DHS 102.01
DHS 102.01 Application. Application for medical assistance (MA) shall be made pursuant to s.
49.47 (3), Stats., for medically indigent persons, s.
49.46, Stats., for categorically needy persons s.
49.473, Stats., for women diagnosed with breast or cervical cancer or precancerous conditions, and s.
49.471, Stats., for persons under BadgerCare Plus, and this chapter. Applications shall be made and reviewed in accordance with the following provisions:
DHS 102.01(1)
(1)
Right to apply. Any person may apply for MA. The application shall be made via the department's internet website, over the telephone, by fax, on a paper form, or in person with the agency.
DHS 102.01(2)(a)
(a) Except as provided under par.
(b), application for Wisconsin MA shall not be accepted for a person residing outside Wisconsin.
DHS 102.01(2)(b)
(b) If a Wisconsin resident becomes ill or injured when absent from the state or is taken outside the state for medical treatment, application for Wisconsin MA for that person shall be made on a Wisconsin application form and witnessed by the public welfare agency in the other state in accordance with
42 CFR 435.403.
DHS 102.01(3)
(3)
Where application is made. Application shall be made to the agency in the county in which the primary person resides. An individual residing in a nursing home is considered a resident of the county where the nursing home is located. However, an application for a person in a state facility — northern, central, or southern center for the developmentally disabled; Winnebago or Mendota mental health institute; or the University of Wisconsin hospitals — shall be received and processed by the agency in the county in which the person resided at the time he or she was admitted to the facility.
DHS 102.01(4)(a)(a) Persons inquiring about or applying for MA shall be given all of the following information by the agency in electronic and paper formats, and orally as appropriate:
DHS 102.01(4)(b)
(b) Information must be provided to applicants and members in plain language and in an accessible and timely manner.
DHS 102.01(4)(c)
(c) Applicants and members must be informed of the availability of accessible information and language services and how to access language services or auxiliary aids. At minimum, the agency must provide non-English language taglines indicating the availability of language services.
DHS 102.01(4)(d)
(d) For individuals who are limited English proficient, the agency must provide language services including oral interpretations and written translations at no cost to the individual.
DHS 102.01(4)(e)
(e) For individuals with disabilities, the agency must provide auxiliary aids and services at no cost to the individual, in accordance with the Americans with Disabilities Act,
42 USC 12101 to
12213.
DHS 102.01(5)
(5)
Special application situations. Under the following circumstances, the following special application procedures shall apply:
DHS 102.01(5)(a)
(a) When a person 19 years of age or older is living in the household of the primary person but is not the primary person or the primary person's spouse, the agency shall determine the eligibility of that person and that person's spouse or child, if any, separately from the rest of the persons listed on the application.
DHS 102.01(5)(b)
(b) When an unmarried man and woman reside together and have a minor child-in-common, the agency shall determine the eligibility of the man and woman together on one application if the man is the father of the child, which shall be determined as follows:
DHS 102.01(5)(b)1.
1. If both the woman and the man are available, the man shall be considered the father of the child if his name is on the birth record, if paternity has been established under ch.
767, Stats., or if a completed statement of paternity form has been signed by him and the mother and has been mailed or delivered to the agency.
DHS 102.01(5)(b)2.
2. If only the man is in the home and the woman is not available to participate in the steps necessary to fulfill the requirements of subd.
1., the man shall be determined to be the father of the child if any of the following circumstances apply:
DHS 102.01(5)(b)2.b.
b. He provides the agency with an affidavit in which he states that he is the child's father and proves that he and the child's mother lived together at the time of conception.
DHS 102.01(5)(b)2.c.
c. He files with the department a declaration of paternal interest under s.
48.025, Stats., and proves that he and the child's mother lived together at the time of conception.
DHS 102.01(5)(b)2.d.
d. He provides the agency with a written statement in which he acknowledges his paternity and proves that he and the child's mother lived together at the time of conception.
DHS 102.01(5)(b)2.e.
e. He submits to the agency a sworn statement describing in sufficient detail the circumstances upon which he bases his claim to be the child's father and the agency has no reason to doubt his credibility.
DHS 102.01 Note
Note: The statement of paternity form (F-05024 for English; F-050245 for Spanish) can be obtained from the Division of Public Health, P.O. Box 309, Madison, WI 53701.
DHS 102.01(5)(c)
(c) When a child or adult resides in a MA-certified skilled nursing facility,intermediate care facility, or inpatient psychiatric facility, or is hospitalized and is unable to live outside of the hospital, the agency may determine individually the eligibility of the child or adult.
DHS 102.01(5)(d)
(d) When a foster child resides in a licensed foster home or a child resides in a group home, the agency shall consider the child as the primary person for purposes of application.
