MGE 216221 (05/02/2025)
IRIS backdated after 50-day delay caused by fiscal employer agent under corrective action

The attached proposed decision of the Administrative Law Judge dated March 10, 2025 is hereby adopted as the final order of the Department.

Preliminary Recitals

Pursuant to a petition filed on December 11, 2024, under Wis. Stat. § 49.45(5), and Wis. Admin. Code § HA 3.03(1), to review a decision by the Douglas County Department of Human Services regarding Medical Assistance (MA), a hearing was held on January 23, 2025, by telephone. The record was held open for two weeks for submission of additional evidence.

The issue for determination is whether the Petitioner’s date of enrollment in the IRIS program can be adjusted.

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: Emily Tribby
Douglas County Department of Human Services
1316 North 14th Street
Suite 400
Superior, WI 54880

ADMINISTRATIVE LAW JUDGE:
Jason M . Grace
Division of Hearings and Appeals

Findings of Fact

1. Petitioner (CARES # —) is a resident of Barron County. He was enrolled in IRIS, with TMG his IRIS consultant agency (ICA).
2. On July 15, 2024, notice was issued to the Petitioner’s representative informing of the need to complete the annual Medicaid renewal otherwise benefits would end August 31, 2024.
3. On or about August 13, 2024, the Petitioner submitted renewal documents.
4. The deadline to complete the renewal was extended to September 30, 2024.
5. On August 21, 2024, notice was issued to the Petitioner’s representative informing of the need to submit additional documents to complete the renewal pertaining to a checking account and employment by September 9, 2024.
6. On September 10, 2024, notice was issued to the Petitioner that his healthcare benefits (including Medicaid and Community Waivers) would be ending on October 1, 2024, as needed action was not taken.
7. The Petitioner was disenrolled from Medicaid and IRIS as of October 1, 2024.
8. On October 3, 2024, the income maintenance agency processed the requested renewal documents submitted by the Petitioner on October 1, 2024, and found he regained Medicaid eligibility.
9. On October 4, 2024, the ADRC forwarded an IRIS referral to TMG to re-enroll Petitioner into the program.
10. On October 7, 2024, TMG confirmed that Petitioner’s health and safety could continue to be met by the IRIS program and that his plan remained accurate.
11. Prior to the Petitioner’s disenrollment from IRIS, his fiscal employer agent (FEA) was iLIFE. That FEA is subject to a corrective action plan imposed by the Department that prevents enrolling new clients, including prior clients through the expedited re-enrollment process.
12. Also on October 7, 2024, TMG sent a work request to GT Independence to establish it as the Petitioner’s new FEA.
13. On October 14, 2024, TMG e-mailed GT Independence to obtain an update on the processing of the FEA request.
14. On October 15, 2024, TMG received an e-mail from GT Independence that indicated the processing of the FEA request could take 5-7 business days.
15. On October 21, 2024 and October 28, 2024, TMG e-mailed GT Independence for an update on the processing of the FEA paperwork.
16. On October 30, 2024, TMG e-mailed iLIFE seeking to resolve a claim that it failed to provide GT Independence requested paperwork.
17. On November 19, 2024, TMG e-mailed GT Independence inquiring as to what was needed for Petitioner’s enrollment.
18. On or about November 25, 2024, the processing of the FEA request was finalized and GT Independence was established as the Petitioner’s new FEA. GT Independence backdated his start date in its system to October 7, 2024.
19. On November 26, 2024, Petitioner was re-enrolled into the IRIS program.
20. On December 11, 2024, the Petitioner filed an appeal with the Division of Hearings and Appeals seeking to adjust his IRIS enrollment date.

Discussion

The Include, Respect, I Self-Direct (IRIS) program is a Medicaid 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. 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 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 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”).

Petitioner filed an appeal because he was involuntarily disenrolled from the IRIS program from October 1, 2024 through November 25, 2024, and his providers are therefore unable to be paid for care they provided him during that time period. Respondent contended that Petitioner cannot receive coverage of long-term care services unless he is currently enrolled in the IRIS program. The following IRIS program policy supports that position:

An IRIS participant’s enrollment date refers to the date of activation of the service authorization; therefore, the IRIS program prohibits the payment of providers and/or participant-hired workers prior to the enrollment date.

IRIS Policy Manual, §5.5B.

Respondent explained that Petitioner was involuntarily disenrolled from IRIS because the IM agency temporarily terminated his Medicaid eligibility as of October 1, 2024, for failure to timely complete his annual renewal. As detailed in the Findings of Fact, the renewal was completed late, and on October 3, 2024, the IM agency found that Petitioner remained eligible for Medicaid and backdated his Medicaid eligibility to October 1, 2024.

A result of the Petitioner’s failure to timely complete his renewal is that he was also disenrolled from the IRIS program. His involuntarily IRIS disenrollment as of October 1, 2024, is consistent with the following published policy:

Once enrolled in BadgerCare Plus or Medicaid, a renewal must be completed at least once each year. The IM agency will mail a letter to the participant the month before the renewal is due. The renewal is conducted by the IM agency and can be done online at access.wi.gov, by phone, by mail, by fax, or in person. The renewal ensures the participant continues to meet all program rules and is receiving appropriate benefits. If continued financial eligibility for Medicaid is not confirmed, then the participant becomes ineligible for the program and will be disenrolled (see Enrollment—Disenrollment and Suspensions).

IRIS Policy and Procedure Publication P-03515 §B.1.ii.

An IRIS member is not automatically re-enrolled in the IRIS program after completing a late Medicaid renewal. In this case, the Petitioner contacted the ADRC and a referral for IRIS re-enrollment was sent to TMG on October 4, 2024.

