Contents. Introduction. Eligibility Assessment Tools. Application Assistance. Fact Sheets. Resource Lists

Transcription

1 Wisconsin s Medicaid and BadgerCare programs offer great benefits to families in need of health care. The resources in this kit provide information that will let you and your agency assist families to apply for health care coverage, use the coverage once enrolled, identify alternative options for coverage, and resolve problems as they come up. Contents Introduction Eligibility Assessment Tools Application Assistance Fact Sheets Resource Lists Connecting kids to health care coverage This kit is produced by Covering Kids Wisconsin to help families connect to free and low-cost health coverage. It is funded by The Robert Wood Johnson Foundation. The kit is prepared and distributed by ABC for Health. For more information, call ABC for Health at

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3 Introduction Welcome and Overview Welcome to the AdvoKit for Health Care Access This kit is a tool for advocates and professionals who are assisting families to apply for Family Medicaid/BadgerCare using Wisconsin s simplified application form. It provides a list of Medicaid programs that use this application form, fact sheets on the programs, eligibility guidelines, line-by-line directions for completing the application, important contact information and some alternative financing options for those who do not qualify for Family Medicaid programs. In addition to these materials for professionals and advocates, each AdvoKit for Health Care Access includes a copy of Covering Kids Wisconsin s 3 Steps to Family Health Coverage. The 3 Steps kit is for families to use. It contains step-by-step guidance on how to apply for, use and keep Medicaid or BadgerCare. In addition, the kit folder can be used collect family health coverage records in one easy-tofind location. You and the work you do are the keys to putting these resources into action. We are excited about sharing the kits with you, and look forward to enhancing and expanding the information they contain. This Introduction gives a brief overview of the kits as well as ways to get in touch with us to provide comments, get technical assistance and stay current. AdvoKit Basics The AdvoKit has five sections. Following the Introduction, sections 2 and 3 Eligibility Assessment Tools and Application Assistance provide a template for helping families and pregnant women apply for Medicaid or BadgerCare using the Wisconsin Family Medicaid/BadgerCare Application. The unique feature of this simplified application is that it allows advocates and professionals to assist applicants in completing this application form right in the clinic or agency office, rather than setting up an appointment with the county social or human service department. Now, applications can be mailed or faxed to your local county or tribal economic support office face-to-face interviews are no longer required. This creates some wonderful advantages for families which are realized only when the completed applications are accurately and carefully done. Next, the Fact Sheet section contains basic fact sheets about the Medicaid programs that use the simplified application and advocacy tips that may be of use to applicants. When appropriate, these can be copied and added to the 3 Steps kits. And finally, there is the Resource Lists section, which provides contact information or Web links to additional information about the Medicaid programs covered in the kit. In addition, there is an extensive list of other health financing programs and services that may be helpful to families or individuals who do not qualify for Medicaid or BadgerCare. The Financing & Advocacy Resources becomes an active Web tool on the ABC for Health website, where the Web links will take you directly to program and agency information. updated March 2002 page A-1

4 Introduction Welcome and Overview Working with 3 Steps to Family Health Coverage This kit is intended to support your counseling role with families, not replace it. There is no substitute for the knowledge, experience and community-specific information you have to offer. What the kit provides is a framework for you to build on, and the assurance that your clients will have key information in their hands when you can t be by their side. Building on the 3 Steps Kit While we ve tried to include the health care access information families need, we can t really do the job without your help. Of course, each family has unique needs and questions, and so each kit needs to be tailored to meet these needs. This includes contact information for you and your agency, other county resources, brochures or fact sheets for state and local programs, and so on. We ve included some ideas to get you started, but are sure that there are many more we haven t thought of. Adding Local Resources First off, you can add your agency name and a list of local contact resources to the last page of the 3 Steps kit. The space on the back of the Contact Log is largely blank. We put a box at the bottom of the page for you and your agency to complete. The rest of the page is for any other resources you feel are important. These may include: The county social or human service office address and phone number. Contact info for outstation sites (or outstation workers) in your county. Information on where and how to apply for WIC, food stamps, and the free and reduced lunch program. Many people who are eligible for Medicaid are also eligible for these programs. Information on specialized programs that may benefit the family. For example, the family might be able to use the Katie Beckett program for children with special health care needs, or the drug assistance program for people with HIV/AIDS. (Links to website information on these programs are in the Resource Lists section of the AdvoKit.) Some additional suggestions on materials to consider: On the front of the kit file, slide your business card into the transparent slot. In the extra pockets of the kit add pamphlets for local programs. Your AdvoKit comes with fact sheets for various programs (more are available at abcforhealth.org). Add these as needed. updated March 2002 page A-2

