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 “multiple attempts” by the IRIS agency to complete a new screen “between August and November.” With no evidence of any error by the agency, ALJ Kelly Cochrane concluded the petitioner was correctly disenrolled.
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 27, 2023, under Wis. Admin. Code § HA 3.03, to review a decision by the Bureau of Long-Term Support regarding Medical Assistance (MA), a hearing was held on January 17, 2024, by telephone.
The issue for determination is whether the petitioner was correctly disenrolled from the IRIS program.
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: Trace Vandervelde
Bureau of Long-Term Support
PO Box 7851
Madison, WI 53707-7851
ADMINISTRATIVE LAW JUDGE:
Kelly Cochrane
Division of Hearings and Appeals
Findings of Fact
- Petitioner is a resident of Milwaukee County.
- Petitioner was found functionally eligible for the IRIS program after a Long Term Care Functional Screen (LTCFS) was performed on October 10, 2022. He was thereafter enrolled in IRIS in February 2023.
- Between August and November 2023, the IRIS agency made multiple attempts to redetermine petitioner’s eligibility before the expiration of his functional eligibility, but no contact could be made with the petitioner.
- On November 1, 2023 the IRIS agency issued a Notice of Action to petitioner stating that because his annual LTCFS was not able to be performed to determine his eligibility, he was being disenrolled from the IRIS program effective November 16, 2023.
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 regulations require that the Department’s agent must assess the participant’s needs and preferences (including health status) as a condition of IRIS participation. Id., § 441.301(c)(2). The Department’s agent must also develop a service plan based on the assessed needs. 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 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, 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 petitioner received MA-Waiver benefits through IRIS. He was found functionally eligible for the program after a LTCFS was performed on October 10, 2022. He was thereafter enrolled in IRIS in February 2023. To remain eligible, the petitioner must continue to require the level of care generally found in an institution and must complete an annual functional and financial eligibility review. Failure to maintain eligibility could result in disenrollment. See IRIS Policy Manual §§ 2.2D and 2.2D.1. The agency testified to multiple attempts to redetermine petitioner’s eligibility before the expiration of his previous LTCFS, but no contact could be made with the petitioner. See also Exhibit D1.
Petitioner appeared at hearing with his niece and they agreed they understood the disenrollment and that they had or would take the steps necessary to get him re-enrolled with the IRIS program. They are reminded the Aging and Disability Resource Center of Milwaukee County would be the place to help with that process.
Having no evidence to show any error by the agency, I must uphold the disenrollment.
Conclusions of Law
Petitioner was correctly disenrolled from the IRIS program effective November 16, 2023.
THEREFORE, it is
Ordered
The petition for review herein is dismissed.
[Request for a rehearing and appeal to court instructions omitted.]
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