36.2 Enrollment

36.2.1 EM CAPO Administrating Enrollment for Wisconsin Well Woman Medicaid

All initial enrollments and renewals for continuous WWWMA are now processed by EM CAPO . Temporary Enrollment/Presumptive Eligibility enrollment is still processed by the fiscal agent.

Any applications received in local IM or tribal agencies should be faxed to the EM CAPO at (608) 267-3381 immediately upon receipt to prevent any delay in eligibility determination or treatment for the applicant .

CONTACTS:

EM CAPO: DHSEMCAPO@dhs.wisconsin.gov

Fax: (608) 267-3381

Phone: 1-877-246-2276

Customer line: (608) 266-1720

36.2.2 Enrollment Through the Wisconsin Well Woman Program

The WWWP is administered by the DHS Division of Public Health (DPH). WWWP provides eligible women with various health screenings (including breast and cervical cancer screening), referrals, education and outreach.

The WWWP performs the financial and initial non-financial screening for WWWMA for WWWP enrollees. A WWWP enrollee must have a health screening through WWWP, be diagnosed, and need treatment for breast or cervical cancer to be considered for WWWMA.

WWWP LCA s enroll women in WWWP and perform some of the basic non-financial and all financial data gathering, and verification for WWWMA. They also coordinate the WWWP member’s referral to a health care provider for breast and cervical cancer screening.

The WWWP LCA will complete the F-44818 (formerly DPH-4818) with the assistance of the applicant prior to the applicant’s health care screening. The F-44818 enrolls the woman in WWWP. Her WWWP eligibility will be recorded in interChange as ”Med Stat CS”.
The WWWP member will receive a breast and cervical cancer screening from a WWWP provider. If the WWWP member is diagnosed with breast or cervical cancer, her provider will complete the F-10075 recording the diagnosis and indicating that treatment is required. The provider will sign and date the F-10075. The WWWP member will also sign and date the F-10075. The signature dates do not have to be the same date.
The provider will fill in the beginning and end dates of the temporary enrollment/presumptive eligibility for WWWMA on the F-10075
The provider will forward a copy of the F-10075 to the WWWP LCA.
The WWWP LCA will provide the member with a copy of the signed F-10075 and F-44818 forms.
The WWWP LCA will check to be sure correct temporary eligibility dates (if appropriate) are entered on the F-10075 and explain that the member’s temporary enrollment for WWWMA will end on the last day of the following calendar month.

36.2.2.1 Temporary Enrollment / Presumptive Eligibility (TE) Available Only To Women Enrolling Through WWWP

Temporary Enrollment (TE) for WWWMA is available for women to assure immediate access to cancer treatment. The provider doing the medical screening enters the TE dates in the section "Temporary Eligibility Begin Date” and "Temporary Eligibility End Date” on the F-10075. The dates should cover the time period beginning on the date of diagnosis through the last day of the following calendar month.

The WWWP LCA should then fax a copy of the completed F-10075 to the fiscal agent at (608) 221-8815 within five days of the diagnosis date. The fiscal agent will enter the temporary enrollment data in ForwardHealth interChange (with a medical status code of CB) and send the member a ForwardHealth card with the temporary enrollment dates activated on the card. (If the member had a previous ForwardHealth card, it will be reactivated.)

Until the ForwardHealth card arrives or is reactivated, the new WWWMA member may receive services by presenting both of the following completed forms to any Medicaid provider:

WWWP Enrollment Form F-44818
WWWMA Determination Form (F-10075).

To continue receiving WWWMA, the member or the WWWP LCA must submit an F-10075 to the EM CAPO. If the member does not apply, her WWWMA benefits will terminate at the end of the month following the month of diagnosis.

The TE period extends from the date of diagnosis on the F-10075 through the following month. A new TE period would only occur if a new cancer diagnosis was established for the same member.

Note: If the member applies during her TE certification period and the EM CAPO is not able to process her application, within the 30-day processing time frame, the EM CAPO will extend the members' eligibility for an additional 30 days from the last day of her Wisconsin Well Woman Medicaid TE with a medical status of "CB”. Submit an F-10110 (formerly DES 3070) to extend the Well Woman Medicaid TE for an additional calendar month.

36.2.3 WWWP Members Enrolling For Continuous WWWMA

36.2.3.1 Applications For WWWMA Through Well Woman Program (WWWP)

To apply for WWWMA through the WWWP, the applicant or the WWWP LCA must send or fax the completed F-44818 and F-10075 forms to the EM CAPO. The applicant may apply for WWWMA at any time after the WWWP screening and diagnosis. Eligibility may only be backdated to the first of the month up to three months prior to the application date or from the date of diagnosis, whichever is most recent. (For requests to back date farther than three months, refer to the BEPS policy analyst.)

Use the F-44818 and F-10075 in place of the standard application forms. This program requires manual determination. Do not enter the woman's information into CARES as an application.

The date of receipt of the F-10075 is the filing date. Use the verification policy listed in Chapter 20 for any items requiring verification.

