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Wisconsin Department of Health and Family Services |
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Wisconsin Department of Health and Family Services |
2.1.3.1 Assistance in Applying
2.1.3.1.1 Durable Power of Attorney
2.1.3.2.1 Intercounty Placements
2.1.3.2.2 Applications Outside Wisconsin
2.1.3.5 Signing the Application
2.1.3.5.1 Authorized Representative
2.1.3.5.2 Guardian or Conservator
2.1.3.5.3 Witnessing the Signature
2.1.3.5.4 Spousal Impoverishment Cases
A valid application for a subprogram of MA must include the client’s:
Name, and
Address, and
Signature in the Rights and Responsibilities section
of a MA application.
The date the application is received by the Economic Support Agency ( ESA ) with the client’s name, address and signature is the filing date. The 30-day processing timeframe begins on the filing date.
However, non-financial and financial information is needed to determine eligibility. Collect any other necessary information before approving or denying the application.
The client may be assisted by any person s/he chooses in completing an application. Any person that s/he chooses to apply on his/her behalf must be designated as an authorized representative (IMM, Ch. I, Part A, 18.3.0).
The client may have a guardian or conservator (IMM, Ch. I, Part A, 19.0.0) complete the application for him/her. Ensure that any person claiming to be a guardian or conservator is authorized to apply on the client’s behalf.
Assist the client in completing the application if s/he needs assistance. When a client contacts the incorrect agency for him/her, redirect him/her to the correct agency immediately. If the contact is an application form received by mail or fax, send the application form to the correct location within the same day or the next working day after receipt. Remember, if the application is faxed the same day the application is received, the filing date is preserved.
A client's Durable Power of Attorney may appoint an authorized representative (2.1.3.5.1) for purposes of making a Medicaid application if authorized on the power of attorney form. The Durable Power of Attorney Form will specify what authority is granted.
The appointment of a Durable Power of Attorney does not prevent a client from filing his/her own application for Medicaid nor does it prevent the client from granting authority to someone else, to apply for public assistance on his/her behalf.
The client must apply in the county in which s/he resides. A client who resides in a nursing home/hospital for 30 days or more and will have their Medicaid eligibility determined as an instituionalized case is a resident of the county in which the nursing home/hospital is located.
The client’s county of residence at the time of admission must receive and process applications for persons in these state institutions:
Northern, Central, and Southern Centers.
Winnebago and Mendota Mental Health Institutes.
The University of Wisconsin Hospital.
Waupaca County receives and processes all applications and reviews for residents of the Wisconsin Veterans Home at King, regardless of the county of residence.
When a county 51.42 board, 51.437 board, human services department or social services department places a person in a congregate care facility that is located in another county, the placing county remains responsible for determining and reviewing the client’s MA eligibility. A congregate care facility is a:
Child care institution.
Group home.
Foster home.
Nursing home.
Adult Family Homes ( AFH ).
Community Based Residential Facility ( CBRF ).
Any other like facility.
The placing county may request the assistance of the receiving county in completing applications for clients who are not MA certified and reviews for MA recipients. The receiving county must then forward the information to the placing county. The placing county remains responsible for determining the client’s eligibility. If the placing county requests assistance from the receiving county, the placing county must provide the other agency with:
The client’s name, age, and SSN.
The date of placement.
The client’s current MA status.
The name and address of the congregate care facility in which the person has been placed.
The name of the county and agency making the placement.
When there is a dispute about responsibility, the social or human services department of the receiving county may initiate referral to the Department of Health and Family Services (DHFS Area Administration) office for resolution. Pending a decision, the county where the person is physically present must process the application, any changes, and reviews.
Generally, an application should not be taken for a resident of Wisconsin when an individual is outside of Wisconsin. An exception is when a Wisconsin resident becomes ill or injured outside of the state or is taken out of the state for medical treatment. In this case, the application may be taken, using Wisconsin’s application forms (2.1.4.5.1), by the public welfare agency in the other state. The Wisconsin ESA determines eligibility when the forms are returned.
