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) (18) “U.S. national” means any of the following:

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(18)(c) (c) A naturalized U.S. citizen.

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.

subch. II of ch. DHS 109 Subchapter II — Eligibility for SeniorCare Benefits and Services

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)(b) (b) The person is at least 65 years of age.

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)(d) (d) The person pays the program enrollment fee specified in s. DHS 109.16.

DHS 109.11(1)(e) (e)

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. 2.

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(1)(h) (h) The person is not an inmate of a public institution as defined in 42 CFR 435.1009.

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.