CWA 219687 (11/13/2025)
IRIS enrollment reinstated when ADRC faxing mistake caused late renewal

Preliminary Recitals

Pursuant to a petition filed on August 22, 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 October 7, 2025, by telephone.

The issue for determination is whether the petitioner was correctly disenrolled from IRIS as of August 1, 2025.

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: Helen Isidoro, TMG
Bureau of Long-Term Support
PO Box 7851
Madison, WI 53707-7851

ADMINISTRATIVE LAW JUDGE:
Kate J. Schilling
Division of Hearings and Appeals

Findings of Fact

1. Petitioner (CARES # —) is a 60 year resident of Vernon County. She was enrolled with the IRIS program with TMG as her IRIS Consultant Agency.
2. On June 16, 2025, the agency sent a notice to the petitioner that her Medicaid was due for a renewal by July 31, 2025.
3. On June 25, 2025, the petitioner called the agency and completed her Medicaid renewal over the phone.
4. On June 26, 2025, the agency sent out a request for verification of the petitioner’s checking account balance, life insurance policy, her spouse’s wages, and her spouse’s signature. The verification items were due by July 15, 2025.
5. On July 10, 2025, the petitioner and her spouse called the agency and requested an extension for submission of the verification items. The agency extended the due date for verifications to July 31, 2025.
6. On July 23, 2025, the agency received the petitioner’s spouse’s paystubs, the spouse’s signature, and verification of the bank account.
7. On July 25, 2025, the agency sent out a new Notice of Required Next Steps stating that the agency still needed verification of the life insurance policy, which was due by August 13, 2025.
8. On August 1, 2025, the petitioner was involuntarily disenrolled in IRIS due to her Medicaid eligibility ending as of July 31, 2025.
9. On August 6, 2025, the petitioner’s spouse called the IM agency and stated that they had sent in the life insurance verification with the other documents they had faxed to the agency on July 23, 2025. The IM agency representative double checked the documents they had received on July 23, 2025, and did not find the verification of the life insurance policy.
10. On August 6, 2025, the IM agency representative reached out to the Aging and Disability Resource Center (ADRC) staff person who had faxed the petitioner’s documents to the IM agency to ensure they received all of the documents. The ADRC staff confirmed that the IM agency had received all 11 pages they had faxed over on July 23, 2025.
11. On August 7, 2025, the petitioner faxed both pages of the life insurance policy verification to the IM agency.
12. On August 8, 2025, the IM agency mailed a notice to the petitioner that her Medicaid had been approved retroactive to August 1, 2025, and there had been no gap in her Medicaid coverage.
13. On August 15, 2025, the ADRC referred the petitioner to the ICA for re-enrollment back into IRIS.
14. The IRIS Fiscal Employer Agency (FEA) that the petitioner had previously worked with was closing and was not accepting new participants or re-enrollments. The petitioner had to select a new FEA and go through the full orientation process before IRIS enrollment could occur.
15. On September 25, 2025, the petitioner was re-enrolled in IRIS. The gap in her IRIS eligibility was from August 1 through September 24, 2025.

Discussion

The IRIS program is a Medicaid long term care waiver program that serves older adults 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. The broad purpose of all of these programs, including IRIS, is to help participants design and implement home and community based services as an alternative to institutional care. See IRIS Policy Manual §1.1B, Medicaid Eligibility Handbook §28.1, et. seq., and 42 C.F.R. §441.300, et. seq.

The Department of Health Services 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), IRIS fiscal employer agents (FEAs), and income maintenance agencies (IM agencies).

The IRIS waiver application most recently approved by the Centers for Medicare and Medicaid Services (CMS) is available on-line at https://www.dhs.wisconsin.gov/iris/hcbw.pdf. See Application for 1915(c) HCBS Waiver: WI.0484.R03.00 – Jan 01, 2021. State policies governing administration of the IRIS program are included in the IRIS Policy Manual (available at http://www.dhs.wisconsin.gov/publications/P0/P00708.pdf), 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 petitioner lost Medicaid eligibility as of August 1, 2025, due to a failure to provide verification of a life insurance policy during her Medicaid renewal. This caused the petitioner’s IRIS program benefits to end as of the same date. The petitioner was able to re-establish her Medicaid eligibility with the IM agency on August 8. The IM agency backdated Medicaid card services (non-long term care eligibility) to August 1, 2025, pursuant to policy in the Medicaid Eligibility Handbook (MEH) §2.8.2.

