Policy History for 5.16.10 Changes

rELEASE 05-01

 

5.16.10 Changes

The following changes must be reported to the SC Program within ten days:

 

  1. Address.

  2. Household Composition (examples include marriage, divorce, separation)

  3. Death.

 

Changes may be reported by phone to the SeniorCare Customer Service Hotline at 1-800-657-2038.

 

Changes may also be reported by writing to:

SeniorCare

P.O. Box 6710

Madison, WI 53716-0710

 

Participants are asked to include an SSN on any written correspondence.

 

If a participant reports any changes before the case has been confirmed in CARES Client Assistance for Re-employment & Economic Support, the new information will be used in his/her SC eligibility determination.

 

Changes reported after the case has been confirmed in CARES will be applied to the participant’s SC benefits as follows:

 

  1. Address change:
     

    1. Reports of address changes within Wisconsin will result in SeniorCare notices being sent to the new address.  SC benefit levels will not change for the current benefit period.
       

    2. Address changes that result in termination of Wisconsin residency result in discontinuation of SC benefits.  Provide the participant with at least 10 days notice before the effective date of an adverse action.  

      Note:        Reporting an out-of-state address does not necessarily signify that an applicant is not a Wisconsin resident (5.16.3).

 

  1. Death

 

A participant’s death ends SC eligibility on the date of death.  A 10-day notice for adverse action is not required when an adverse action is the result of a participant‘s death.  The “early termination date” for the participant should be equal to the participant’s date of death.

 

If a participant’s spouse dies, the participant will remain eligible at the same benefit level through the current SC benefit period.  The participant may wish to re-apply to establish a new benefit level if the spouse’s death will result in a reduction in income Income is anything you receive in cash or in kind that you can use to meet your needs for food, clothing, and shelter..

 

  1. Change in household composition
     

If a participant experiences a change in household composition, the SC benefit level will not change through the remainder of the SC benefit period. The participant may wish to re-apply to establish a new benefit level if the change in household composition will result in a better level of participation.

 

  1. Inmate of a public institution (1.1.2).
     

An inmate of a public institution is ineligible for SC on the date incarceration begins.  Provide the participant with adequate notice before the effective date of the adverse action.  The “early termination date” is equal to the notice mailing date.
 

If a participant’s spouse is an inmate of a public institution the participant benefit level will remain the same through the current benefit period.  The participant may wish to re-apply to establish a new benefit level if the spouse’s incarceration will result in a better level of participation.
 

  1. Change in Circumstance
     

An applicant who wishes to change or correct information on his/her submitted application may do so prior to eligibility being confirmed in CARES.
 

Depending on the nature of a client-reported error or agency discovered error, a participant’s eligibility will be re-determined (5.16.10.1).  Provide the participant with at least 10 days notice before the effective date of an adverse action.  If the case has already been confirmed in CARES, the applicant may opt out and reapply if s/he so desires.

 

Example:  Sally and Fred are husband and wife and applied for SC in July.  Both Sally and Fred were found eligible with a deductible (Level 2a) for August.  In September, Fred loses his job.  He reports the change to the SC program.  This change will not affect Sally or Fred’s SC benefits, because Fred reported the change after his case had been confirmed in CARES.  In order to have eligibility redetermined Fred and Sally will need to file a re-application (5.16.11) and submit enrollment fees for each.  Without the income from Fred’s job, Sally and Fred would be able to purchase prescription drugs at the co-payment level, if a reapplication is filed.

 

If Fred had reported the change prior to his case being confirmed in CARES, the change would have been applied to Sally and Fred’s eligibility determination, and they would have paid the co-payment amounts for prescription drugs.  If Fred and Sally wish, they may request to file a reapplication (5.16.11) to change their benefit level.

5.16.10.1 Correction of Errors

All errors made on the SeniorCare Application (HCF 10076) must be reported by the participant or his/her Authorized Representative, POA, or Guardian to the SeniorCare Customer Services Hotline at 1-800-657-2038 (TTY and  translation services are available) or in writing to:  

 

SeniorCare

P.O. Box 6710

Madison, WI 53716-0710

 

An error may include, but is not limited to:

 

  1. Doubling of income (totaling income on the application).
     

  2. Income amounts are off by a factor of 100. (lack of decimal)
     

  3. Application processing errors.
     

An applicant who wishes to change/correct information on his/her submitted application may do so prior to eligibility being confirmed in CARES (5.16.10).
 

