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:
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 109.13 SeniorCare 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)(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)(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)(bm)
(bm)
Exclusion of copayment. A copayment is not required for a vaccine or vaccine administration.
DHS 109.13(2)(c)
(c)
Exclusion for drugs. 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(2)(d)
(d)
Exclusion for vaccines and vaccine administration. The department will not cover reimbursement of a vaccine or vaccine administration in any of the following circumstances:
DHS 109.13(2)(d)1.
1. A vaccine is not on the federal centers for disease control and prevention's advisory committee on immunization practices list of vaccines recommended for immunization to adults.
DHS 109.13(2)(d)2.
2. A vaccine is not administered by a SeniorCare provider in an allowed place of service.
DHS 109.13(2)(e)
(e)
Exclusion for vaccines. The department will not cover reimbursement of a vaccination when the vaccine is allocated through the federal government at no cost to the provider.