After the petitioner’s Medicaid was reinstated, she was referred to the ADRC to re-enroll in IRIS. The ADRC referred her to the IRIS program for enrollment on August 15, 2025. Given that it was only 15 days after she had been disenrolled from IRIS, the petitioner would have been eligible for expedited re-enrollment into IRIS. Expedited re-enrollment would have streamlined the process of the re-enrollment by being able to reinstate the most recent IRIS service plan, rehiring supportive home care staff, and avoiding the need to complete the new participant orientation and paperwork. IRIS Policy and Procedure Publication P-03547 (updated September 2024) §B.1.b. However, the FEA that the petitioner had previously been enrolled with was closing and no longer accepting new enrollments. Therefore, the petitioner was unable to do an expedited re-enrollment back into IRIS. The petitioner selected a new FEA and had to complete the full orientation process before IRIS enrollment could begin. The petitioner was re-enrolled into IRIS as of September 25, 2025. This left a gap from August 1 through September 24, 2025, where the petitioner was not eligible for IRIS.

At the hearing, the petitioner’s husband explained that he had been working with a staff person from the local ADRC to submit verification documentation for the annual Medicaid renewal. He testified that he had given the ADRC staff all of the documentation to fax over to the IM agency on July 23, 2025. Inadvertently, the ADRC staff did not realize that the last page of the verification documents she had been given to fax over to the IM agency was double-sided. Therefore, only the first page of the life insurance statement was faxed over to the IM agency. Unfortunately, it was the second page of the life insurance statement that contained the face values and cash values of the policy that was needed for Medicaid asset verification purposes. As the IM agency did not receive the verification of the life insurance policy cash value and face value, the petitioner’s Medicaid ended as of July 31, 2025. It was not until August that the petitioner and her spouse figured out what had happened, and they promptly sent over the copy of the life insurance statement to the IM agency directly.

The petitioner’s spouse’s testimony at the hearing was credible and is corroborated by documentation contained within the hearing record. The agency submitted a copy of the fax that was sent initially by the ADRC on July 23, 2025, as well as a copy of the two page life insurance policy statement with the cash values later sent by the petitioner. (IM agency Exhibits 6 & 7) It is clear that both pages go together as part of the verification documents from the life insurance company. Moreover, the first page is a fax cover sheet dated July 18, 2025, with the life insurance company’s letterhead at the top. The second page is the Policy Benefit Inquiry Form from the life insurance company containing the same date as well as the policy number, the cash value, and face value of the policy.

While ADRCs do not have primary responsibility for assisting people with Medicaid applications, they do provide general assistance in helping people with Medicaid and other benefits.

Access to Publicly Funded Long-Term Care Programs and Services (P-03062-03)

1. Assuring Access to Publicly Funded Long-Term Care Programs and Services

The ADRC must assure that customers who request access to and indicate potential eligibility for publicly fund long-term care are informed about and assisted in accessing these programs, consistent with the requirements in this scope of services and with any additional direction provided by DHS, including but not limited to Wis. Admin. Code § DHS 10.31(6).

(Emphasis added.) 2024 ADRC Scope of Services contract, Section H, page 11. Furthermore, the Wisconsin administrative code provides that ADRC staff will assist people in obtaining necessary verifications for eligibility for long-term care programs.

(5) Verification of information. A financial and non-financial eligibility application for the family care benefit shall be denied when the applicant or enrollee is able to produce required verifications but refuses or fails to do so. If the applicant or enrollee is not able to produce verifications or requires assistance to do so, the agency taking the application may not deny assistance but shall proceed immediately to assist the person to secure necessary verifications.

(Emphasis added.) Wis. Admin. Code §DHS 10.31 (5). In this case an administrative oversight by the ADRC staff caused the petitioner to lose her IRIS benefits. The petitioner had provided all the necessary verifications to the ADRC on July 23, 2025, with the understanding that they would be faxed over to the IM agency on the same day. The petitioner relied on the staff at the ADRC in believing that her Medicaid renewal would be completed in July and that her Medicaid and IRIS benefits would continue. It was not until after her IRIS benefits had lapsed that she realized there was a problem.

The ADRCs provide unbiased information and referral services for people with disabilities and older adults. They are a wealth of information regarding public benefits such as Medicaid, Medicare, Social Security benefits, FoodShare, dementia, FamilyCare, IRIS, etc. They also provide general support to people applying for Medicaid or maintaining their benefits. Here, the petitioner was disenrolled from IRIS due to an administrative error by ADRC staff. The petitioner should not be worse off for having relied on ADRC staff intended to assist with this process. As such, I am ordering that her IRIS benefits be reinstated as they were erroneously terminated on August 1, 2025.

Conclusions of Law

The petitioner was incorrectly disenrolled from IRIS as of August 1, 2025.

THEREFORE, it is

Ordered

That the case is Remanded to the IRIS agency with instructions to reinstate the petitioner’s IRIS eligibility as of August 1, 2025, so that there is no gap in her IRIS coverage. The agency shall do this within 7 days of the date of this decision.

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