Wis. Admin. Code Department of Health Services DHS 109.11 - Application and determining eligibility

(1) CONDITIONS FOR ELIGIBILITY. A person who meets all of the following requirements shall be eligible for SeniorCare and shall be issued a prescription drug card for use in purchasing prescription drugs:

(a) The person is a resident of the state of Wisconsin as defined in s. 27.01(10) (a), Stats. The temporary absence of a resident from the state shall not be grounds for denying or terminating SeniorCare eligibility unless another state has determined the person is a resident in the other state for purposes of medical assistance.

(b) The person is at least 65 years of age.

(c) The person is not a recipient of medical assistance, or as a recipient, does not receive prescription drug coverage. Persons who only receive Medicare buy-in benefits under s. 49.468, Stats., 42 USC 1396a(a)(10)(E), or 42 USC 1396u-3, are not considered a medical assistance recipient under this chapter.

(d) The person pays the program enrollment fee specified in s. DHS 109.16.

(e)

1. Except as provided in subd. 2., the person requesting SeniorCare benefits has a social security number and furnishes the number to the department.

2.

a. If an applicant does not have a social security number, the applicant or a person acting on behalf of the applicant shall apply to the federal social security administration for a number. The department may not deny or delay services to an otherwise eligible applicant pending issuance or verification of the individual's social security number.

b. If the applicant or a person acting on behalf of an applicant refuses to furnish a number or apply for a number, the applicant shall be ineligible for SeniorCare.

(f) The person is a U.S. national or an alien legally residing in the U.S. and whose status qualifies them for medical assistance under 8 USC 1611 through 8 USC 1613, except that an alien whose status would qualify them only for emergency medical assistance benefits under 42 USC 1396b(v)(3) is not eligible for SeniorCare.

(g) The applicant, participant, or person described in sub. (2) (d) who is acting on behalf of the applicant or participant provides correct and truthful information as specified under sub. (2) (c).

(h) The person is not an inmate of a public institution as defined in 42 CFR 435.1009.

(2) APPLICATION FOR SENIORCARE. Application for SeniorCare shall be made pursuant to s. 49.688, Stats., and this chapter. Applications shall be made and reviewed by the department in accordance with the following provisions:

(a) Right to apply. Any person may apply to the department for SeniorCare on a form prescribed by the department.

Note: Application forms for SeniorCare are widely available through various local agencies. A copy of the application form is also available at the Department's Internet web site at: http://dhs.wisconsin.gov.

(b) Access to information. The department shall provide information, in writing or orally, as appropriate, to persons inquiring about or applying for SeniorCare: coverage; conditions of eligibility; scope of the program and related services available; and applicant and participant rights and responsibilities.

(c) Providing correct and truthful information. The applicant, participant, or person described in par. (d) acting on behalf of the applicant or participant shall provide to the department full, correct and truthful information necessary for eligibility determination, redetermination, or for processing SeniorCare prescription claims, including health insurance policies or other health care plans and claims or causes of action against other parties on the part of the applicant or participant. The applicant, participant, or person described in par. (d) acting on behalf of the applicant or participant shall report changes in circumstances that may affect eligibility to the department within 10 calendar days of the change.

(d) Signing the application. The applicant or the legal guardian, authorized representative or, where the applicant is incompetent or incapacitated, someone acting responsibly for the applicant, shall sign each application. Two witnesses shall also sign the application when the applicant signs the application with a mark.

(3) REFUSAL TO PROVIDE INFORMATION. If an applicant refuses or fails to provide information necessary for the determination of SeniorCare eligibility, the department shall deny eligibility to the applicant or participant and the spouse of the applicant or participant.

(4) DEPARTMENT VERIFICATION OF INFORMATION.

(a) The department may verify information provided by the applicant in the application under sub. (2) under any of the following circumstances:

1. The applicant has been convicted of public assistance-related fraud.

2. The applicant is repaying aid determined to be previously owed by the applicant pursuant to an agreement with the district attorney's office.

3. The applicant is known to have provided erroneous information on a previous SeniorCare or medical assistance application that resulted in an incorrect issuance of medical assistance or SeniorCare assistance.

