Alert! This chapter may be affected by an emergency rule:
DHS 109.11(3) (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.
DHS 109.11(4) (4)Department verification of information.
DHS 109.11(4)(a)(a) The department may verify information provided by the applicant in the application under sub. (2) under any of the following circumstances:
DHS 109.11(4)(a)1. 1. The applicant has been convicted of public assistance-related fraud.
DHS 109.11(4)(a)2. 2. The applicant is repaying aid determined to be previously owed by the applicant pursuant to an agreement with the district attorney's office.
DHS 109.11(4)(a)3. 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.
DHS 109.11(4)(b) (b) The department may verify the following information about the applicant, participant or an ineligible spouse who is in the fiscal test group:
DHS 109.11(4)(b)1. 1. Income.
DHS 109.11(4)(b)2. 2. Health insurance coverage as defined in s. DHS 101.03 (69m) and other plans that provide prescription benefits.
DHS 109.11(4)(b)4. 4. Residence.
DHS 109.11(4)(b)5. 5. Social security number.
DHS 109.11(4)(b)6. 6. Citizenship or alien status.
DHS 109.11(4)(c) (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).
DHS 109.11(5) (5)Eligibility determination process.
DHS 109.11(5)(a)(a) Decision date.
DHS 109.11(5)(a)1.1. 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.
DHS 109.11(5)(a)2. 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.
DHS 109.11(5)(b) (b) Notice of Decision.
DHS 109.11(5)(b)1.1. 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.
DHS 109.11(5)(b)2. 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.
DHS 109.11(5)(c) (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.
DHS 109.11(5)(d) (d) Withdrawal from program.
DHS 109.11(5)(d)1.1. 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:
DHS 109.11(5)(d)1.a. a. Ten days following the issuance of the eligibility notice.
DHS 109.11(5)(d)1.b. b. Thirty days from the date the application was filed.
DHS 109.11(5)(d)2. 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.
DHS 109.11(5)(d)3. 3. The effective date of a withdrawal under this paragraph will be the date the department issues a notice of decision concerning the withdrawal.
DHS 109.11(5)(e) (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.
DHS 109.11(6) (6)Review of eligibility. The department shall redetermine a SeniorCare participant's eligibility any time one of the following conditions is met:
DHS 109.11(6)(a) (a) Promptly after the department learns of a change in the person's circumstances that may affect eligibility or indicates the need for redetermination.
DHS 109.11(6)(b) (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).
DHS 109.11(6)(c) (c) At any time the department has a reasonable basis for believing that a participant is no longer eligible for SeniorCare.
DHS 109.11(6)(d) (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.
DHS 109.11 History History: 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.
DHS 109.12 DHS 109.12Calculation of eligible benefits and services. Persons the department determines to be eligible for SeniorCare benefits and services under s. DHS 109.11 may be subject to program deductible and spend-down amounts that participants must pay before the participant may receive the full SeniorCare benefits and services for the remainder of a benefit period. Whether and to what extent the deductibles and spend-down amounts under s. DHS 109.13 apply to a given participant depends on the annual income of the participant's fiscal test group. The department shall calculate income for the participant's fiscal test group as follows:
DHS 109.12(1) (1)SeniorCare fiscal test group. The SeniorCare fiscal test group shall consist solely of the applicant unless the applicant is residing with a spouse. If the applicant is residing with a spouse, the SeniorCare fiscal test group shall consist of the applicant and the applicant's spouse, unless the spouse is an SSI recipient or the spouses are living together in a nursing home.
DHS 109.12(2) (2)Annual income. The department shall calculate annual income for SeniorCare applicants as follows:
DHS 109.12(2)(a) (a) Income shall be based on a prospective estimate of annual budgetable income under par. (c) for all persons in the SeniorCare fiscal test group.
DHS 109.12(2)(b) (b) The annual period used as the basis for the estimate shall be the 12 calendar months beginning with the month in which the SeniorCare application was filed.
DHS 109.12(2)(c) (c) Budgetable income shall consist of gross earned and unearned income with the following exceptions:
DHS 109.12(2)(c)1. 1. Self-employment income shall be calculated by deducting only estimated business expenses, losses, and depreciation from gross self-employment income.
DHS 109.12(2)(c)2. 2. Income from sources exempted under federal law from consideration for Medicaid eligibility will also be exempt for SeniorCare.
