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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/ |
If CARES Client Assistance for Re-employment & Economic Support is not available, the Health Insurance Information Form ( HCF 10115 ) can be used to collect insurance information. Complete a separate form for each insurance policy if a person has more than one. Listed below are some instructions for filling out this form.
IM/CS Blocks. If you can complete the form in its entirety, check IM. Do not check this box if you refer the form to Child Support for completion.
Added. Check the "Added" box when the policy in question has never been sent to EDS, and is not on their file. Complete the entire form.
Changed or Ended. Check the "Changed or Ended" box when altering information that is already on EDS's file and complete these items:
The shaded area on the top.
MA ID numbers and names of only those case members affected by the change. Date of birth is required. Relationship is not.
The insurance company name in Box 1.
The policy number in Box 6.
The policy start date in Box 9.
The information you want to change. For example, to report the date on which coverage terminated, enter the end date in Box 10.
Deleted. Check the "Deleted" box when removing insurance information.
Do not use a delete transaction in place of a change transaction when valid insurance coverage ends. Use it only if:
The insurance data put on the file was not valid during a period of MA eligibility, or
The information should never have been put on the file because, for instance, it is life insurance.
To change the policy number, the insurance company billing address, or the start date of coverage, send EDS:
A ( HCF 10115 ) marked "Delete" (on which you have deleted the incorrect information), and
A second ( HCF 10115 ) marked "Add" (on which you have added the correct information).
Staple the forms together. Mark on the delete copy in red "1 of 2". Mark on the add copy in red "2 of 2".
When you are submitting a delete form with an add form, complete the add form in its entirety.
For the delete transaction, complete the shaded area on the top.
In Section A, list the MA ID numbers and the names of only those case members affected by the delete and their date of birth.
Enter the insurance company name in Box 1.
Enter the policy number in Box 6.
Enter the policy start date in Box 9.
Policy Number. If the insurance ID card contains nothing but a group number, put the insured person's Social Security Number (SSN) in this space.
Policy Start Date. Use the effective date of the policy listed on the insurance ID card. If the date is not available, make the start date equal to or earlier than the start date of eligibility.
The policyholder’s SSN is voluntary. Failure to provide your SSN may result in a processing delay.
If a retired client has insurance through a former employer, list that former employer and the address, if available.
Send the original to:
EDS - TPL Unit
P.O. Box 7636
Madison, WI 53707-7636
This page last updated in Release Number : 02-04
Release Date : 10/01/02
Effective Date: 10/01/02
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