IRIS participants who fail to comply with program requirements or lose functional eligibility may be disenrolled. In this case, the petitioner needed to complete an annual long-term care functional screen but failed to respond to twelve phone calls and voicemails from TMG about scheduling the screen. ALJ Teresa Perez concluded TMG properly disenrolled the petitioner because it could not confirm her ongoing functional eligibility.
This decision was published with support from the Wisconsin chapter of the National Academy of Elder Law Attorneys.
Preliminary Recitals
Pursuant to a petition filed on November 13, 2023, under Wis. Admin. Code § HA 3.03, to review a decision by the Department of Health Services and its agent, TMG, to disenroll Petitioner from IRIS, a hearing was held on December 19, 2023, by telephone.
The issue for determination is whether the Department, by its agent, TMG, properly disenrolled Petitioner from IRIS as of November 1, 2023 because it was unable to confirm her ongoing functional eligibility.
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: Ivana McDonald, TMG
Bureau of Programs and Policies, IRIS Policy Section
PO Box 7851
Madison, WI 53707-7851
ADMINISTRATIVE LAW JUDGE:
Teresa A. Perez
Division of Hearings and Appeals
Findings of Fact
- Petitioner is a resident of Milwaukee County who receives IRIS benefits.
- TMG is Petitioner’s IRIS consultant agency (“ICA”).
- Petitioner’s most recent long term care functional screen (“LTCFS”) was completed on October 12, 2022.
- Petitioner was required to complete an updated LTCFS by October 12, 2023 as a condition of continued IRIS enrollment.
- Sonja Mietz, a Screening Specialist employed by TMG, called Petitioner on August 21, 2023 and approximately 11 more times thereafter. Each time she called, she left a voice mail message that stated Petitioner needed to complete a long term care functional screen to maintain IRIS services, identified the due date for the screen, left her name and phone number, and asked Petitioner to call back to schedule appointment.
- TMG mailed Petitioner a Notice of Action dated October 17, 2023 informing her that her IRIS enrollment would be terminated effective November 1, 2023 because she failed to complete a long term care functional screen.
- On November 13, 2023, Petitioner contacted her IRIS Consultant (“IC”) and asked why she was being disenrolled from IRIS. Her IC explained the need to complete the LTCFS and provided her instructions on how to do so.
- On November 13, 2023, the Division of Hearings and Appeals received a request for a state fair hearing from Petitioner regarding TMG’s decision to disenroll her from IRIS.
Discussion
The Include, Respect, I Self-Direct (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. 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).
Once an individual is found eligible for IRIS, they are required to undergo an annual functional and financial eligibility review. See IRIS Policy Manual §2.2D and HCBS Waiver App. B-6, Para. g. The Department of Health Services has the right to disenroll IRIS participants who fail to comply with IRIS Program requirements and who lose functional eligibility. IRIS Work Instructions §7.1A.1.
It is undisputed that Petitioner failed to complete her annual long term care functional screen by October 12, 2023. Screen Liaison Mietz credibly testified that she made several attempts to notify Petitioner of her obligation to complete that screen and of the deadline for doing so. At hearing, Petitioner confirmed that the telephone number that TMG had on file for her and that Screen Liaison Mietz had called was correct. Petitioner testified that she expected information about her obligation to complete the LTCFS to come from her IC rather than from TMG’s Screen Liaison; however, Petitioner acknowledged that she “might have missed [the messages]” left by Screen Liaison Mietz. She also acknowledged that she received the Notice of Action sent by TMG.
TMG, as an agent of the Department of Health Services, had the right to disenroll Petitioner from IRIS because Petitioner failed to comply with the requirement that she complete an annual functional eligibility review and because TMG was, as a result, unable to confirm that Petitioner continued to meet IRIS program eligibility requirements.
Conclusions of Law
The Department, by its agent, TMG, properly disenrolled Petitioner from IRIS as of November 1, 2023 because it was unable to confirm her ongoing functional eligibility.
THEREFORE, it is
Ordered
That Petitioner’s appeal is dismissed.
[Request for a rehearing and appeal to court instructions omitted.]
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