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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 |
SC eligibility is terminated prior to the end of the established benefit period if:
A participant no longer meets non-financial eligibility
requirements, or
S/he requests to withdraw from the program, or
S/he requests to establish a new benefit period
and eligibility for the
new benefit period is confirmed (5.16.11).
When SC eligibility has been terminated prior to the end of the established benefit period and the SC Program is notified that all eligibility requirements are again satisfied, within one calendar month of SC eligibility termination, the benefit period is restored.
Exception: SC participants who lose SC eligibility solely due to receipt of MA benefits do not have their benefit period terminated; however, they are not eligible for SC benefits or services for the calendar months that they receive MA benefits.
If MA eligibility ends prior to the end of the SC benefit period, and the participant is still SC eligible, SC eligibility automatically resumes.
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Example: Amy applies for SC on October 4th and is determined eligible effective November 1st. In December she applies for MA and is determined eligible, effective December 1st. Amy is not eligible for SC benefits or services while she is receiving MA.
In January, Amy inherits $5,000 and is notified that her MA eligibility ends January 31st, because her assets exceed the limit. Amy still meets SC eligibility requirements, so SC eligibility will resume from February 1st through October 31st. |
See 5.16.15 for termination as it applies to the need for an annual review.
Applicants or participants may withdraw from the SC Program at any time. To withdraw by phone, call the SeniorCare Customer Service Hotline at 1-800-657-2038.
A request to withdraw can be made in writing to:
SeniorCare
P.O. Box 6710
Madison, WI 53716-0710
A SC participant is eligible for an enrollment fee refund only if s/he meets the requirements listed in 5.16.3.1.1.
If an applicant chooses to withdraw his/her application prior to eligibility confirmation, s/he will get a refund. If s/he later wishes to “opt in”, s/he will have to re-apply. To re-apply, a new application and enrollment fee are required.
Once eligible, if a participant chooses to “opt-out” and does so within the timeframe for obtaining a refund, s/he will get a refund of the original enrollment fee. If, within thirty calendar days of opting out, the participant requests to opt in, s/he would need to send in another enrollment fee but would not have to send in another application form. Eligibility will be restored back to the beginning of his/her benefit period, once the fee is received and processed.
The enrollment fee must be received by the deadline identified in the CARES notice to comply with the administrative rule requirement that s/he meets eligibility requirements. If within thirty calendar days of opting out s/he does not contact SC and SC does not receive the enrollment fee, s/he will have to submit a new application and another $30 enrollment fee if s/he wants to come back into the program.
If the participant chooses to opt-out and does not do so within the timeframe for obtaining a refund, s/he will not get a refund. Customer Service should counsel the participant that s/he will not be getting a refund, and s/he can keep his/her case open in the event his/her circumstances change and s/he wants to use the SC benefit in the next 12 months.
If the participant still opts out, but contacts SC within thirty calendar days of opting out to request to opt in, the original enrollment fee that had not been refunded will be applied. S/he will not have to send in another application form. The person will be made eligible back to their original eligibility begin date for that benefit period. This requires a manual work-around because the system will require another $30 enrollment fee to be credited for CARES to process correctly.
This page last updated in Release Number: 04-02
Release Date: 04/30/04
Effective Date: 04/30/04