Before taking any negative action, the Medicaid agency must give adequate notice. In this case, TMG mailed notice of IRIS disenrollment due to a missed renewal to the wrong address. ALJ Brian Schneider concluded the petitioner did not receive adequate notice and the termination of her IRIS benefits was incorrect.
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 December 12, 2024, under Wis. Admin. Code, §HA 3.03, to review a decision by TMG to discontinue Include, Respect, I Self-Direct (IRIS) eligibility, a hearing was held on February 12, 2025, by telephone. A hearing set for January 29, 2025 was rescheduled at the petitioner’s request.
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 Medera
TMG
2424 Rimrock Rd., Suite 230
Fitchburg, WI 53713
ADMINISTRATIVE LAW JUDGE:
Brian C. Schneider
Division of Hearings and Appeals
Findings of Fact
- Petitioner (CARES # —) is a resident of Dane County.
- Petitioner was and is eligible for IRIS with TMG as her consulting agency. Petitioner was scheduled to complete a Medical Assistance (MA) renewal by the end of November, 2024. Due to mailing issues, her representative, —, did not get the renewal package and did not discover that MA closed effective December 1 until after the closure. She filed the renewal on December 3, and MA eventually was reopened retroactive to December 1, so there has been no loss of MA.
- On October 25, 2024, petitioner’s TMG case manager sent — a letter telling her that petitioner needed to complete the renewal or IRIS would close November 30. The letter was sent to an old, incorrect address, however, and — did not receive it.
- IRIS closed effective December 1, 2024 without any additional notice. After the renewal was completed, IRIS reopened with TMG still the consulting agency effective January 1, 2025.
Discussion
The IRIS program was developed pursuant to a Medical Assistance waiver obtained by the State of Wisconsin, pursuant to section 6087 of the Deficit Reduction Act of 2005 (DRA), and section 1915(c) of the Social Security Act. It is a self-directed personal care program.
As with any negative action in the MA-related realm, the IRIS agency must notify the recipient in writing of a proposed discontinuance. IRIS Policy Manual, §11.1A. Here TMG sent a letter to petitioner’s representative explaining that IRIS could close at the end of November, but the notice was sent to the wrong address. As a result, petitioner did not receive adequate notice of the negative action. I thus conclude that the termination of IRIS was incorrect because petitioner did not receive notice prior to the action.
Conclusions of Law
The termination of IRIS was incorrect because petitioner did not receive notice prior to the action.
THEREFORE, it is
Ordered
That the matter be remanded to TMG with instructions to restore petitioner’s IRIS eligibility and its services effective December 1, 2024. It shall do so within 10 days of this decision.
[Request for a rehearing and appeal to court instructions omitted.]
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