5 Introduction Welcome and Overview A Brief Tour of the 3 Steps Kit The first page of the 3 Steps kit can be used to orient your client to what s included in the kit. If your client is unfamiliar with the BadgerCare or Medicaid programs, Family Health Coverage Facts, page 2 of the kit, provides a very brief description of the services and the eligibility requirements. The chart on income was included to give applicants a general sense about the income limits, but they should always be encouraged to submit an application when in doubt or if slightly over income. Family Health Coverage Facts is followed by the three steps. The first step is Applying, and the resources you have in the AdvoKit are really focused on this step. Page 5 of the 3 Steps kit is a Family Record. There is a summary here of information needed to complete an application for Medicaid or BadgerCare. Steps two and three of the kit provide a guide to getting enrolled in an HMO and tips on important program rights and responsibilities. You may wish to just point out that the information on these pages will be helpful after someone receives a Forward card. The Contact Log, page 9, is an important tool for keeping a record of mail and phone contacts. This is a good time to remind applicants to keep any mail they receive related to health coverage and expenses, and put it in the file. If you are helping your client fill out a simplified application, it s a good idea to put the date the application was completed and mailed as the first entry in the Log. Finally, there is a page on Handling Common Problems, where some frequently asked questions are dealt with. However, when questions come up for which you don t have answers, feel free to contact ABC for Health for technical assistance at Please make additional copies of the 3 Steps kit pages as you need them. Tracking Progress and Results Other AdvoKit Materials By helping your clients complete a Wisconsin Family Medicaid/BadgerCare Application, you ve put them on the road to health coverage. The next step is making sure they arrive. We suggest that you check in periodically with your clients to find out if they got coverage, if their applications were processed smoothly or not, and if they re successfully using health services and maintaining their coverage. They ll benefit from your ongoing attention, and you ll learn about the impact of your work. The Advocate s Screening Form, included in the AdvoKit, is a good tool for tracking clients and outcomes. Covering Kids also wants to learn about the impact of these kits. You can help us. We ll be following up with both professionals using the AdvoKit and a sample group of their clients who ve received the 3 Steps kit. We want to know how the kits have been used, how they ve affected the application process and outcomes, and how they could be improved. We hope you ll participate in our evaluation and help link us to families who would be willing to participate as well. The final page in the AdvoKit is the 3 Steps updated March 2002 page A-3

6 Introduction Welcome and Overview Distribution Log. You can use this to keep track of the people to whom you ve given a 3 Steps kit and whether they consent to have you share their name and contact information with ABC for Health so we can include them in our evaluation. How to Stay Current As you may know, many of the eligibility criteria for Medicaid and BadgerCare change from year to year. In order to keep the kits current, be sure to check the ABC for Health website at There you will find a section on specific updates affecting information in the kits. Additionally, the ABC for Health website will contain printable versions of other kit materials, as well as up-to-date resource lists and links. Covering Kids offers additional resources described below that will help you stay current and engaged with Medicaid eligibility and enrollment issues. Get connected to Covering Kids information resources Covering Kids publishes two newsletters and sponsors several trainings and forums each year. Our weekly newsletter, the Weekly Update, is a digest of health care financing program and regulation changes, upcoming legislation alerts, new research and policy reports, and advocacy tips or case stories. The bimonthly Kids Coverage Monitor will keep you in the loop about Covering Kids events and Wisconsin s progress and problems in getting children enrolled in health coverage. Cultivate your connections in the community and statewide We all have a lot to learn from each other about how to improve and streamline access to health coverage and services for low- to moderate-income families. Local coalitions are a powerful way to increase your understanding of the issues and contribute your insights to collaborative solutions. Covering Kids is working to support and strengthen community voices by linking up local coalitions and providing regional and statewide opportunities to address upper-level policymakers. If you have a local coalition that s interested in health care access issues, consider sending a representative to Covering Kids Statewide Coalition meetings, or send us your meeting minutes so we can communicate your issues and insights to state policymakers. If you don t have a local coalition, contact Covering Kids about other networking and coalition-building opportunities in your area. Call Alice Porter, the Covering Kids Coordinator, at , ext 206. Connect with ABC for Health for technical assistance Remember, you may contact staff at ABC for Health any time you have questions regarding eligibility, application processes, health care laws, or consumer rights and responsibilities. Call (608) or (800) You can also info@safetyweb.org. updated March 2002 page A-4

