MGE 218539 (08/20/2025)
Automatic IRIS disenrollment with no advance notice was incorrect

Preliminary Recitals

Pursuant to a petition filed on June 3, 2025, under Wis. Stat. § 49.45(5), and Wis. Admin. Code § HA 3.03(1), to review a decision by the Daiana Ramos, Dane County Dept. of Human Services regarding Medical Assistance (MA), a hearing was held on July 22, 2025, by telephone.

The issue for determination is whether the agency correctly terminated the petitioner’s IRIS benefits as of May 31, 2025.

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: Jennifer Madera, TMG
Daiana Ramos, Dane County Dept. of Human Services
1819 Aberg Avenue
Suite D
Madison, WI 53704-6343

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

Findings of Fact

1. Petitioner (CARES # —) is a 68 year old resident of Dane County. She has been receiving long-term care services under the IRIS program since April 1, 2018.
2. The petitioner had been receiving Medicaid through her Supplemental Security Income (SSI) benefits. On an unknown date, the petitioner became eligible for Disabled Adult Child (DAC) benefits through the Social Security Administration causing her income to go up to $1,447; therefore, she lost her SSI benefits.
3. On May 31, 2025, the petitioner’s SSI-MA and IRIS benefits ended.
4. On June 6, 2025, the petitioner’s guardian submitted a new application for EBD Medicaid to reinstate her IRIS benefits.
5. On June 8, 2025, the petitioner was sent a notice from the WI Dept. of Health Services that her IRIS benefits had ended on May 31, 2025.
6. On June 30, 2025, the agency approved the petitioner’s eligibility for Medicaid benefits. Her Medicaid card services were backdated to June 1, 2025. The agency staff certified her for community waivers in the Forward Health system which updated the following day on July 1, 2025.
7. On July 1, 2025, the Aging and Disability Resource Center (ADRC) sent re-enrollment referrals to the petitioner’s IRIS Consultant Agency (ICA) and the IRIS Fiscal Employer Agency (FEA).
8. As of the date of the hearing, the petitioner was in “referral” status with the ICA and FEA. She had not yet been re-enrolled in the IRIS program.

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.

In this case, the petitioner had been receiving SSI-MA and IRIS benefits. On an unknown date prior to May 2025, one of the petitioner’s parents had passed away causing the petitioner to qualify for Social Security Disabled Adult Child (DAC) benefits. The DAC benefit caused her income to increase from $967 to $1,447 per month, rendering her ineligible for SSI benefits and SSI Medicaid as of May 31, 2025. The MMIS computer data system that contains Medicaid eligibility for IRIS benefits automatically disenrolled the petitioner from IRIS as of May 31, 2025, due to her loss of SSI Medicaid.

The petitioner’s guardian re-applied for Medicaid on June 6, 2025, and subsequently provided the requested verification items to the agency. The petitioner was approved for Medicaid benefits on June 30, 2025. While her Medicaid card services benefits were backdated to June 1, 2025, by the IM agency, IRIS benefits are not able to be backdated in the same fashion. The IM agency updated the certification for community waivers in the computer as of June 30, 2025. This was updated in the Forward Health system on July 1, 2025. The ADRC made the referral for re-enrollment to the ICA and FEA on July 1, 2025. As this referral was not made within 30 days of the date of the IRIS disenrollment, the petitioner did not qualify for expedited re-enrollment into the IRIS program. As of the date of the hearing, she had not yet been re-enrolled.

It is well-settled precedent that beneficiaries must be given at least 10 days advance notice prior to an adverse action, such as a reduction or termination in benefits. Goldberg v. Kelly, 397 U.S. 254 (1970); See also Medicaid Eligibility Handbook § 23.1.4.2. This right is also specifically stated within the IRIS Policy Manual which cites the 1915(c) Medicaid HCBS Waiver.

11.2 Notice of Action
The IRIS program must provide a Notice of Action (NOA) to program participants when an “adverse action,” defined as a denial, reduction, termination, or limitation of previously authorized services (meaning services/goods on a participant’s plan) exists or when a participant is determined financially, or functionally, ineligible for the IRIS program.

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The participant must receive the NOA at least ten calendar days before the effective date of the action. If the participant decides to grieve or appeal the action, then he or she has 45 calendar days to do so. Information concerning procedures for exercising the participant’s right to an appeal process accompanies the NOA.

(Emphasis added.) IRIS Policy Manual § 11.2. In the present case, the petitioner’s guardian testified that it is possible that the petitioner’s representative payee received a notice from Social Security that her SSI benefits would be ending; however, that notice did not provide notification that her community waiver (IRIS) benefits would be ending. Likewise, the IM agency representative testified at the hearing that no advance notice of termination of community waivers was sent from the IM agency because the petitioner had been on SSI Medicaid which is maintained outside of the CARES computer system. Similarly, the TMG staff testified that the ICA did not send out advance notice of termination of IRIS benefits as it was not aware that the petitioner’s SSI Medicaid was ending and that she would be terminated from the IRIS program. The only notice of termination of the IRIS program within the hearing record is a notice dated June 8, 2025 which stated that IRIS benefits ended as of May 31, 2025. This notice was dated after the termination of IRIS benefits, and it did not contain notice of appeal rights, or the right to continued benefits pending the appeal process as required in the IRIS Policy Manual § 11.2A. As the petitioner did not receive proper advance notice of the termination of her IRIS benefits, her coverage must be reinstated back to June 1, 2025.

Conclusions of Law

The petitioner did not receive proper advance notice of the termination of her IRIS benefits; therefore, the termination of her benefits was incorrect.

THEREFORE, it is

Ordered

That the case is Remanded to the IRIS agency with instructions to reinstate the petitioner’s IRIS eligibility as of June 1, 2025, so that there is no gap in her IRIS coverage. The agency shall do this within 10 days of the date of this decision.

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