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)3.3. Age.
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).