When an agency error causes delay in an individual’s enrollment in an MCO, the Department may adjust the individual’s enrollment date. In this case, the petitioner switched from the IRIS program to the Family Care program with the help of the ADRC, but the ADRC provided the wrong enrollment date, resulting in a gap in benefits. ALJ Kelly Cochrane, in a decision adopted as final, concluded the petitioner’s enrollment should be backdated.
This decision was published with support from the Wisconsin chapter of the National Academy of Elder Law Attorneys and Krause Financial.
The attached proposed decision of the Administrative Law Judge dated August 21, 2025 is hereby adopted as the final order of the Department.
[Request for a rehearing and appeal to court instructions omitted.]Preliminary Recitals
Petitioner filed an appeal with the Division of Hearings and Appeals on May 23, 2025 under Wis. Admin. Code § DHS 10.55, regarding Medical Assistance (MA), specifically the Include, Respect, I Self-direct (IRIS) program. After receiving his appeal, the Division of Hearings and Appeals opened a file—CWA-218386. The hearing was originally held on July 9, 2025, by telephone. At that time, it was determined that the matter required appearances from the Aging and Disability Resource Center (ADRC) and the care management organization (CMO) that petitioner was transferred to under the Family Care Program (FCP). The matter was rescheduled and a second day of hearing was held on August 5, 2025, by telephone. It was determined from that hearing that this appeal should be considered a FCP case type and was re-coded as FCP-218386 post-hearing.
The issue for determination is whether the petitioner’s enrollment date for the FCP should be backdated.
There appeared at that time the following persons:
PARTIES IN INTEREST:
Petitioner:
—
Petitioner’s Representative:
—
Respondent:
Department of Health Services
1 West Wilson Street, Room 651
Madison, WI 53703
By: Catherine Moe, Quality Improvement Coordinator, ADRC
ADRC of Milwaukee County
Aging Resource Ctr—Suite 300
1220 W Vliet St
Milwaukee, WI 53205
ADMINISTRATIVE LAW JUDGE:
Kelly Cochrane
Division of Hearings and Appeals
Findings of Fact
- Petitioner is a resident of Milwaukee County.
- Petitioner was enrolled in the IRIS program until April 24, 2025, when the lRIS agency received a voluntary disenrollment form signed by petitioner. He was disenrolled that day.
- Petitioner worked with the ADRC to facilitate his disenrollment from IRIS and his subsequent enrollment into the FCP.
- The ADRC provided a transfer form to the FCP provider, Community Care Inc. to facilitate his enrollment into the FCP. It failed to state the correct date for enrollment.
- Petitioner was enrolled in the FCP on May 2, 2025.
Discussion
The IRIS program was developed pursuant to an MA waiver obtained by the State of Wisconsin, pursuant to section 1915(c) of the Social Security Act. It is a self-directed personal care program. The federal government has promulgated 42 C.F.R. § 441.300 – .310 to provide general guidance for this program.
The broad purpose of 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, available online at https://www.dhs.wisconsin.gov/publications/p0/p00708.pdf. The IRIS waiver application (IRIS Waiver) 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. State policies governing administration of the IRIS program are included in the IRIS Policy Manual, 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 Medicaid Eligibility Handbook (MEH) explains how Adult Home and Community-Based Waivers work amongst the various waiver subprograms. See MEH, § 28.1, available online at http://www.emhandbooks.wisconsin.gov/meh-ebd/meh.htm#t=home.htm.
The IRIS Waiver states:
Voluntary Termination of Participant Direction.
Only persons who elect to self-direct are eligible for IRIS, so if a participant voluntarily dis-enrolls from IRIS, the participant has the option to explore alternative Wisconsin long-term care programs.
If a participant wants to voluntarily dis-enroll, the participant is directed to return to the Aging and Disability Resource Center (ADRC) to go through enrollment counseling to select a different long-term care program. ADRCs communicate the participant’s decision to the ICA, and, if the person selects to enroll in another ICA or LTC program, then until the participant is officially enrolled in the other long-term care program, the ICA ensures the participant’s health and welfare and continued IRIS supports and services.
See IRIS Waiver, p. 201; see also Exhibit G.
In this case, the petitioner’s IRIS enrollment was terminated by the IRIS agency per the disenrollment form and therefore his IRIS eligibility ended on April 24, 2025. There is no showing of an error by the IRIS agency and none was alleged. The problem, as conceded at the second hearing, was that the ADRC failed to complete the form correctly showing the transfer date to the FCP as of April 25, 2025. Thus, petitioner had a gap in payment for services from April 25-May 1, 2025, because he was not enrolled into the FCP until May 2, 2025.
The FCP is a MA waiver program that provides appropriate long-term care services for elderly or disabled adults. Wis. Stat. § 46.286; see also Wis. Admin. Code, Chapter DHS 10. The ADRC is charged with assisting a person found eligible for the FCP who wishes to enroll in a CMO of the person’s choice. See Wis. Admin. Code § DHS 10.23(2)(i). With many entities involved in the administration of the FCP—Income Maintenance (IM) agencies, ADRCS, and CMOs—eligibility and enrollment issues can occur. When this happens, applicants through no fault of their own are at risk of delayed enrollment. The ADRC specialist appeared at hearing and conceded that the ADRC sent the disenrollment form to IRIS and the enrollment form to the CMO with an incorrect enrollment date for the FCP and that the enrollment date should have been April 25, 2025.
Over the past several years, the DHS has issued final decisions that mitigate the effects of delayed enrollment due to agency error. See e.g., In re —, DHA Case No. 167655 (Wis. Div. Hearings & Appeals March 21, 2016) (DHS) and In re —, DHA Case No. 173457 (Wis. Div. Hearings & Appeals Sept. 15, 2016) (DHS). In those cases, the DHS found that where there is an agency error that causes a delay in the processing of an individual’s MA benefit and, in turn, a delay in the individual’s enrollment in an CMO, the DHS may adjust the individual’s enrollment date. The DHS issued a Final Decision that DHA does not have the authority to make a final decision to adjust the enrollment date; rather, only the DHS may issue a final decision adjusting an enrollment date for Community Waivers. See In re —, DHA Case No. 192893.
In this matter there is no evidence that petitioner was responsible for the delay in his enrollment. Because DHS must make the final decision to adjust the enrollment date for the FCP, this Decision is issued as a Proposed Decision.
Conclusions of Law
- An error by the ADRC resulted in a delay, causing petitioner to be enrolled with his FCP CMO on May 2, 2025.
- Petitioner’s FCP enrollment date should be April 25, 2025.
THEREFORE, it is
Ordered
That if this Proposed Decision is adopted by the Secretary of the Department of Health Services as the Final Decision in this matter, the agency must, within 10 days of the date of the Final Decision, take all necessary administrative steps to revise the petitioner’s FCP enrollment date to April 25, 2025.
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