure of his Community Waivers / Medicaid that occurred on June 1, 2025 after he failed to complete his annual Medicaid renewal. The agency’s evidence showed that Petitioner’s Medicaid renewal was initially due by February 28, 2025 but that deadline was extended a few times—first, because the income maintenance agency failed to begin processing the renewal until after February 28, 2025 and then, to allow Petitioner additional time to comply with the agency’s request for verification. The final extended deadline to comply with the verification request was April 24, 2025. Petitioner was issued proper written notice of both that request and of the agency’s intention to close her Community Waivers effective June 1, 2025 if the requested verification was not submitted.

Petitioner’s representative at hearing did not dispute that the renewal was completed after the final deadline. She explained that, around that time, her mother and two sisters had passed away and that she was able to tend to some, but not all, of the demands that were then on her plate. Although that is entirely understandable, an administrative law judge does not have the discretion to allow a hardship exception despite the difficult circumstances described by Petitioner’s representative. Petitioner’s Medicaid renewal was ultimately due by June 1, 2025 and it was not completed until July 8, 2025. The income maintenance agency and the IRIS Consultant Agency therefore correctly applied program requirements by terminating Petitioner’s Community Waivers eligibility and by subsequently disenrolling him from IRIS.

The next question that must be addressed is whether Petitioner may be re-enrolled in IRIS while there is an unpaid cost share delinquency from his prior period of enrollment. Program policy requires participants seeking to re-enroll after a previous disenrollment to “demonstrate the remediation of any existing concerns relating to their previous referral withdrawal or disenrollment.” IRIS Policy and Procedure: Program Enrollment Sec. A.1.c., Publication No. P-03547 (09/2024), p. 2. Program policy further provides that an individual may be considered “unwilling or unable to remediate existing concerns” when “there are unpaid cost share arrears and/or unresolved repayment agreements that the [individual] refuses to pay in full prior to enrollment.” Id. at Sec. A.3.b.v.1., p. 7.

Although Petitioner was not disenrolled for failing to pay his cost share, the ICA demonstrated that he had not consistently paid his cost share, that he entered into more than one repayment agreement—most recently on February 26, 2025, that he made one payment after signing that agreement, and that he then missed at least two additional payments (i.e,, in April 2025 and May 2025) just prior to being disenrolled for failing to timely complete his Medicaid renewal. Under these specific circumstances, I find that the ICA acted appropriately in declining to re-enroll Petitioner on grounds that he is unwilling or unable to remediate existing concerns.

Finally, I note that at hearing, Petitioner’s representative challenged the accuracy of the $4,193.05 outstanding balance that the ICA asserted Petitioner currently owes. She testified that the ICA had not subtracted a $1,632.98 payment that Petitioner had made towards the delinquent cost share amount in April 2023. The ICA’s representative countered that, in fact, the $1,632.98 figure was the amount of wages that Petitioner paid to her in her capacity as his caregiver and that Petitioner had not paid that sum to the IRIS Program. The hearing record was held open to allow both parties to submit documentation relevant to that dispute. The ICA submitted a copy of a paycheck made out to Petitioner’s representative for $1,632.98 by GT Independence (i.e., an IRIS fiscal employer agency) dated April 28, 2023 and Petitioner’s representative left a voice mail message for the undersigned administrative law judge almost immediately after the hearing explaining that she had checked her bank statements and realized that her testimony was mistaken.

Conclusions of Law

1. First Person Care Consultants properly disenrolled Petitioner from IRIS on July 1, 2025 because he did not timely complete his Medicaid renewal and his eligibility for Community Waivers thus lapsed as of June 1, 2025.
2. Petitioner is not currently entitled to re-enroll in IRIS because he accrued a cost share delinquency, entered into a repayment plan, and failed to consistently comply with that plan prior to his disenrollment, and because he has not demonstrated an ability to repay the delinquency at this time.

THEREFORE, it is

Ordered

That Petitioner’s appeal is dismissed.

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