(b) The department may verify the following information about the applicant, participant or an ineligible spouse who is in the fiscal test group:

1. Income.

2. Health insurance coverage as defined in s. DHS 101.03(69m) and other plans that provide prescription benefits.

3. Age.

4. Residence.

5. Social security number.

6. Citizenship or alien status.

(c) The department shall deny or terminate an applicant's or participant's SeniorCare eligibility if the applicant or participant is able to produce required verifications but refuses or fails to do so. If the applicant or participant cannot produce verifications, or requires assistance to do so, the department may not deny eligibility to the applicant or participant, but shall proceed immediately to verify the data elements in par. (b).

(5) ELIGIBILITY DETERMINATION PROCESS.

(a) Decision date.

1. Except as provided in subd. 2., the department shall determine the applicant's eligibility for SeniorCare as soon as possible, but not later than 30 days from the date the department receives a signed application that contains, at a minimum, the name and address of the applicant.

2. If a delay in processing the application occurs because of a delay in securing necessary information, the department shall notify the applicant in writing that there is a delay in processing the application, specify the reason for the delay, and inform the applicant of his or her right under s. DHS 109.17 to appeal the delay.

(b) Notice of Decision.

1. Except as provided under subd. 2., the department shall send timely and adequate notice to an applicant or participant to indicate that the applicant's or participant's participation in SeniorCare has been authorized, reduced, denied or terminated. In this paragraph, "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 rules supporting the action, and an explanation of the individual's right to request a hearing under s. DHS 109.17, and the circumstances under which the benefits and services under s. DHS 109.13 will be continued if a hearing is requested.

2. When the department determines a prescription drug billing must be corrected due to an incorrect billing, and that correction results in a change in the benefits and services received under s. DHS 109.13, the timely notice requirements under subd. 1. do not apply.

(c) Withdrawal of application. Except as provided in par. (d), an applicant may withdraw a SeniorCare application and request a refund of the enrollment fee in s. DHS 109.16 at any time before the department has made an eligibility determination.

(d) Withdrawal from program.

1. Deadline for refund of enrollment fee. An applicant who is notified that he or she is eligible for SeniorCare and who has not received any SeniorCare prescription drug benefit or service described in s. DHS 109.13 may request to withdraw the application and receive a refund of the enrollment fee in s. DHS 109.16 up to the latter of the following:

a. Ten days following the issuance of the eligibility notice.

b. Thirty days from the date the application was filed.

2. A recipient may ask to withdraw from the program after the deadline in subd. 1., but will not receive a refund of the enrollment fee.

3. The effective date of a withdrawal under this paragraph will be the date the department issues a notice of decision concerning the withdrawal.

(e) Applications during program suspensions. If the department makes the determination under s. 49.688(7) (b), Stats., to suspend benefits and services for new applicants or the entire program, the department shall continue to process applications and determine eligibility while the suspension is in effect.

(6) REVIEW OF ELIGIBILITY. The department shall redetermine a SeniorCare participant's eligibility any time one of the following conditions is met:

(a) Promptly after the department learns of a change in the person's circumstances that may affect eligibility or indicates the need for redetermination.

(b) Within 12 months after the date the person has been determined to be eligible as part of the annual review conducted under s. DHS 109.14(7).

(c) At any time the department has a reasonable basis for believing that a participant is no longer eligible for SeniorCare.

(d) When the department learns that the program enrollment fee payment has been returned for non-sufficient funds and the recipient fails to provide the enrollment fee within 10 days of the date the department sends a letter requesting payment.

(e) Paragraphs (a) to (d) shall not be enforced until the first day of the month following the end of the emergency period defined in section 1135 (g) (1) (B) of the Social Security Act, 42 USC 1320b-5(g) (1) (B), and declared by the United States Secretary of Health And Human Services in relation to the COVID-19 pandemic.

Notes

Wis. Admin. Code Department of Health Services DHS 109.11

CR 02-154: cr. Register April 2003 No. 568, eff. 5-1-03; correction in (4) (b) 2. made under s. 13.92(4) (b) 7, Stats., Register December 2008 No. 636. Amended by, CR 21-067: cr. (6) (e) Register March 2022 No 795, eff. 4-1-22, r. (6) (e) 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 (6) (e) made under s. 35.17, stats., Register March 2022 No. 795, eff. 4/1/2022

Par. (e) 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.