Under IRIS policy, a member may be eligible for an expedited re-enrollment when the member’s disenrollment from the program was effective less than 30 days prior to their new program start date. See IRIS Policy and Procedure Publication P-03547 (09/2024) §B.1.b. The expedited re-enrollment process provides, in relevant part, the following:

The expedited re-enrollment process allows participants who have been disenrolled from the IRIS program, for the reasons indicated below, to be re-enrolled in the program with an abbreviated referral period. The referral process for the participant remains the same as an initial enrollment, meaning that the ADRC or Tribal ADRS must refer the participant to the ICA using the IRIS Authorization Form (F-00075).

This process applies only to participants who are found eligible for the IRIS program again following:

• Release from an incarceration.
• Discharge from an institution for mental disease (IMD) admission.
• Discharge from a suspension that has lasted longer than 90 days.
• Reinstatement of Medicaid eligibility after it had lapsed.

When a participant is re-enrolling in the program, the ICA may reinstate their most recently active IRIS Service Plan (including all orientation, FEA-related, Participant-Hired Worker (PHW) or provider-related, and plan-related documentation) and re-enroll the participant immediately following receipt of their referral when their disenrollment was effective less than 30 days prior to their new program start date. To be eligible for an expedited re-enrollment, the paiticipant’s most recently active plan must successfully address their health and safety. …

Id. The Department provided further guidance to TMG clarifying that a participant is eligible for the expedited re-enrollment process if the IRIS participant has been referred to the ICA within 30 days of their previous disenrollment date.

In this case, the ADRC provided TMG an IRIS referral to re-enroll the Petitioner in the program on October 4, 2024. By October 7, 2024, TMG confirmed that the Petitioner’s most recent IRIS plan was still current and that there were no health and safety concerns precluding enrollment in the program. The only outstanding issue was that his prior FEA, iLIFE, was precluded from enrolling new clients, even prior clients, while under its current corrective action plan that was imposed by the Department. Thus, a new FEA needed to be established prior to the Petitioner’s re-enrollment in IRIS. That re-enrollment was delayed in this case from October 7, 2024 until November 26, 2024, due to the need to set up a new FEA.

The Department provided TMG the following guidance regarding the expedited re-enrollment process while iLIFE is under its current sanction:

Effective October 1, 2024, iLIFE will not be eligible to receive now [sic] enrollments (including participants eligible for an Expedited Re-enrollments) until their Corrective Action Plan (CAP) has been successfully completed. It should be noted that the ADRC’s have been notified and LTC Scorecards will be updated accordingly.

Cases where a participant is referred back to the IRIS program and the ICA determines the participant is eligible for an Expedited Re-enrollment, the ICA will notify the new FEA that the participant is eligible for an Expedited Re-enrollment via a “Critical Work Request” via WISITS.

The new FEA will “fast track” the enrollment process by prioritizing the enrollment, as well as contacting iLife to obtain any documents that will streamline the enrollment process.

iLife will be informed to provide all requested documentation to the new FEA within 2 business clays of receiving the request.

To simply the process, iLife must be prepared to send the following documents:

• EIN Documents.
• Active PHW packets only.
• All current participant documents.

TMG Exhibit E1.

The record in this case indicates that on October 7, 2024, TMG sent a Work Request to GT Independence to establish it as the Petitioner’s new FEA. As noted above, the new FEA was not finalized until November 25, 2024. The record before me does not attribute the delay in finalizing the new FEA to the actions or inactions of the Petitioner or his representative.

TMG supported the adjustment of the Petitioner’s IRIS re-enrollment date given the delay in establishing the new FEA but did not advocate for a specific date. I would note that if iLIFE had not been under a corrective action plan (CAP) the Petitioner likely would have been re-enrolled in the IRIS program on October 7, 2024, with iLIFE continuing to act as his FEA. That also likely would have been his re-enrollment date if, prior to his temporary Medicaid and IRIS disenrollment, he had been using any of the other FEAs not subject to the iLIFE CAP. Based on the foregoing, I find the record supports adjusting the Petitioner’s IRIS enrollment date to October 7, 2024.

The Department has been willing to adjust the start date for enrollment of Family Care participants if it determines that agency error caused unreasonable delays despite the general preclusion on backdating enrollment into Family Care, which is a managed care program. See, e.g., In re —, DHA Case No. 205394 (Wis. Div. Hearings & Appeals Sept. 29, 2022) (DHS), In re —, DHA Case No. 207295 (Wis. Div. Hearings & Appeals Sept. 29, 2022) (DHS). However, the Department clarified in a Final Decision that DHA does not have the authority to make a final decision to adjust the enrollment date in the Family Care Program. That is a remedy that only the Department may authorize.

Although this is an IRIS rather than a Family Care matter, in light of the adjusted enrollment date sought, I am issuing this as a proposed decision in line with the above-referenced line of final decisions. I would note that the Department’s Secretary previously indicated in a final decision that DHA does not have the authority to adjust the IRIS enrollment date under the expedited re-enrollment process and that it is a remedy that only the Department may authorize. See —, DHA Case No. 209367 (Wis. Div. Hearings & Appeals Jan. 4, 2024) (DHS).

Conclusions of Law

Petitioner’s enrollment date for IRIS should be adjusted to October 7, 2024.

THEREFORE, it is

Ordered

That, if this proposed decision is adopted as final by the Department Secretary, the agency must, within ten days of the date of the Final Decision, take all necessary administrative steps to revise the Petitioner’s IRIS enrollment date to October 7, 2024.

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