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Wisconsin Department of Health and Family Services Obsolete Medicaid Eligibility Handbook For the current MEH, see http://www.emhandbooks.wi.gov/meh-ebd/ For the current BC Plus Handbook, see http://www.emhandbooks.wi.gov/bcplus/ |
5.16.3.1.2 Refunds to Deceased Participants
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:
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).
SC prescription drug benefits include use of the SC card to receive discounted drug prices in levels 1, 2a, and 2b. A refund may be issued if such charges are reversed by the pharmacy.
Use of the SC card at Level 3 where a spenddown has not been met constitutes receipt of SC prescription drug services. A refund may be issued if such claims are reversed by the pharmacy.
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Example 1: Henry was a SC participant at Level 1 whose benefit period began 12/01/04. Henry passed away on 12/04/04. His daughter reported Henry’s death to the SC program on 12/10/04 and requested a refund of his $30 enrollment fee. Henry’s SC card had been used on 12/01/04 to purchase a prescription, however the pharmacy had reversed those charges on 12/05/04 since Henry’s prescription had not been picked up. The $30 enrollment fee should be refunded in this case since Henry did not receive any SC prescription drug benefits or services. |
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Example 2: Julie is a SC participant at Level 2b. Julie’s SC application filing date was 10/26/04 and her benefit period began 11/01/04. On 11/15/04 Julie calls SeniorCare Customer Service Hotline to withdraw from the SC program and request a refund of her $30 enrollment fee. Julie used her SC card on 11/10/04 when she purchased a prescription. Although Julie requested a refund within 30 days of her application filing date, she is not entitled to a refund, because she received her prescription at a discounted cost by using her SC card. |
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Example 3: Mike is a Level 3 SC participant . Mike’s SC application filing date was 10/28/04 and his benefit period began 11/01/04. On 11/20/04, Mike requests to withdraw from the SC program and that his $30 enrollment fee be refunded to him. Mike used his SC card on 11/18/04 when he purchased a prescription, however, he had not met his Level 3 spenddown, so he did not receive a discounted price for his prescription. Mike is entitled to a refund of his enrollment fee if the pharmacy reverses this prescription claim. He made the refund request within 30 days of his application filing date and he has not received any SC prescription drug benefits or services. If the claims are not reversed, Mike is not entitled to a refund. |
In all opt-out cases, a refund will be issued only if the request to withdraw from the SC program is received 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 received 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 45 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 the calendar month 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 the current or next calendar month. 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: 06-01
Release Date: 03/13/06
Effective Date: 03/13/06