DHS 102.01(5)(e)
(e) When a child is a parent or is pregnant, but not married and not under the care of a relative as specified in s.
49.19 (1) (a), Stats., the agency shall determine individually the eligibility of the child.
DHS 102.01(5)(f)
(f) In cases where 3 generations reside together, the agency shall consider the first generation to be caring for both the second-generation and third-generation children.
DHS 102.01(5)(g)1.1. When a completed application is received before the death of an applicant who dies before eligibility is determined, the agency shall process and take action on the application in the same manner as with any other application.
DHS 102.01(5)(g)2.
2. An application on behalf of a deceased person may be made by an interested person who attests to the correctness of the eligibility information on behalf of the deceased.
DHS 102.01(6)
(6)
Providing correct and truthful information. The applicant, recipient, or person described in sub.
(7) acting on behalf of the applicant or recipient is responsible for providing to the agency, the department or its delegated agent, full, correct and truthful information necessary for eligibility determination or redetermination and for disclosing assets which the agency determines may affect the applicant's or recipient's eligibility, including but not limited to health insurance policies or other health care plans and claims or courses of action against other parties on the part of the applicant or recipient. Changes in income, assets or other circumstances which may affect eligibility shall be reported to the agency within 10 days of the change.
DHS 102.01(7)(b)
(b) Each application submitted online, over the telephone, by fax, or on paper shall be signed by the applicant or the applicant's caretaker relative, legal guardian, authorized representative or, where the applicant is incompetent or incapacitated, by someone acting responsibly for the applicant.
DHS 102.01(7)(c)
(c) When an institutionalized person who is applying for MA or an institutionalized recipient whose eligibility for MA is being redetermined has a community spouse, both the institutionalized spouse and his or her spouse, their authorized representatives or someone acting responsibly for the institutionalized spouse or his or her spouse shall sign the application. Failure of either spouse or that person's authorized representative or someone acting responsibly on behalf of either spouse to sign the application shall result in ineligibility for the institutionalized spouse under s.
DHS 103.075. Except as provided under s.
DHS 103.075 (5) (e), the agency shall proceed to determine eligibility for the institutionalized spouse under s.
DHS 103.04 (4).
DHS 102.01(7)(d)
(d) The signatures of 2 witnesses are required when the application is signed with a mark.
DHS 102.01 History
History: Cr.
Register, February, 1986, No. 362, eff. 3-1-86; am. (7),
Register, March, 1993, No. 447, eff. 4-1-93; emerg. am. (intro.) and cr. (5) (h), eff. 7-1-99
; am. (intro.) and cr. (5) (h),
Register, March, 2000, No. 531, eff. 4-1-00; correction in (7) made under s. 13.93 (2m) (b) 7., Stats.,
Register February 2002 No. 554; corrections in (7) made under s. 13.92 (4) (b) 7., Stats.,
Register December 2008 No. 636;
CR 23-046: am. (intro.), (1), r. and recr. (4), am. (5) (a), (b) (intro.), 1., 2. (intro.), a. to d., r. (5) (h), r. and recr. (7) Register April 2024 No. 820, eff. 5-1-24. DHS 102.02
DHS 102.02 Refusal to provide information. If a person refuses to provide information necessary for the determination of eligibility, all persons whose eligibility depends upon the withheld information shall be denied eligibility.
DHS 102.02 History
History: Cr.
Register, February, 1986, No. 362, eff. 3-1-86.
DHS 102.03
DHS 102.03 Verification of information. DHS 102.03(1)(1)
An agency that has complied with subs.
(1g) and
(1r) shall deny an application for MA when the applicant or recipient is able to produce required verifications but refuses or fails to do so, except that a refusal or failure by an applicant for MA to verify assets does not affect eligibility for BadgerCare Plus under s.
49.471, Stats. If the applicant or recipient is not able to produce verifications, or requires assistance to do so, the agency may not deny assistance but shall proceed immediately to verify the data elements.
DHS 102.03(1g)
(1g) An individual shall not be required to provide additional information or documentation if it is not required to determine eligibility for the type of Medicaid or BadgerCare Plus, under subch.
IV of ch. 49, Stats., that the member is requesting.
DHS 102.03(1r)
(1r) An individual shall not be required to provide additional information of documentation unless information needed by the agency cannot be obtained electronically or the information obtained electronically is not reasonably compatible with information by or on behalf of the individual. Income information obtained through an electronic data match shall be considered reasonably compatible with income information provided by or on behalf of an individual if both are at or below the applicable standard for MA.
