Policy History for 5.17.6 APPLICATION

Release 06-01

5.17.6 APPLICATION

5.17.6.1 Applications for Wisconsin Well Woman Medicaid by Family Planning Waiver participants

To apply for Wisconsin Well Woman Medicaid, through the Wisconsin Well Woman Program, the client must send or bring the completed DPH 4818 and HCF 10075 forms to her local ES agency.  The client may apply for Wisconsin Well Woman Medicaid at any time after the client’s WWWP screening diagnosis.  ES may only back-date the client’s eligibility to the first of the month up to three months prior to the application date, or the first of the day after the date of diagnosis occurs, whichever is later.

Use the two forms listed in 5.17.5 in place of the standard application forms.  Do not enter the woman's information into CARES Client Assistance for Re-employment & Economic Support for purposes of Wisconsin Well Woman MA eligibility, as the program requires manual determination.
 

The date of receipt of the HCF 10075 is the filing date.  Use the verification policy listed in  chapter 1.2 for any items requiring verification.

Complete the following steps to certify a client for Wisconsin Well Woman Medicaid:
 

1. Review DPH 4818 for a “No” answer to the following questions:
    

1. Does the client have any health insurance? (Item #32)

If the client answers “Yes,” determine if the insurance is one of those listed in 5.17.2.1.  If “Yes,” the woman is ineligible for Wisconsin Well Woman Medicaid.  Refer her to the WWWP, and send a manual negative notice.

2. Does the client have Medicare Part B? (Item #33)

and

Ask the client if she has Medicare Part A.

If the client answers “Yes” to either of the other questions, the client is ineligible for Wisconsin Well Woman Medicaid.

2. Review DPH 4818 to ensure that the following fields have been completed: 1-5, 9-13, 16-25, 27-45.
    

If the form is incomplete, request that the client provide any missing information.  If the client does not provide all necessary information, there may be a delay in benefits.
 

3. Review HCF 10075 for a SSN.  If the SSN is missing from HCF 10075 and is not present on DPH 4818 (#6a), ask the client to provide her SSN and enter it on HCF 10075.  Providing an SSN for the WWWP is voluntary, but providing a SSN, or applying for one, is required for Wisconsin Well Woman Medicaid.

If the client fails to provide a SSN, or fails to apply for a SSN (IMM, Ch. I, Part C, 8.4.3.1) within the 30-day application processing time or within ten days (whichever is later), send a manual negative notice to the client indicating that the she is not eligible for Wisconsin Well Woman Medicaid.

4. Ask the client if she is a citizen.

If the client is not a citizen, ask her what her alien status is and to provide her alien registration card.  Verify that the client is in a qualified alien status using the SAVE system (IMM, Ch. I, Part D, 4.0.0).

Note: Some clients 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 alien has been screened for WWWP, determine her eligibility for emergency services using the criteria in 3.2.3.

5. If there are any questionable items, contact the WWWP Local Coordinating Agency.

6. Submit a HCF 10110 (formerly DES 3070) with a medical status code of “CB” to certify any client who has met the criteria listed above.  Submit the completed HCF 10110 to EDS through one of the following methods:

1. Mail:
   
   EDS Attn:  Eligibility Lead Worker WWWMA

6406 Bridge Rd

Madison, WI  53716

2. E-mail:  eds_3070@dhfs.state.wi.us

When submitting an e-HCF 10110 (formerly DES 3070), enter “

Attn:  Eligibility Lead Worker WWWMA” in the “Comments” section.

3. FAX:  (608) 221-8815

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

1. Up to three months prior to the filing date, or
    

2. To the first day of the month in which the date of the diagnosis occurs ( HCF 10075 ), or

Note: Only for women entering WWWMA through the Wisconsin Well Woman Program backdate to the day following the diagnosis date.

If the client applies during her PE Wisconsin Well Woman Medicaid period, and you are not able to process her application within the 30-day processing time frame, extend her eligibility for an additional 30 days from the last day of her Wisconsin Well Woman Medicaid PE ( HCF 10075 “Comments” section) with a medical status of “CB.”

To contact the Local Coordinating Agencies refer to #27 of DPH 4818.

5.17.6.1 Applications for Wisconsin Well Woman Medicaid by Family Planning Waiver participants

A Wisconsin Well Woman Medicaid Determination form (HCF 10075) submitted by a FPW participant is a  request to enroll in WWWMA and dis-enroll in FPW.

Women 15-44 years of age, enrolled in FPW in CARES who meet the following criteria, will be eligible for WWWMA.  These are women who:
 

• Are screened for, and diagnosed with, cervical cancer or precancerous condition of the cervix through the FPW.
   

or
 

• Receive a clinical breast exam through FPW and through follow up medical testing independent of the FPW are diagnosed with breast cancer.
  
  and
   

• Are found to be in need of treatment for breast or cervical cancer or a precancerous cervical condition as determined by their physician.
  
   

\This page last updated in Release Number : 05-01

Release Date: 01/11/05

Effective Date: 01/11/05