Complete the following steps to certify the member for WWWMA:

Review the F-44818 . There should be a ”No” answer to the following questions:

1. Does the applicant have any health insurance? (Item #32 on F-4818)

If the applicant answers "Yes”, determine if the insurance is one of those listed in 36.3.3 that covers treatment for her breast or cervical cancer. If she has coverage for the treatment, she is ineligible for WWWMA.

Does the applicant have Medicare Part B? (Item #33 on F-44818)

1. Does the applicant have Medicare Part A.

If the applicant answered ”Yes” to any of these questions in a-c, the applicant is ineligible for WWWMA. The EM CAPO will refer her back to the Well Woman Program and send a manual negative notice.

Review the F-44818 to ensure that the following fields have been completed: 1-5, 9-13, 16-25, and 27-45.

If the form is incomplete, the EM CAPO will request that the applicant provide any missing information. If the applicant does not provide all necessary information, there may be a delay in eligibility determination and benefits.

Review F-10075 for an SSN . If the SSN is missing from the F-10075 and is not present on the F-44818 (# 6a); the CAPO will ask the applicant to provide her SSN. Providing an SSN for the Well Woman Program is voluntary, but providing an SSN, or applying for one, is required for WWWMA

If the applicant fails to provide an SSN, or fails to apply for an SSN within the 30-day application processing time or within ten days (whichever is later), the CAPO will send a manual negative notice to the applicant indicating that the she is not eligible for WWWMA because she did not provide an SSN.

Ask the applicant if she is a citizen.

If the applicant is not a citizen, ask her what her immigration status is and to provide her immigrant registration card. Verify that the applicant is in a qualified immigration status using the SAVE system.

Note: Some applicants with breast and cervical cancer who do not meet the immigration-related eligibility criteria may be eligible to receive emergency services. If a non-qualifying immigrant has been screened by Well Woman Program, determine her eligibility for emergency services using the criteria in 7.1 US Citizens and Nationals.

If there are any questionable items, contact the Well Woman Program Local Coordinating Agency.

The EM CAPO will update interChange (iC) with the WWWMA eligibility information using a medical status code of ”CB” to certify any member who has met the criteria listed above. Submit the completed F-10110 to the fiscal agent through one of the following methods:
1. Mail:

HP Enterprise Services

Attn: Eligibility Lead Worker WWWMA

313 Blettner Blvd

Madison WI

53714-2405

FAX: (608) 221-8815

interChange

Certify the member for 12 months from the filing date and backdate to whichever is more recent:

Up to three months prior to the filing date, or
To the date of the diagnosis (F-10075),

Never certify a woman for Well Woman Medicaid prior to her date of diagnosis.

Example 1: Gina applies for Well Woman Medicaid (WWWMA) at the Local Coordinating Agency (LCA) on September 20th 2009. The LCA submits the F-44818 and F 10075 to CAPO. The F-10075 indicates that Gina is enrolled in Well Woman Program (WWWP). The LCA provides a copy of the F-4818 documenting Gina's enrollment in the WWWP. Gina's date of diagnosis on the F-10075 is August 6th 2009. Gina meets the following non-financial requirements: citizenship/ID documentation, provides a valid SSN and has no public or private insurance that will cover her cancer treatment and she is under 65 years of age.

CAPO will certify Gina in interChange (iC) effective August 6th, 2009 through July 31 2010 with a CB medical status code. CAPO will send Gina a notice indicating her eligibility dates. About one month from the end of Gina’s eligibility period, CAPO will send Gina a recertification notice indicating she needs to recertify for WWWMA.

For initial WWWMA certifications, if the applicant applies during her WWWMA TE certification period and EM CAPO is not able to process her application within the 30 day processing time frame, EM CAPO will extend the applicant's eligibility for an additional 30 days from the last day of her WWWMA TE in iC with a medical status of "CB.” Note this extension in the CARES Comments section if appropriate.

To contact the WWWP LCA, refer to #27 of F-44818.

36.2.4 Enrollment for Family Planning Only Services Members

Women enrolled in FPOS who meet one of the following criteria (regardless of age), will be eligible for WWWMA:

Are screened for, and diagnosed with, cervical cancer or a precancerous condition of the cervix
Receive a clinical breast exam through a FPOS provider and through follow up medical testing (independent of the FPOS) and
- Are found to be in need of treatment for breast or cervical cancer or precancerous cervical condition and
- Do not have other insurance that would cover their cancer treatment.

36.2.4.1 Applications for Wisconsin Well Woman Medicaid Through Family Planning Only Services

A Wisconsin Well Woman Medicaid Determination form (F-10075) submitted by a FPOS member or her representative is a request to enroll in WWWMA and disenroll from FPOS. Women 15 through 44 years of age, enrolled in FPOS in CARES who meet the criteria 36.2.4 Enrollment for Family Planning Only Services Members above, will be eligible for Well Woman Medicaid.

A Wisconsin Well Woman Medicaid Determination form (F-10075) submitted by a FPOS member or her representative is a request to enroll in WWWMA and disenroll from FPOS. Women who are enrolled in FPOS in CARES and meet the criteria in the 36.2.4 above may be eligible for WWWMA.

This page last updated in Release Number: 16-01

Release Date: 06/10/2016

Effective Date: 04/01/2014