Chapter DHS 102

DHS 102.04 DHS 102.04 Eligibility determination.

DHS 102.04(1) (1) Decision date.

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(1)(c)1. 1. That there is a delay in processing the application.

DHS 102.04(1)(c)2. 2. The reason for the delay.

DHS 102.04(1)(c)3. 3. The applicant’s right to appeal the delay under s. 49.45 (5), Stats.

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.

DHS 102.04(3) (3) Review of eligibility. A recipient’s eligibility shall be redetermined in any of the following circumstances:

DHS 102.04(3)(a) (a) When information previously obtained by the agency concerning anticipated changes in the individual’s situation indicates the need for redetermination.

DHS 102.04(3)(b) (b) Promptly after a report is obtained which indicates a change in the individual’s circumstances that may affect eligibility.

DHS 102.04(3)(c) (c) In accordance with sub. (5), no more frequently than once every 12 months for persons eligible for BadgerCare Plus or MA under s. 49.46 (1) (a) 15. or 49.47 (4) (a) 1., Stats.

DHS 102.04(3)(d) (d) At least every 12 months for SSI-related persons and persons eligible for the medicaid purchase plan, in accordance with sub. (4), except that when a person is determined to be permanently blind or disabled the agency may consider their blindness or disability as continuing until it is determined that they are no longer blind or disabled.

DHS 102.04(3)(e) (e) At any time the agency has a reasonable basis for believing that a recipient is no longer eligible for MA.

DHS 102.04(5) (5) Procedures for reviewing eligibility.

DHS 102.04(5)(a) (a) A review of eligibility under sub. (3) (c) or (d) shall be conducted without requiring information from the individual if the agency is able to do so based on reliable information contained in the recipient’s case record or more current information available to the agency, including but not limited to information accessed through data bases accessed by the agency.

DHS 102.04(5)(b) (b) If the agency is able to redetermine eligibility based on such information, the agency shall notify the recipient of all of the following:

DHS 102.04(5)(b)1. 1. The eligibility determination and basis.

DHS 102.04(5)(b)2. 2. The requirement that the recipient must inform the agency if any of the information contained in such notice is inaccurate, but that the recipient is not required to sign and return such notice if all information provided on such notice is accurate.

DHS 102.04(5)(c) (c) If the agency cannot redetermine eligibility in accordance with par. (a), the agency shall do all of the following:

DHS 102.04(5)(c)1. 1. Provide the recipient with all of the following:

DHS 102.04(5)(c)1.a. a. A renewal form containing information available to the agency that is needed to renew eligibility.

DHS 102.04(5)(c)1.b. b. At least 30 days from the date of the renewal form to respond and provide any necessary information and to sign the renewal form.

DHS 102.04(5)(c)1.c. c. Notice of the agency’s intended action concerning the renewal of eligibility.

DHS 102.04(5)(c)2. 2. Verify any information provided by the recipient.

DHS 102.04(5)(c)3. 3. Reconsider in a timely manner the eligibility of a person who is terminated for failure to submit the renewal form or necessary information, if the person subsequently submits the renewal form within 90 days after the date of termination without requiring a new application.

DHS 102.04 History History: Cr. Register, February, 1986, No. 362, eff. 3-1-86; emerg. am. (2) and (3) (c), eff. 7-1-99; am. (2) and (3) (c), Register, March, 2000, No. 531, eff. 4-1-00; am. (3) (d), Register, November, 2000, No. 539, eff. 12-1-00; correction in (1) made under s. 13.93 (2m) (b) 7., Stats., Register February 2002 No. 554; 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: r. and recr. (1), am. (3) (intro.), (a) to (d), cr. (5) Register April 2024 No. 820, eff. 5-1-24; renumbering of (5) (b) to (5) (c) made under s. 13.92 (4) (b) 7., Stats., and correction in (5) (c) made under s. 35.17, Stats., Register April 2024 No. 820.

DHS 102.05 DHS 102.05 Fraud. When the agency director or a designee has reason to believe that fraud has been committed by an applicant or recipient, or by the representative of an applicant or a recipient, the case shall be referred to the district attorney.

DHS 102.05 History History: Cr. Register, February, 1986, No. 362, eff. 3-1-86.