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 HistoryHistory: 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 109.12DHS 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)(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)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 109.13DHS 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: