DHS 109.15(4)(b)1.a. a. If the annual income of the fiscal test group exceeds 240% of the poverty line for a 2-person family, the spouse may receive spend-down services under s. DHS 109.13 (4) (a) 2.

DHS 109.15(4)(b)1.b. b. When determining whether the spouse meets the SeniorCare spend-down under s. DHS 109.13 (4) (c), the amount of the SeniorCare spend-down shall be prorated. The prorated amount shall be the annual spend-down amount under s. DHS 109.13 (4) (b) multiplied by the number of months of the spouse’s benefit period derived from subs. (1) and (2), divided by 12. Only prescription drug costs of the spouse may count towards meeting the prorated spend-down.

DHS 109.15(4)(b)1.c. c. If the spouse meets the prorated spend-down during the benefit period, the spouse may receive the deductible benefit and services under s. DHS 109.13 (3) (b). When determining whether the spouse meets the SeniorCare deductible under s. DHS 109.13 (3) (c) and (d), the amount of the SeniorCare deductible shall be prorated. The prorated deductible amount shall be $850 multiplied by the number of months of the spouse’s benefit period derived from subs. (1) and (2), divided by 12.

DHS 109.15(4)(b)1.d. d. If the spouse meets the prorated deductible during the benefit period, the spouse may receive the prescription benefit under s. DHS 109.13 (2) (b).

DHS 109.15(4)(b)2. 2. ‘Annual income between 160-240% of poverty line.’

DHS 109.15(4)(b)2.a. a. If the annual income of the fiscal test group is greater than 160%, but not in excess of 240% of the poverty line for a 2-person family, the spouse may receive the deductible benefit and services under s. DHS 109.13 (3) (b).

DHS 109.15(4)(b)2.b. b. When determining whether the spouse meets the SeniorCare deductible under s. DHS 109.13 (3) (c) and (d), the amount of the SeniorCare deductible shall be prorated. The prorated deductible amount shall be the dollar amount specified in s. DHS 109.13 (3) (c) multiplied by the number of months of the spouse’s benefit period derived from subs. (1) and (2), divided by 12.

DHS 109.15(4)(b)2.c. c. If the spouse meets the prorated deductible during the benefit period, the spouse may receive the prescription benefit under s. DHS 109.13 (2) (b).

DHS 109.15(4)(b)3. 3. ‘Annual income less than 160% of poverty line.’

DHS 109.15(4)(b)3.a. a. If the annual income of the fiscal test group does not exceed 160% of the poverty line for a 2-person family, the spouse may receive the prescription benefit under s. DHS 109.13 (2).

DHS 109.15(5) (5) If the income of the spouse was used to determine the SeniorCare benefit for the participant, the department shall determine the benefit as follows:

DHS 109.15(5)(a) (a) Annual income exceeds 240% of poverty line.

DHS 109.15(5)(a)1. 1. ‘Participant has not met spend-down.’ If the annual income of the fiscal test group exceeds 240% of the poverty line for a 2-person family, and the participant has not met the spend-down by the date the spouse becomes eligible for SeniorCare, the spouse may receive spend-down services under s. DHS 109.13 (4).

DHS 109.15(5)(a)2. 2. ‘Participant has met spend-down.’

DHS 109.15(5)(a)2.a. a. If the annual income of the fiscal test group exceeds 240% of the poverty line for a 2-person family and the participant met the spend-down before the spouse becomes eligible for SeniorCare, or the participant and spouse meet the spend-down during the benefit period, the spouse may receive the deductible benefit and services under s. DHS 109.13 (3).

DHS 109.15(5)(a)2.b. b. When determining whether the spouse meets the SeniorCare deductible under s. DHS 109.13 (3) (b) and (c), the amount of the SeniorCare deductible shall be prorated. The prorated deductible amount shall be $850 multiplied by the number of months of the spouse’s benefit period derived from subs. (1) and (2), divided by 12.

DHS 109.15(5)(a)3. 3. If the spouse meets the prorated deductible during the benefit period, the spouse may receive the prescription benefit under s. DHS 109.13 (2) (b).

DHS 109.15(5)(b) (b) Annual income between 160-240% of poverty line.

DHS 109.15(5)(b)1. 1. If the annual income of the fiscal test group is greater than 160%, but not in excess of 240% of the poverty line for a 2-person family, the spouse may receive the deductible benefit and services under s. DHS 109.13 (3).

DHS 109.15(5)(b)2. 2. When determining whether the spouse meets the SeniorCare deductible under s. DHS 109.13 (3) (b) and (c), the amount of the SeniorCare deductible shall be prorated. The prorated deductible amount shall be the dollar amount specified in s. DHS 109.13 (3) (c) multiplied by the number of months of the spouse’s benefit period derived from subs. (1) and (2), divided by 12.

DHS 109.15(5)(b)3. 3. If the spouse meets the prorated deductible during the benefit period, the spouse may receive the prescription benefit under s. DHS 109.13 (2) (b).

DHS 109.15(5)(c) (c) Annual income less than 160% of poverty line. If the annual income of the fiscal test group does not exceed 160% of the poverty line for a 2-person family, the spouse may receive the prescription benefit under s. DHS 109.13 (2).

DHS 109.15 History History: CR 02-154: cr. Register April 2003 No. 568, eff. 5-1-03; CR 04-050: am. (4) (b) 1. c. and 2. b. and (5) (a) 2. b. and (b) 2. Register October 2004 No. 586, eff. 11-1-04.

DHS 109.16 DHS 109.16 Fees. For each 12-month benefit period, a program participant shall pay a program enrollment fee of $30. The department shall refund the fee to applicants found to be ineligible for SeniorCare.

DHS 109.16 History History: CR 02-154: cr. Register April 2003 No. 568, eff. 5-1-03; CR 04-050: am. Register October 2004 No. 586, eff. 11-1-04.

DHS 109.17 DHS 109.17 Applicant appeals.

DHS 109.17(1) (1) Except as provided under sub. (2), any person whose application for SeniorCare is denied or is not acted upon promptly under s. DHS 109.11 (5), or who believes that the benefits or services the person may receive under s. DHS 109.13 have not been properly determined, or that his or her eligibility has not been properly determined under s. DHS 109.11 (5), may file an appeal pursuant to the requirements under ch. HA 3 that apply to the medical assistance program.

DHS 109.17(2) (2) 

DHS 109.17(2)(a) (a) A request for a hearing concerning the SeniorCare program may only be made in writing and only to the division of hearings and appeals.