7 Eligibility Assessment Tools Overview In this section you will find tools to help you assess whether a client might be eligible for Medicaid or BadgerCare. The first tool is a chart listing the Medicaid programs for which the simplified application can be used. Medicaid has seven programs that can be accessed through the simplified application. Each program is listed on the chart, with information on who is eligible for which program, what the financial eligibility criteria are (including whether use of the deductible feature is applicable), and whether benefits can be backdated. Below the Medicaid chart you will find a listing of monthly income guidelines for families of any size. Caution: These income amounts are general guidelines and they change each year. There are several factors that can increase the amount of income a family can have and still be eligible for Medicaid coverage. If a family appears to be over income, it is still useful to have them apply to determine if they are eligible for one of these health care coverage programs. The Advocate s Screening Form is next, providing a useful way to assess whether a family should be using the Wisconsin Family Medicaid/BadgerCare Application Form to apply for coverage. For example, if you are unsure whether or not a family currently has health coverage or if they meet other Medicaid program guidelines, use this tool before starting a simplified application. The form also allows you to track the families you ve helped, the services you ve provided, and the results of your advocacy work. This will be useful in demonstrating the value of your work with families in your community. updated March 2002 page B-1

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9 Eligibility Assessment Tools Medicaid Reference Charts Program BADGERCARE MEDICAID THROUGH AFDC HEALTHY START HEALTHY START NEWBORN HEALTHY START OBRA KIDS MEDICALLY NEEDY MEDICAID FOR EMERGENCY SERVICES Who is eligible? Children ages 6-19 and their parents Children ages 6-19 and their parents Pregnant women and children under age 6 Children born to Medicaid recipients are eligible for 12 months Children ages 6-19 Children ages 6-19 Noncitizens Financial Criteria Income at or below 185% FPL. No asset test Income varies No asset test Income at or below 185% FPL No asset test Deductible? Backdated benefits? Services Covered No No Medicaid services No Yes Medicaid services Yes Yes Medicaid services None NA NA Medicaid services Income below 100% FPL Deductible calculated if over income Must meet Medicaid requirements Yes Yes Medicaid services Yes Yes Medicaid services Yes Yes Emergency services updated May 2002 page B-3

10 Eligibility Assessment Tools Medicaid Reference Charts Federal Poverty Level Chart (May 1, 2002 April 30, 2003) Monthly Gross Income Amounts Family Size 100% 150% 185% 200% 1 $ 738 $ 1107 $ 1365 $ $ 995 $ 1492 $ 1840 $ $ 1251 $ 1877 $ 2315 $ $ 1508 $ 2262 $ 2790 $ $ 1765 $ 2647 $ 3265 $ $ 2021 $ 3032 $ 3740 $ $ 2278 $ 3417 $ 4214 $ $ 2535 $ 3802 $ 4689 $ $ 2791 $ 4187 $ 5164 $ $ 3048 $ 4572 $ 5639 $ 6096 updated May 2002 page B-4

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12 Advocate s Screening Form Date of Referral Referring Person Agency Phone ( ) Client Contact Information Name Spouse/Partner s Name Address City Zip County Work/Daytime Phone ( ) Evening Phone ( ) No Phone Best Time to Contact Is it okay to call you at work? yes no Medicaid Eligibility Screening Questions Have you or anyone in your family applied for Medicaid or BadgerCare? yes no Do you have a Forward card? yes no If yes, call to verify if coverage is current If no, continue to use this form to screen for potential Medicaid eligibility. Please draw a sociogram of the family and the relationships in this family (for example, step-child, step-parent) Please tell us more about your background and family situation What is your marital status? married divorced separated widowed never married What is your race or ethnicity? white american indian asian black hispanic multiracial Please list all persons currently living in your home (please check the box for a stepchild and note each person s health insurance coverage status) Name Age Date of Birth Sex Relationship to you Stepchild? Current Coverage (circle all that apply) M / F Private Insurance / Medicaid / None M / F Private Insurance / Medicaid / None M / F Private Insurance / Medicaid / None M / F Private Insurance / Medicaid / None M / F Private Insurance / Medicaid / None M / F Private Insurance / Medicaid / None over

