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Wisconsin Department of Health and Family Services Medicaid Eligibility Handbook |
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Wisconsin Department of Health and Family Services Medicaid Eligibility Handbook |
To be non-financially eligible for SC, an applicant must:
Be at least 65 years of age.
Be a Wisconsin resident.
A Wisconsin resident is an individual who meets at least one of the following criteria:
Has a permanent residence in Wisconsin.
Is considered a Wisconsin resident for tax purposes.
Is a registered voter in Wisconsin.
A SC participant may temporarily live outside the State of Wisconsin, as long as s/he maintains permanent residency in Wisconsin. Residency in a Wisconsin nursing home or an assisted living facility will meet this requirement.
Be a U.S. citizen or a qualifying legal alien
(3.2.2).
An applicant who is a resident alien will need to provide
a copy of both sides of his/her alien card and identify his/her country
of origin. If there are discrepancies between reported and verified
data, supporting legal documentation must be provided by the applicant.
When legal documentation is not available and SSA benefits have
been verified, this requirement has been met.
Verification of alien status can be made through the U.S.
Bureau of Citizenship and Immigration Services’ Systematic Alien Verification
for Entitlement ( SAVE ) program.
Provide a Social Security Number ( SSN ) or be
willing to apply for one (1.2.3.1).
Applications without the SSN will not be returned. Applicants will be contacted and given an opportunity to provide a SSN. Eligibility will not be confirmed until the SSN or proof of application for SSN has been supplied. If the SSN or the proof of application is not received within 30 days of application for SC, eligibility will be denied and any enrollment fee received will be refunded. The individual can reapply once they have their SSN. The Eligibility begin date will be based on the new application receipt date.
If a person requires assistance in obtaining a SSN, the SC Program will assist him/her in applying for one.
Not be a full-benefit MA recipient (7.1.2). This
includes participants who are covered by Family Care MA. (5.13.3)
Individuals are not considered MA recipients for SC if they have an unmet MA deductible (4.9) or receive one of the following:
Medicare premium assistance (5.14).
Family Care non-MA (5.13).
TB-related MA (5.11.7)
Emergency Services (3.2.3).
Not be an inmate of a public institution (1.1.2,
#4).
Cooperate with providing information and/or verification
necessary to determine eligibility (1.2.2) and for quality
assurance purposes.
If a person requires assistance in obtaining the required verification, the SC program will assist him/her.
If a person is not able to produce the required verification, and the SC program is not able to produce the required verification, the SC program may not deny assistance.
If a person is able to produce required verification but refuses or fails to do so, the application will be denied.
In addition to the non-financial requirements listed above, each applicant must pay a $30 annual enrollment fee. The enrollment fee must be paid prior to eligibility confirmation. When a participant reapplies for a new benefit period, a new enrollment fee is required.
When a SC enrollment fee check is returned for non-sufficient funds, the applicant is mailed a form letter and provided ten calendar days to submit a replacement check. If a replacement check is not received, a form letter giving another 10 days to replace the fee is sent to the participant. If the check is still not replaced, then the eligibility is terminated. A notice of decision is mailed to the participant. The termination date is 10 days after the notice of the decision (mail) date.
No Application Received
If CAPO receives a fee without an application a manual notice and application will be sent, if possible, to the individual from whom the fee was received. If an Application is not received by CAPO within 45 days of the receipt of the fee, a refund will be processed at the request of the person who submitted the fee.
Application Denied
Anytime an application for SC is denied, a refund of the paid enrollment fee is automatically issued. A refund may be requested prior to eligibility being confirmed or within specified timelines outlined below.
Opt out
Refunds are based on individual participation. A SC participant may receive an enrollment fee refund if s/he received an initial eligibility notification, but has not received any SC prescription drug benefits or services and requests to withdraw from the program (5.16.12.1).
In all opt-out cases, a refund will be issued only if the request to withdraw from the SC program is made by the later of:
Ten days following issuance of the eligibility notice, or
30 days from the application filing date.
The date by which a request for refund must be made will be printed on the initial eligibility determination notice. Filing of a hearing request will not delay these deadlines for refunds.
A refund may also be requested by the family member of a deceased participant when all the following criteria are met:
S/he received an eligibility notification, and
Death occurs prior to the start of or within 30 days of the beginning of the SC benefit period, and
The request is made within 10 days of the date of death; and
S/he had not received any SC prescription drug
benefits or services.
NOTE: If all of the above conditions are met, a refund will be issued even if the death is reported beyond the refund deadline date.
Once the opt-out of eligibility is confirmed, the participant will have 30-days to contact the CAPO if s/he chooses to “opt in” to the program. S/he would need to send another enrollment fee if the original enrollment fee has been refunded. A new application is not required to opt in.
A participant who decides after the 30-day period that s/he wants to rejoin the program will need to complete a new application and submit the enrollment fee.
A single applicant should apply for SC no sooner than 30 days before his/her 65th birthday.
When a couple applies where one spouse is 65 or older and the other is under 65 at the time of application, only the spouse that is 65 or older can be determined eligible. If both apply, the younger spouse would be denied SC unless s/he is turning 65 within 30 days. If the younger spouse will turn 65 within the 12-month enrollment period, s/he will receive a notice pending his/her eligibility for the enrollment fee approximately one month prior to his/her 65th birthday.
Applicants who have prescription drug coverage under other health insurance plans, including Medicare Parts A and B, may enroll in SC. SC is the payor of last resort except state funded only programs such as Wisconsin Chronic Disease Program ( WCDP ) and HIRSP.
SC will coordinate benefit coverage with all other health insurance coverage. SC may also coordinate benefits with pharmacies that accept discount cards. Questions about individual health insurance coverage should be directed to the health insurance company. Questions regarding insurance carriers should be directed to:
Office of Commissioner of Insurance
Bureau of Market Regulation
PO Box 7873
Madison, WI 53707-7873
1-800-236-8517
This page last updated in Release Number: 04-02
Release Date: 04/30/04
Effective Date: 04/30/04