DHS 109.12 History History: CR 02-154: cr. Register April 2003 No. 568, eff. 5-1-03.
DHS 109.13 DHS 109.13SeniorCare benefits and services.
DHS 109.13(1)(1)Conditions for receiving SeniorCare benefits and services. A person who meets the eligibility requirements under s. DHS 109.11 (1) may receive SeniorCare benefits or services, subject to the conditions under this section. Except during a period of program suspension under s. 49.688 (7) (b), Stats., SeniorCare benefits and services shall be available only for prescription drugs prescribed for the eligible person and dispensed with a date of service during the eligible person's benefit period.
DHS 109.13(2) (2)Prescription benefit.
DHS 109.13(2)(a)(a) Income category applicability. A person may receive the prescription benefit in par. (b) under any of the following conditions:
DHS 109.13(2)(a)1. 1. The person is a member of a fiscal test group with an annual income less than or equal to 160% of the poverty line for a family the size of the fiscal test group.
DHS 109.13(2)(a)2. 2. The person is a member of a fiscal test group with an annual income greater than 160% but not in excess of 240% of the poverty line for a family the size of the fiscal test group and has met the deductible as described in sub. (3) (d) during the current benefit period.
DHS 109.13(2)(a)3. 3. The person is a member of a fiscal test group with an annual income greater than 240% of the poverty line for a family the size of the fiscal test group and has met both of the following thresholds during the current benefit period, in the following order:
DHS 109.13(2)(a)3.a. a. The spend-down as described in sub. (4) (c).
DHS 109.13(2)(a)3.b. b. The deductible as described in sub. (3) (d).
DHS 109.13(2)(b) (b) Copayment. Except as provided under sub. (3) (e), a person receiving the SeniorCare prescription benefit may purchase prescription drugs from participating SeniorCare providers for one of the following copayment amounts:
DHS 109.13(2)(b)1. 1. A copayment of $5 for each prescription drug that bears only a generic name.
DHS 109.13(2)(b)2. 2. A copayment of $15 for each prescription drug that does not bear only a generic name.
DHS 109.13(2)(c) (c) Exclusion. If a drug is covered by a third party and the participant makes a copayment to the SeniorCare provider, the department is not responsible for refunding the copayment amount to the participant.
DHS 109.13(3) (3)Deductible benefit and services.
DHS 109.13(3)(a)(a) Income category applicability. A person may receive the SeniorCare benefit and services under par. (b) under any of the following conditions:
DHS 109.13(3)(a)1. 1. The person is a member of a fiscal test group with an annual income greater than 160%, but not in excess of 240% of the poverty line for a family the size of the fiscal test group.
DHS 109.13(3)(a)2. 2. The person is a member of a fiscal test group with an annual income greater than 240% of the federal poverty line for a family the size of the fiscal test group, but only for the remainder of the benefit period after he or she has met the spend-down as described in sub. (4) (c).
DHS 109.13(3)(b) (b) Benefit and services.
DHS 109.13(3)(b)1.1. Except as provided under sub. (4) (d), a person receiving the SeniorCare deductible benefit and services may purchase prescription drugs from participating SeniorCare providers at the program payment rate.
DHS 109.13(3)(b)2. 2. The department shall maintain a record of the prescription drug purchases of each person receiving the SeniorCare deductible services and shall inform participating SeniorCare providers when the person receiving the SeniorCare deductible benefits and services has met the deductible within the benefit period as described in par. (d).
DHS 109.13(3)(c) (c) Amount. The amount of the SeniorCare deductible is based on a fiscal test group's income as a percentage of the federal poverty line for a family the size of the fiscal test group, as follows:
DHS 109.13(3)(c)1. 1. If the fiscal test group's income is more than 160% of the federal poverty line, but not more than 200%, the deductible is $500.
DHS 109.13(3)(c)2. 2. If the fiscal test group's income is more than 200% of the federal poverty line, the deductible is $850.
DHS 109.13(3)(d) (d) Meeting the deductible. The deductible is considered met and the person shall receive the prescription benefit under sub. (2) (b) when, under the following conditions, the person has spent the dollar amount specified in par. (c) in purchasing prescription drugs:
DHS 109.13(3)(d)1. 1. Only purchases of prescription drugs prescribed for the eligible individual count toward meeting the deductible.
