State of Wisconsin |
Release 24-02 |
All members must cooperate in providing TPL coverage information for nursing home, hospital, and long-term care insurance policies. All members must do the following:
Any nursing home, hospital, or long-term care insurance payments that exceed the amount that Medicaid has paid in benefits for that member will be refunded to that member.
Terminate Medicaid eligibility for the individual who is not cooperating in providing TPL insurance information (see Section 9.1.2 TPL Cooperation), unless they have good cause (see Section 9.1.4 TPL Good Cause Claim).
To assign hospital or long-term care insurance payments, the member must complete the Long-Term Care Insurance Policy – Assignment of Benefits form (F-01567) that requests all current or future payments be made payable to the state of Wisconsin.
The member must send the completed Long-Term Care Policy-Assignment of Benefits form to his or her long-term care carrier and mail a copy to the following address:
Wisconsin DHS
TPL Unit
PO Box 6220
Madison, WI 53784-6220
The long-term care carrier must mail payments to the following address:
Wisconsin DHS
TPL Unit
PO Box 6220
Madison, WI 53784-6220
The assignment of payments includes all ongoing payments for as long as the member receives Medicaid. Terminate Medicaid eligibility for the individual who refuses to assign these payments.
In some cases, the insurance policy will require that payments be made directly to the patient or member. The member must forward these payments to the state of Wisconsin. Failure to forward any payment may result in the member losing his or her eligibility for not cooperating with providing TPL coverage and access information. When forwarding payments, the member must write on the back of the check “Pay to the order of the state of Wisconsin” and sign the check.
Members should mail payments, along with the corresponding EOB , to the following address:
Wisconsin DHS
TPL Unit
PO Box 6220
Madison, WI 53784-6220
Close the case for non-cooperation with TPL requirements if the member refuses to forward the third-party payments to the state.
This page last updated in Release Number: 15-02
Release Date: 07/30/2015
Effective Date: 07/30/2015
The information concerning the Medicaid program provided in this handbook release is published in accordance with: Titles XI and XIX of the Social Security Act; Parts 430 through 481 of Title 42 of the Code of Federal Regulations; Chapters 46 and 49 of the Wisconsin Statutes; and Chapters HA 3, DHS 2, 10 and 101 through 109 of the Wisconsin Administrative Code.
Notice: The content within this manual is the sole responsibility of the State of Wisconsin's Department of Health Services (DHS). This site will link to sites outside of DHS where appropriate. DHS is in no way responsible for the content of sites outside of DHS.
Publication Number: P-10030