If a participant has been found eligible for either an incorrect SC benefit level or spenddown amount due to an error, action will be taken to correct the mistake.  The effective date of the correction is based on whether the error is determined to be Agency Error or Applicant /Participant error, as follows:

5.16.10.1.1 Agency Error

Agency Error for SC will be determined on a case by case basis.  If the error resulted in an overpayment, past benefits are not recoverable. If the error resulted in an underpayment, corrected benefits will be restored back to initial eligibility date of the benefit period.

5.16.10.1.2 Applicant/Participant Error

If the error resulted in an overpayment, benefit recovery will Error be pursued and the correction is processed with an effective date based on adverse action notice. Provide the participant with at least 10 days notice before the effective date of an adverse action.

 

If the error resulted in an underpayment and s/he reported the error within 45 days of the mail date of the notice of decision, restore corrected benefits back to the initial eligibility date of the benefit period.  If the error is not reported within 45 days of the notice of decision mail date, the effective date of the correction is the first of the month in which the error is reported.

 

Example 1:  In August, Charlie lost this job at the Burger Palace.  In September Charlie applied for SC.  In his application Charlie erroneously reported income of $1150 per month from the Burger Palace job.,   Charlie’s notice of decision had a mail date of  October 1, and stated that Charlie had a $1500 spenddown.

 

Depending on when Charlie reports this error his benefits may be corrected back to the eligibility begin date or the first month in which the error was reported. (5.16.10.1).  

 

If he reported the error by November 15, within the first 45 days after the notice of decision mail date, his benefits would be corrected back to the original effective date.

 

If he reported the error November 16 or later (more than 45 days after the notice of decision mail date), the benefit level change would be made effective the first of the month in which the error was reported.

 

Example 2:  Eric applied for SC in July and was determined eligible at level 1 effective August 1st.  Prior to applying for SC, Eric got a part-time job that had begun in June.  When Eric applied for SC, he neglected to report his anticipated part-time earnings on the SC application.

 

Eric receives his notice of decision, dated August 8th.  The notice informs he is eligible at level 1.  Eric reviews the income used in his eligibility determination that is printed in the notice.  Eric realizes that he forgot to report his earnings from his part – time job and he calls the CS Hotline on August 21 to report his error.

 

Eric reports to the CS Correspondent that he is working 10 hours per week and earns $10 per hour.  He plans to keep the job as long as possible.  He estimates that his earnings will be $5200 for his 12-month benefit period.  The only other income that Eric receives is Social Security.  His earnings in addition to the annual Social Security income add up to an annual estimated income of $19,700.  Or level 2b.

 

Since the income correction will result in a negative impact on his eligibility,  the effective date of the corrective benefit is October 1, providing Eric with a 10-day notice of the negative action in his case.

 

Prior to reporting this mistake, Eric had purchased several prescriptions at the co-pay levels with his SC Card.  Since the correction resulted in Eric’s eligibility at level 2b, he must now meet an $850 deductible between October 1 and July 31 ( the end of his 12- month benefit period),  SC will have overpaid Eric’s benefits and could seek recovery of the overpaid amount.

5.16.10.2 Fraud

Fraud is defined as intentionally getting or helping another person get benefits to which s/he is not entitled.  Penalties for fraud include a fine of up to $10,000, imprisonment up to one year, or both, and suspension from the SC program.

 

Fraudulent acts include:

 

  1. Intent to provide misleading, fraudulent, omitted, or incomplete information on the SC application;

  2. Not reporting an event that knowingly affects initial or continued eligibility for SC;

  3. Applying for SC on behalf of another person and use of any part of the benefit for oneself; or

  4. Allowing another person to use someone else’s card to get prescription drugs.

 

This page last updated in Release Number: 04-02

Release Date: 04/30/04

Effective Date: 04/30/04