MGE 219014 (10/06/2025)
IRIS disenrollment for missed renewal deadline was correct

Preliminary Recitals

Pursuant to a petition filed on July 7, 2025, under Wis. Stat. § 49.45(5), and Wis. Admin. Code § HA 3.03(1), to review a decision by the Jefferson Cty Workforce Developmt Ctr regarding Medical Assistance (MA), a hearing was held on September 26, 2025, by telephone.

The issue for determination is whether petitioner’s IRIS re-enrollment date should be revised.

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: C. Fischer
Jefferson Cty Workforce Developmt Ctr
874 Collins Rd
Jefferson, WI 53549

ADMINISTRATIVE LAW JUDGE:
John Tedesco
Division of Hearings and Appeals

Findings of Fact

1. Petitioner is a resident of Jefferson County.
2. Petitioner was enrolled in IRIS.
3. On 5/12/25 the county agency sent petitioner a notice informing him that his Medicaid renewal. The notice stated that the renewal was required to be completed by 6/17/25. The notice advised that if the renewal was not completed by that date then benefits could end on 6/30/25. The notice further warned: “[e]ven if they get benefits back after losing them, there could be time when they are not covered.”
4. The notice provided details about how to complete a renewal by phone, mail, or online.
5. The notice advised: “To complete your renewal, you may be required to provide proof of your answers. If you need help getting any of the items listed, contact your agency. In some situations, you may be asked to give proof of other items not listed here.”
6. On 5/27/25 the agency sent a notice to petitioner entitled: “Required Next Steps To Receive Your Benefits.” There was only one action the notice called for petitioner to complete. The notice required that petitioner submit information relating to a bank account at —. The notice stated that this was due no later than 6/16/25. The notice requested a statement and offered assistance in the event a statement was not readily available. The notice explained that the information could be sent by mobile device, online, by fax, mail, or in person.
7. On 6/17/25 the agency had not received the required documents. The agency sent a notice informing petitioner that his Medicaid would close as of 7/1/25.
8. On 7/1/25 petitioner Medicaid closed. This resulted in petitioner’s IRIS also closing automatically.
9. — issued a letter relating to the account in question on 7/7/25. This was provided to the agency on 7/8/25.
10. On 7/9/25 the petitioner’s Medicaid case was re-opened.
11. On 7/10/25 the ADRC sent a referral to the CMO to enable expedited re-enrollment.
12. Expedited re-enrollment was completed on 8/4/25.

Discussion

The IRIS waiver application (Waiver) most recently approved by the Centers for Medicare and Medicaid Services (CMS) is available online 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 Department of Health Services (DHS) 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”), FEAs, and IM agencies.

To participate in the IRIS program, individuals must be 18 years of age or older, meet the nursing home level of care, and meet the financial and non-financial eligibility criteria for one of the following: a full-benefit category of Elderly Blind or Disabled (EBD) MA, BadgerCare Plus, Wisconsin Well Woman Medicaid, Adoption Assistance or Foster Care Medicaid. See MEH § 28.1.5. As part of determining ongoing eligibility, all IRIS participants must complete an annual functional and financial eligibility review. Failure to maintain that eligibility may result in disenrollment. See IRIS Policy Manual, § 2.0 (https://www.dhs.wisconsin.gov/publications/p03515.pdf). The agency has the right to disenroll members from IRIS for losing their financial eligibility. See IRIS Waiver, p. 202; IRIS Work Instructions, Ch. 7 (https://www.dhs.wisconsin.gov/publications/p03515.pdf).

In this case, the petitioner’s MA, and therefore his IRIS eligibility, ended on 6/30/25 for failing to timely complete his annual review. The agency can backdate MA eligibility under separate MA policy, and that was done.

Iris enrollment dates may be revised if the agency is the cause of a wrongful termination of IRIS enrollment. See, e.g. In Re —, DHA Case Number CWA-216814 (Final Decision June 18, 2025). In this case I am entirely unpersuaded that the error of disenrollment or re-enrollment delay was caused by any agency. The cause of the problem here was petitioner’s. Petitioner was notified by mailing on May 12, 2025 that his renewal was due to be completed by June 17, 2025. The notice clearly stated “benefits could end on June 30, 2025 … even if they get benefits back after losing them, there could be a time when they are not covered.”

Because Medicaid had not been renewed by May 16 the Medicaid case was closed with an effective date of May 31, 2025.

A notice was sent to petitioner on 5/27/25 stating that only one thing was required as verification to complete the renewal. This notice was sent with more than enough time to complete the renewal by the due date. But, petitioner did not submit the — document until 7/8/25 which was more than a week after the closure of his Medicaid.

This followed the adverse action date when the agency acted to close the Medicaid case. The agency can backdate MA eligibility under separate MA policy, and that was done to make sure there was not break in Medicaid coverage. See MEH §§ 2.8.2, 3.1.6, and 3.1.6.2. The IRIS program’s policy is different, however. IRIS went through its process of expedited re-enrollment which took until 8/4/25. Neither the county agency nor the ADRC did anything in error. The problem was caused by petitioner not submitted the document relating to the — account.

Conclusions of Law

Petitioner failed to prove that he was wrongfully terminated from IRIS due to agency error or that there was any undue delay in re-enrolling him.

THEREFORE, it is

Ordered

That this appeal is dismissed.

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