Wis. Admin. Code Department of Health Services DHS 102.04 - Eligibility determination

(1) DECISION DATE.

(a) As soon as possible but not later than 30 days from the date the agency receives a signed application completed to the best of the applicant's ability, the agency shall determine the applicant's eligibility for MA.

(b) If medical examination reports are needed to determine disability or blindness, the agency shall make the disability decision no later than 60 days from the date the agency receives the signed application.

(c) If a delay in processing the application occurs because of a delay in securing necessary information, the agency shall notify the applicant in writing of all of the following:

1. That there is a delay in processing the application.

2. The reason for the delay.

3. The applicant's right to appeal the delay under s. 49.45 (5), Stats.

(2) NOTICE OF DECISION. The agency shall send timely and adequate notice to applicants and recipients to indicate that MA has been authorized or that it has been reduced, denied or terminated. In this subsection, "timely" means in accordance with 42 CFR 431.211, and "adequate notice" means a written notice that contains a statement of the action taken, the reasons for and specific regulations supporting the action, and an explanation of the individual's right under s. 49.45 (5), Stats., to request a hearing and the circumstances under which benefits will be continued if a hearing is requested.

(3) REVIEW OF ELIGIBILITY. A recipient's eligibility shall be redetermined in any of the following circumstances:

(a) When information previously obtained by the agency concerning anticipated changes in the individual's situation indicates the need for redetermination.

(b) Promptly after a report is obtained which indicates a change in the individual's circumstances that may affect eligibility.

(c) In accordance with sub. (5), no more frequently than once every 12 months for persons eligible for BadgerCare Plus or MA under s. 49.46 (1) (a)15. or 49.47 (4) (a) 1., Stats.

(d) At least every 12 months for SSI-related persons and persons eligible for the medicaid purchase plan, in accordance with sub. (4), except that when a person is determined to be permanently blind or disabled the agency may consider their blindness or disability as continuing until it is determined that they are no longer blind or disabled.

(e) At any time the agency has a reasonable basis for believing that a recipient is no longer eligible for MA.

(5) PROCEDURES FOR REVIEWING ELIGIBILITY.

(a) A review of eligibility under sub. (3) (c) or (d) shall be conducted without requiring information from the individual if the agency is able to do so based on reliable information contained in the recipient's case record or more current information available to the agency, including but not limited to information accessed through data bases accessed by the agency.

(b) If the agency is able to redetermine eligibility based on such information, the agency shall notify the recipient of all of the following:

1. The eligibility determination and basis.

2. The requirement that the recipient must inform the agency if any of the information contained in such notice is inaccurate, but that the recipient is not required to sign and return such notice if all information provided on such notice is accurate.

(c) If the agency cannot redetermine eligibility in accordance with par. (a), the agency shall do all of the following:

1. Provide the recipient with all of the following:

a. A renewal form containing information available to the agency that is needed to renew eligibility.

b. At least 30 days from the date of the renewal form to respond and provide any necessary information and to sign the renewal form.

c. Notice of the agency's intended action concerning the renewal of eligibility.

2. Verify any information provided by the recipient.

3. Reconsider in a timely manner the eligibility of a person who is terminated for failure to submit the renewal form or necessary information, if the person subsequently submits the renewal form within 90 days after the date of termination without requiring a new application.

Notes

Wis. Admin. Code Department of Health Services DHS 102.04

Cr. Register, February, 1986, No. 362, eff. 3-1-86; emerg. am. (2) and (3) (c), eff. 7-1-99; am. (2) and (3) (c), Register, March, 2000, No. 531, eff. 4-1-00; am. (3) (d), Register, November, 2000, No. 539, eff. 12-1-00; correction in (1) made under s. 13.93(2m) (b) 7, Stats., Register February 2002 No. 554. Amended by, CR 21-067: cr. (4) Register March 2022 No 795, eff. 4-1-22, r. (4) eff. the first day of the month after the emergency period, as defined in 42 USC 1320b-5(g) (1) (B) and declared in response to the COVID-19 pandemic, ends; correction in (4) made under s. 35.17, Stats., Register March 2022 No. 795, eff. 4/1/2022 Amended by, CR 23-046: r. and recr. (1), am. (3) (intro.), (a) to (d), cr. (5) Register April 2024 No. 820, eff. 5-1-24; renumbering of (5) (b) to (5) (c) made under s. 13.92 (4) (b) 7, Stats., and correction in (5) (c) made under s. 35.17, Stats., Register April 29 No. 820, eff. 5/1/2024

Sub. (4) is repealed by CR 21-067 effective the first day of the month after the emergency period, as defined in 42 USC 1320b-5(g) (1) (B) and declared in response to the COVID-19 pandemic, ends.