DHS 102.03(2)
(2) The agency shall verify those data elements deemed appropriate under the circumstances of the case history for an applicant who has been convicted of public assistance-related fraud, is repaying aid pursuant to an agreement with the district attorney's office, or is known to have provided erroneous information on a previous application which resulted in an incorrect issuance of assistance.
DHS 102.03(3)
(3) Each of the following items shall be verified when applicable:
DHS 102.03(3)(b)
(b) Pregnancy, when the agency has information that contradicts the member's self-attestation. If there is no contradictory information, the agency shall accept the member's self-attestation of pregnancy.
DHS 102.03(3)(d)
(d) Social security number, subject to all of the following requirements:
DHS 102.03(3)(d)1.
1. Services must not be denied or delayed to an otherwise eligible individual pending issuance or verification of the individual's social security number by the Social Security Administration.
DHS 102.03(3)(d)2.
2. Any of the following individuals are not required to provide a social security number:
DHS 102.03(3)(d)2.a.
a. Individuals who are deemed eligible for MA, based on being born to a pregnant woman eligible for MA in Wisconsin, until they turn 1 year of age.
DHS 102.03(3)(d)2.c.
c. Individuals who do not have a social security number and may only be issued a social security number for a valid non-work reason in accordance with
20 CFR 422.104.
DHS 102.03 History
History: Cr.
Register, February, 1986, No. 362, eff. 3-1-86; emerg. am. (1), eff. 7-1-99;
am. (1),
Register, March, 2000, No. 531, eff. 4-1-00; corrections in (3) (b) and (c) made under s.
13.92 (4) (b) 7., Stats.,
Register December 2008 No. 636;
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;
CR 23-046: am. (1), cr. (1g), (1r), am. (3) (intro.), (a), (b), r. (3) (c), renum. (3) (d) to (3) (d) (intro.) and am., cr. (3) (d) 1., 2., am. (3) (e) to (h), cr. (3) (j) Register April 2024 No. 820, eff. 5-1-24; correction in (3) made under s. 13.92 (4) (b) 7., Stats., and correction in (1g) made under s. 35.17, Stats., Register April 2024 No. 820. DHS 102.035
DHS 102.035 Verification of United States citizenship. DHS 102.035(1)(1)
The agency shall verify citizenship through a data match with the Social Security Administration. If citizenship cannot be verified through a data match with the Social Security Administration, the agency must verify citizenship through satisfactory documentary evidence as specified in s.
49.84 (6) (d), Stats., except that any of the following are exempt from the requirement to verify citizenship:
DHS 102.035(1)(e)
(e) Individuals who are or were deemed eligible for MA in Wisconsin on or after July 1, 2006, based on being born to a pregnant woman eligible for MA.
DHS 102.035(2)
(2) The agency shall not re-verify or require an individual to re-verify citizenship at a renewal of eligibility or upon a subsequent application following a break in coverage.
DHS 102.035(3)
(3) If citizenship cannot be promptly verified, a reasonable opportunity period of 95 days shall be provided to applicants during which efforts must continue to obtain verification or, if necessary, request documentation. Benefits may not be delayed, denied, reduced, or terminated during the reasonable opportunity period if the individual is otherwise eligible for MA. A reasonable opportunity period shall only be granted once for verification of an individual's U.S. citizenship.
DHS 102.035 History
History: CR 23-046: cr. Register April 2024 No. 820, eff. 5-1-24. DHS 102.036
DHS 102.036 Verification of immigration status. DHS 102.036(1)(1)
The agency shall verify immigration status of persons declaring a satisfactory immigration status either through the electronic service established by the U.S. department of health and human services, or the department of homeland security.
DHS 102.036(2)
(2) Persons applying for MA emergency services provided under
42 USC 1396b(v) or applying for an unborn child under s.
49.471, Stats. shall not be required to verify their immigration status.
DHS 102.036(3)
(3) If immigration status cannot be promptly verified, a reasonable opportunity period of 95 days shall be provided to applicants during which efforts must continue to obtain verification or, if necessary, request documentation. Benefits shall not be delayed, denied, reduced, or terminated during the reasonable opportunity period if the individual is otherwise eligible for MA. An additional reasonable opportunity period may be granted when a change in immigration status is reported.
DHS 102.036(4)
(4) Unless the individual reports a change in immigration status or information is received that indicates a potential change in the individual's status, the agency shall not re-verify or require an individual to re-verify immigration status at a renewal of eligibility or upon a subsequent application following a break in coverage.
DHS 102.036 History
History: CR 23-046: cr. Register April 2024 No. 820, eff. 5-1-24. DHS 102.04(1)(a)(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.
DHS 102.04(1)(b)
(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.
DHS 102.04(1)(c)
(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:
DHS 102.04(2)
(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.