The client must sign the application form with his/her regular signature or with a mark except when:
A guardian signs for him/her. When
an application is submitted with a signature of someone claiming to be
the client’s guardian, obtain a copy of the document that designates the
signer of the application as the guardian. From
the documents provided, ensure that the individual claiming to be the
client’s guardian can file an application on his/her behalf (2.1.3.5.2). File
the copy of the document in the case record.
An authorized representative signs for the client
(2.1.3.5.1).
Someone acting responsibly for the client signs the form on behalf
of the client, if the client is incompetent or incapacitated.
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Example: Carl is in a coma in the hospital. Sherry, a nurse that works at the hospital, can apply for MA on Carl’s behalf. |
A superintendent of a state mental health institute
or center for the developmentally disabled signs on behalf of a patient.
A Warden signs the application for a client that
is an inmate of a state correctional institution that is out for more
than 24 hours (3.1.9.1).
The director of a county social or human services
department delegates, in writing (retain a copy of this written authorization),
to the superintendent of the county psychiatric institution the authority
to sign and witness an application for residents of the institution.
The social or human services director may
end the delegation when there’s reason to believe that the delegated authority
is not being carried out properly.
The client’s durable power of attorney (§
243.07, Wis.
Stats.) signs the application. A
durable power of attorney is a person to whom the client has given power
of attorney authority and agrees that the authority will continue even
if the client later becomes disabled or otherwise incapacitated.
When a submitted application is signed by
someone claiming to be the client’s durable power of attorney:
Obtain a copy of the document the client used
to designate the signer of the application as the durable power
of attorney.
Review the document for a reference that indicates
the power of attorney authority continues notwithstanding any subsequent
disability or incapacity of the client.
Do not consider the application properly signed unless both of these conditions are met. File a copy of the document in the case record.
The client may authorize someone to represent him/her (IMM, Ch. I, Part A, 18.3.0).
If the client wishes to authorize someone to represent him/her when applying by mail, instruct him/her to complete the authorized representative section of the application form.
If the client needs to appoint an authorized representative when applying by telephone or in person, instruct the client to complete the Medicaid Authorization of Representative form ( HCF 10126 ).
An authorized representative is responsible for submitting the signed application (completed insofar as able) and any required documents.
When appointing an authorized representative, someone other than the authorized representative must witness the client’s signature. If the client signs with a mark, two witness signatures are required.
Your agency’s social services department determines the need for a guardian or conservator (IMM, Ch. I, Part A, 19.0.0). Determine the guardian type specified by the court.
Only the person designated as the guardian of the estate (IMM, Ch. I, Part A, 19.2.0), guardian of the person and the estate, or guardian in general may sign the application. You may not require a conservator (IMM, Ch. I, Part A, 19.4.0) or guardian of the person (IMM, Ch. I, Part A, 19.1.0) to sign the application.
For mail and telephone applications, as well as reviews, the application form does not require an agency staff person to witness the signature. It does not affect the State of Wisconsin’s ability to prosecute for fraud nor does it prevent the MA program from recovering benefits provided incorrectly due to a client’s misstatement or omission of fact.
Two witnesses are required when the application is signed with a mark.
All spousal impoverishment MA applications and reviews require the signatures of both the institutionalized person and the community spouse, or of another authorized person (IMM, Ch. I, Part A, 18.0.0).
If the institutionalized person 's signature is missing, deny the application.
If the community spouse's signature is missing, test the institutionalized person's eligibility as if s/he were unmarried unless one or more of the following conditions exists:
The institutionalized person assigns to the state
all rights to support from the community spouse.
The institutionalized person is not able to make
an assignment of support from the community spouse because the institutionalized
person is physically or mentally impaired, and
The ESA
has the right to bring a support proceeding against the community spouse
without an assignment.
The denial of eligibility will be an undue hardship
for the institutionalized person (5.10.4.4).
If one or more of the above conditions exists, test the institutionalized person's eligibility using spousal impoverishment policies.
When policy requires a witness to the institutionalized person's signature (IMM, Ch. I, Part A, 18.1.0 and IMM, Ch. I, Part B, 8.0.0), the community spouse's signature must also be witnessed.
This page last updated in Release Number : 05-02
Release Date: 05/10/05
Effective Date: 05/10/05
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