DHS 109.03
DHS 109.03 Definitions. Unless otherwise defined in this chapter, the definitions in s.
DHS 101.03 apply to this chapter. In addition, in this chapter:
DHS 109.03(1)
(1) “Deductible benefits and services" means both of the following:
DHS 109.03(1)(a)
(a) The prescription drugs which may be purchased by a SeniorCare participant with income over 160% of the poverty line for amounts no greater than the program payment rate.
DHS 109.03(1)(b)
(b) The department's tracking of prescription drug purchases by a SeniorCare participant with income over 160% of the poverty line so SeniorCare providers know when the participant may receive the SeniorCare prescription benefit.
DHS 109.03(2)
(2) “Department" means the department of health services, or its agent.
DHS 109.03(3)
(3) “Fiscal test group" means the person or persons in a household whose income and need is included in determining which SeniorCare benefits or services an applicant may receive.
DHS 109.03(5)
(5) “Innovator multiple-source drug" means a multiple source drug that was originally marketed under an original new drug application approved by the U.S. food and drug administration.
DHS 109.03(6)
(6) “Lock-in provider" means a single, SeniorCare-certified provider, selected by the participant or designated by the department in the event the participant is unwilling or unable to identify a provider, who is responsible for either personally providing all non-emergency care received by the participant under the MA program, or referring the participant to a specific provider for such needed non-emergency care.
DHS 109.03(7)
(7) “Participant" means a person who has applied for SeniorCare and meets the eligibility criteria under s.
DHS 109.11 (1) and may receive benefits and services during the benefit period under s.
DHS 109.14.
DHS 109.03(9)
(9) “Prescription benefit" means the prescription drugs that may be purchased with a $5 or $15 payment by a SeniorCare participant with low income or who has spent at least the dollar amount specified in s.
DHS 109.13 (3) on the purchase of prescription drugs during the current benefit period.
DHS 109.03(10)
(10) “
Prescription drug” or “drug” means any of the following:
DHS 109.03(10)(b)
(b) A vaccine recommended and approved for administration to adults by the federal centers for disease control and prevention's advisory committee on immunization practices.
DHS 109.03(12)
(12) “Program payment rate” means the rate of payment made for the identical drug specified under s.
49.46 (2) (b) 6. h., Stats., plus a dispensing fee that is equal to the dispensing fee permitted to be charged for prescription drugs for which coverage is provided under s.
49.46 (2) (b) 6. h., Stats.
DHS 109.03(13)
(13) “Retail price" means the provider's charge for providing the same service to private paying customers.
DHS 109.03(14)
(14) “SeniorCare" means the program of prescription drug assistance for eligible elderly persons under s.
49.688, Stats.
DHS 109.03(15)
(15) “SeniorCare provider" means an MA certified pharmacist, pharmacy or dispensing physician.
DHS 109.03(16)
(16) “Spend-down" means the amount of money a SeniorCare participant must spend on prescription drugs before the participant becomes eligible for SeniorCare deductible and copayment benefits and services.
DHS 109.03(17)
(17) “Spend-down services" means the department's monitoring of participant prescription drug purchases to determine when the participant's SeniorCare fiscal test group's purchases have equaled the difference between the fiscal test group's annual income and 240% of the poverty line for a family the size of the fiscal test group.
DHS 109.03(18)(a)
(a) A person born in one of the 50 states, the District of Columbia, Puerto Rico (on or after January 13, 1941), Guam, the U.S. Virgin Islands (on or after January 17, 1917), America Samoa, Swain's Island or the Northern Mariana Islands.
DHS 109.03(18)(b)
(b) A person born outside of the United States to at least one U.S. citizen parent.
DHS 109.03 History
History: CR 02-154: cr.
Register April 2003 No. 568, eff. 5-1-03;
CR 04-050: am. (9)
Register October 2004 No. 586, eff. 11-1-04; corrections in (intro.) and (2) made under s.
13.92 (4) (b) 6. and
7., Stats.,
Register December 2008 No. 636;
CR 20-039: am. (12)
Register October 2021 No. 790, eff. 11-1-21;
CR 22-046: renum. (10) to (10) (intro.) and am., cr. (10) (a), (b)
Register June 2023 No. 810, eff. 7-1-23.
DHS 109.11
DHS 109.11 Application and determining eligibility. DHS 109.11(1)(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:
DHS 109.11(1)(a)
(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.
DHS 109.11(1)(c)
(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.
DHS 109.11(1)(e)1.1. Except as provided in subd.
2., the person requesting SeniorCare benefits has a social security number and furnishes the number to the department.
DHS 109.11(1)(e)2.a.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.
DHS 109.11(1)(e)2.b.
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.
DHS 109.11(1)(f)
(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.
DHS 109.11(1)(g)
(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).
DHS 109.11(2)
(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:
DHS 109.11(2)(a)
(a) Right to apply. Any person may apply to the department for SeniorCare on a form prescribed by the department.
DHS 109.11 Note
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.
DHS 109.11(2)(b)
(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.
DHS 109.11(2)(c)
(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.
DHS 109.11(2)(d)
(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.
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)(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)(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)(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)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)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)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;
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.
DHS 109.12
DHS 109.12 Calculation 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:
