CWA 220664 (03/04/2026)
IRIS disenrollment for failure to talk and meet with ICA over several months

Preliminary Recitals

Pursuant to a petition filed on October 31, 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 February 5, 2026, by telephone. The hearing was rescheduled multiple times at the request or with the consent of the petitioner.

The issue for determination is whether respondent correctly disenrolled the 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
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. Petitioner is a resident of Milwaukee County. The petitioner was enrolled in the IRIS program, with Advocates4U as his IRIS consultant agency.
2. Petitioner has medical conditions that include dementia, anxiety, depression, schizophrenia, arthritis, hypertension, diabetes, and pulmonary embolism. His LTCFS notes that he has short and long term memory loss and that he is unable to make decisions independently due to dementia and requires assistance with all decisions. It further notes he is his own guardian.
3. Petitioner needs assistance with the Activities of Daily Living (ADLs) of bathing, dressing, eating, mobility, toileting, and transfers. He also needs assistance with the Instrumental Activities of Daily Living (IADLs) of meal preparation, medication administration/management, money management, laundry/chores, telephone, and transportation. It is noted he needs overnight care and that he has memory loss.
4. Petitioner’s IRIS services are comprised mainly of SHC hours. He self-directed his PC services through enrollment in the IRIS SDPC program.
5. Petitioner lives with his wife, who is also one of his SHC caregivers.
6. On October 13, 2025, the respondent issued notice to petitioner that his IRIS enrollment was being terminated effective October 31, 2025. The basis for the action was as follows:
   

   You have been non-compliant with IRIS program requirements. You have not completed a home visit since 04/09/2025 despite numerous attempts by your IRIS Consultant. You also do not maintain contact for monthly phone calls as required.

   You have had a history of not maintaining contact with your IRIS Consultant. Since 2024, there have been 5 no contact letters sent to you on 07/15/2025, 10/08/2024, 06/2024, 05/02/2024, and 03/13/2024. In May of 2025 the IRIS Consultant attempted contact on 5/13, 5/14, 5/15, 5/22, 5/28. You informed the SDPC RN that you would like to be disenrolled from IRIS on 5/22. On 5/22 you called the IRIS Consultant but did not leave a voicemail and when the IRIS Consultant called back there was no answer.

   In June of 2025 the IRIS Consultant attempted contact on 6/5, 6/12, 6/13, 6/26.

   In July of 2025 the IRIS Consultant attempted contact on 7/8, 7/11, 7/14. The IRIS Consultant attempted a pop up home visit on 7/15 unsuccessfully. A no contact letter was mailed on 7/18.

   In August of 2025 the IRIS Consultant attempted contact on 8/13, 8/19, 8/25, 8/26, 8/27. The IRIS Consultant received a missed call from you on 8/29, but no voicemail was left. On 8/1 you and the IRIS Consultant scheduled a home visit for 8/6. On 8/6, you called to reschedule the visit, but declined the proposed date. On 8/26, the IRIS Consultant received a very explicative voicemail from you regarding being upset about a welfare check that was called in.

   In September of 2025 the IRIS Consultant attempted contact on 9/3, 9/9. You called the IRIS Consultant multiple times, the IRIS Consultant also had a missed call from your preferred contact, —. When the IRIS Consultant called back there was no answer. On 9/4, the IRIS Consultant scheduled a visit for 9/8. On 9/5, the IRIS Consultant received an illegible voicemail from you and tried to call back to confirm the home visit unsuccessfully. On 9/8, the IRIS Consultant received a call from — cancelling the visit. On 9/10 a home visit was scheduled for 9/11, but subsequently cancelled due to your threats of violence to SDPC staff. The IRIS Consultant has made many attempts to conduct home visits and monthly contacts with you without success. Advocates4U has also sent no contact letters. …

7. The petitioner appealed.

Discussion

A consolidated hearing was held on February 5, 2026, to address petitioner’s disenrollment from the IRIS SDPC program (DHA Case No. CWA-221317) and his termination from the IRIS program (DHA Case No. CWA-220664). This decision addresses the termination from the IRIS program. A separate decision has been issued addressing petitioner’s disenrollment from the IRIS SDPC program.

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 waiver approved by the Centers for Medicare and Medicaid Services (CMS) which proves the IRIS program’s authority is available at https://www.dhs.wisconsin.gov/iris/hcbw.pdf.

At issue in this case is whether the respondent was authorized to involuntarily disenroll the petitioner from the IRIS program. The basis for the disenrollment set forth by the respondent was petitioner’s noncompliance with IRS program requirement. Specifically, a failure to allow the ICA appropriately monitor the petitioner by participating in 90 day home visits and maintaining contact by telephone.