DHS 109.13(3)(d)2. 2. Each spouse has a deductible. When both persons in a 2-person fiscal test group are eligible for SeniorCare, each person's purchases of prescription drugs shall only be counted toward meeting the deductible of the person for whom the drugs are prescribed.
DHS 109.13(3)(d)3. 3. Only prescription drugs dispensed with a date of service during the current benefit period described in s. DHS 109.14 may count toward meeting the deductible.
DHS 109.13(3)(d)4. 4. If a person has other available coverage from any third party insurer legally liable to contribute in whole or in part to the cost of prescription drugs provided to a SeniorCare participant, including coverage by a county relief program under ch. 49, Stats., only costs for prescription drugs for the person that are not paid under the person's other available coverage may count toward meeting the deductible.
DHS 109.13(3)(d)5. 5. Only prescription drugs that meet the requirements of s. DHS 109.31 may be applied toward meeting the deductible.
DHS 109.13(3)(d)6. 6. Only claims submitted by a SeniorCare provider shall be considered in determining whether or not the participant has met the deductible.
DHS 109.13(3)(e) (e) Carryover of deductible. When the cost of a prescription applied towards meeting the deductible under par. (d) exceeds the remaining deductible amount, the excess prescription costs shall be applied to the prescription benefit. No participant may be required to pay the copayment under sub. (2) (b) for that prescription.
DHS 109.13(4) (4)Spend-down services.
DHS 109.13(4)(a)(a) Income category applicability.
DHS 109.13(4)(a)1.1. A person may receive the SeniorCare spend-down services under this subsection when he or she is in a fiscal test group with an annual income that exceeds 240% of the poverty line for a family the size of the fiscal test group.
DHS 109.13(4)(a)2. 2. The department shall maintain an accounting of the prescription drug purchases of each person receiving the SeniorCare spend-down services and shall inform participating SeniorCare providers when he or she has met the spend-down within the benefit period as described in par. (c).
DHS 109.13(4)(b) (b) Amount. The amount of a person's SeniorCare spend-down is the difference between the SeniorCare fiscal test group's annual income and 240% of the poverty line for a family the size of the fiscal test group.
DHS 109.13(4)(c) (c) Meeting a spend-down. A SeniorCare spend-down shall be met and the person's subsequent prescription purchases shall count toward meeting the deductible under sub. (3) (c) and (d) when the member or members of the fiscal test group, under the following conditions, have spent the amount of the spend-down in purchasing prescription drugs at the retail price:
DHS 109.13(4)(c)1. 1. When only one person is an eligible member of the SeniorCare fiscal test group in a calendar month, only purchases of prescription drugs prescribed for that person may be counted toward meeting the spend-down in that calendar month.
DHS 109.13(4)(c)2. 2. When 2 spouses are both eligible members of the same SeniorCare fiscal test group in a calendar month, purchases of prescription drugs prescribed for either person may be counted toward meeting the spend-down in that month.
DHS 109.13(4)(c)3. 3. Only prescription drugs dispensed with a date of service during the benefit period described in s. DHS 109.14 may count toward meeting the spend-down.
DHS 109.13(4)(c)4. 4. If a person has other available coverage from any third party insurer legally liable to contribute in whole or in part to the cost of prescription drugs provided to a SeniorCare participant, including coverage by a county relief program under ch. 49, Stats., only costs for prescription drugs for the person that are not paid under the person's other available coverage may be counted toward meeting the spend-down.
DHS 109.13(4)(c)5. 5. Only prescription drugs that meet the requirements of s. DHS 109.31 may be applied to meeting the spend-down.
DHS 109.13(4)(c)6. 6. Only claims submitted by a SeniorCare provider may be considered in determining whether the participant has met the spend-down.
DHS 109.13(4)(d) (d) Carryover of spend-down. When the cost of a prescription applied towards meeting the spend-down under par. (c) exceeds the remaining spend-down amount, the excess prescription costs shall be applied towards meeting the deductible under sub. (3) (d). The program payment rate may not apply to that portion of the prescription counted for the deductible.
DHS 109.13(5) (5)Review of benefits. After the department learns of an error or omission in the information on the application form or other information provided by the recipient used to determine the benefits and services, the department shall promptly redetermine which SeniorCare benefits and services a participant may receive under this section. The benefits and services may only be changed if the error or omission is of factual information available to the recipient at the time he or she filed the application.
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Published under s. 35.93, Stats. Updated on the first day of each month. Entire code is always current. The Register date on each page is the date the chapter was last published.