The IRIS waiver provides:

1. The participant and the IRIS Consultant Agency (ICA) are jointly responsible for assuring the participant’s health and welfare; the effective delivery of waiver services, active, continuous monitoring of the implementation of the service plan in a cost-effective manner; as well as the adherence to the HCBS Settings requirements. If the participant has a legal decision maker who has the authority to make decisions on their behalf, the legal decision maker is required to assume and fulfill the same required self-direction roles and accompanying responsibilities on behalf of the participant.
2. The ICA regularly meets with the participant to ensure that selected services and supports continue to meet the participant’s needs, are furnished in accordance with the service plan, and are accessible to the participant. The regular meetings allow the ICA to monitor the participant’s choice of qualified provider(s) and the effectiveness of their individualized back-up plan. The ICA may mitigate risk of threats to health and safety by connecting the participant with resources for addressing their own health and safety risks. If a threat to health or safety arises, the ICA reports such critical incidents to appropriate parties, which may include Adult Protective Services or law enforcement. This is further defined in Appendix G. If the participant refuses or is unable to address their own health and safety, or refuses the assistance of the ICA, the ICA has the responsibility to recommend program requested disenrollment.The participant’s service plan is a dynamic document that reflects significant changes in the participant’s outcomes, health status, furnished waiver supports and services, non-waiver services, and the participant’s life.
   …
3. The participant and ICA meet frequently for thorough, in-person consultations during the initial service plan planning and implementation phase. After the service plan is implemented, the ICA, at minimum, contacts the participant monthly and meets in-person every 90 days to monitor the implementation of the participant’s service plan.

IRIS Waiver, pg. 199 (emphasis added).

The IRIS waiver provides for involuntary disenrollment in circumstances that include “Unable to reach participant for an extended period of time,” “Health and safety cannot be assured,” and “Material noncompliance with IRIS program requirements ….” Id at pg. 219; see also IRIS Policy and Procedure, P-03547 (09/2024), found online at https://www.dhs.wisconsin.gov/publications/p03547.pdf:

2. Program Requested Disenrollment
   1. Disenrollment Process Program requested disenrollments are involuntary and occur as the result of a participant’s failure to meet programmatic requirements, failure to perform responsibilities of self-direction, or as result of general program noncompliance. In an attempt to prevent program requested disenrollments and to ensure successful program participation, the ICA reviews participant education materials with the participant at enrollment, annually, and as needed. Specific reasons for program requested disenrollment and their definitions are provided below.
      ICAs are responsible for recommending program requested disenrollments when a reason for disenrollment is identified and applicable remediation attempts have not resolved the issue. For any program requested disenrollment identified, ICAs must complete the IRIS Involuntary Disenrollment Request form (F-01319) and submit it to the Department quality assurance staff for review and approval. Once the Department approves the request, the ICA issues the NOA and the appeal rights to the participant. … The reasons for program requested disenrollment, their definitions, and any required remediation include the following:
      …
      9. Program Noncompliance: The ICA selects this reason when a participant refuses to perform responsibilities of self-direction or complete program requirements, as defined by participant education materials and program policies. Examples of noncompliance include refusing to complete a behavior support plan, refusing to develop an emergency backup plan, or refusing to sign the IRIS Service Plan (ISP).
         Note: Participants have the right to abstain from signing the ISP while actively working with the ICA to adjust the plan to become mutually agreeable.

1. 1. 1. Remediation/Documentation Required: The ICA must provide documentation of their efforts to inform the participant of the program requirement and to assist the participant in correcting the situation.
         1. Examples include case notes informing the participant of the requirement, case notes documenting the ICA working with the participant to resolve the situation, participant education forms, and other educational materials.
            …

Pgs. 24-27.

The respondent has provided evidence of a significant history of noncompliance by the petitioner surrounding the obligation to participate in monthly contacts with the ICA and in-person visits every 90 days to monitor implementation of the IRIS service plan. See respondent’s hearing packet and Findings of Fact 6. The respondent documented its remediation efforts in the submitted case notes for the period of May 14, 2025 through October 15, 2025. Exhibit 2.

Based on the record before me, the respondent has identified material noncompliance by petitioner related to a failure to allow the ICA to appropriately monitor the implantation of his IRIS plan through 90 day home visits and maintaining monthly telephone contact. I understand that petitioner’s medical diagnoses, including his dementia, memory loss, and mental illness, likely plays a role in that noncompliance. Petitioner has a spouse and an adult son who provide some degree of assistance in his participation in the IRIS program. It is not clear to me from the record the extent of that assistance. Whatever degree of assistance that they do provide was not sufficient to resolve the noncompliance at issue in this case. The hearing in this matter was rescheduled four times at petitioner’s request. Efforts were made to contact his wife and son to provide petitioner assistance with the hearing process. Neither ultimately appeared at hearing to provide that assistance. The record indicates that respondent acted within its authority in disenrolling petitioner from the IRIS program due to material program noncompliance.

It is clear that petitioner needs long term care services. He will be referred to the Aging and Disability Resource Center upon disenrollment from IRIS and will likely be eligible to enroll in Family Care, a managed long term care program that can provide a level of assistance and oversight that is not available through the self-directed program of IRIS.

Conclusions of Law

The respondent acted within its authority in terminating petitioner’s IRIS enrollment effective October 31, 2025.

THEREFORE, it is

Ordered

That petitioner’s appeal is dismissed.

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