13 Continuation of Advocate s Screening Form for referred on client name screening/referral date Please tell us more about your employment situation What is your current employment status? (check as many as currently apply) employed full-time employed part-time seasonal employment self-employed unemployed What is the employment status of your spouse/partner? (check as many as currently apply) employed full-time employed part-time seasonal employment self-employed unemployed Please provide some information on your family s health status Is any female in your household pregnant? yes no if so, what if her due date? (for more information on coverage options, see Healthy Start and Presumptive Eligibility fact sheets) Do any people in your household have current or ongoing medical needs that are not being met or are difficult to meet? If yes, who are they and what are their needs? If you would like us to review your eligibility, please provide us with the following financial information Does anyone in your household have any past or present unpaid medical bills (including dental, eye care, insurance premiums, etc)? yes no if yes, what is your estimate of your total medical debt? (for more information on using medical debt to offset income for eligibility, see the Medicaid Deductible fact sheet) Does anyone in your household pay child support? yes no if yes, how much is paid out on a monthly basis? Income Information (please list the sources and gross amounts of all household monthly income) Income from Employment (or hourly wage and # of hours) Child Support Unemployment Workers Comp Spousal Support Unearned Income (e.g., disability benefits, interest income) Asset Information (for purposes of calculating unearned income, enter amount of monthly interest earned) CD Savings Account Stocks/Bonds Other Thank you for completing this form! Outcome Information client chose not to pursue eligibility gave brief information and referral lost contact with client completed simplified application provided follow-up / monitoring on application progress client gained Medicaid / BadgerCare eligibility client did not gain eligibility referred case to backup person or other agency (ABC for Health) Outcome Notes

14 Application Assistance The New Simplified Form and Process Wisconsin Family Medicaid/BadgerCare Simplified Application Form (DES 12277) The simplified application is used only when applying for Medicaid or BadgerCare coverage. The attached Family Medicaid / BadgerCare Application Form is for parents with children under age 19, children under age 19, pregnant women, and emergency services for noncitizen and undocumented applicants. If the applicant family would also like to apply for programs such as Food Stamps, Child Care, W-2, or any type of assistance other than Medicaid, this application should not be used. These families must go to their local county/tribal human or social service department, W-2 agency, or Medicaid or BadgerCare outstation site and a face-to-face interview will be required. Note: If the applicant has medical bills within the past three months that need to be covered, complete this application as soon as possible to get the maximum Medicaid coverage available. Medicaid can be backdated up to three months from the month of application. If the applicant is only eligible for BadgerCare, there is no backdate. Therefore, it is important to submit the application before the end of the current month whenever possible. The family can then go to the local county or tribal office to apply for other programs such as Food Stamps or Child Care at a later date. Some verification requirements, such as income, have been eliminated with the simplified application process. The reduced verification applies to all Medicaid programs. Verification is required for the following: Disability or incapacity (see #2 of these instructions) Pregnancy (see #17 in these instructions) Alien Status, Alien Registration Number, and date of entry into the U.S. Those applying for Medicaid or BadgerCare need to provide their Social Security Number (SSN). The economic support worker will verify SSNs for new applicants through the CARES SSN Validation Process. The state has issued instructions to economic support workers telling them not to over-verify unless there is a documented reason to believe that questionable information has been submitted to gain coverage. A worker can ask for documentation from an applicant if: Social Security Number does not match when cross-checked through the validation process. The applicant or recipient appears to be, or is unsure of the correct answer. The applicant provides different answers to the same question at different times. updated May2002 page C-1

15 Application Assistance The New Simplified Form and Process Applicant information does not match when cross-checked with the computer system database. Other reasons a worker may ask for documentation from an applicant may be because: Income varies widely from month to month and it is difficult for the applicant to know how much income to declare until the end of the current month. Self-employment income and depreciation issues can be complex, and it is difficult for the applicant to answer these questions for the current month. The worker must accept self-declaration that an applicant is a citizen. However, alien status for legal noncitizens must be verified by providing Alien Registration Numbers and official government documents that list the alien number and the date of entry into the U.S. Undocumented noncitizens do not have to provide an Alien Registration Number or SSN to apply for Medicaid for Emergency Services. Information provided by undocumented noncitizens will not be shared with the Immigration and Naturalization Service. Eligibility for applicants with an Alien Registration Number and/or a Green Card will be determined based on their Alien status. A chart listing status categories is in the MA Handbook Appendix at Undocumented noncitizens who do not qualify for Medicaid may apply for Medicaid for Emergency Services. Preserving the Filing Date The filing date is the date the application form is received by the economic support agency as long as it contains the individual s name, address, and signature. If you fax this form to the economic support office, the filing date becomes the date the fax is printed at the local agency. If it is the last day of the month, the applicant may want to deliver the application in person. It is important to get some form of written verification that the application was turned in on that date. Note: To ensure the maximum period of Medicaid coverage, file an application before the end of the current month, even if you are unable to answer all the questions. Once the agency receives an application, the economic support worker has 30 days to process it. If additional information is needed, the worker may contact the applicant. The worker will always allow at least 10 days to provide the information even if the 30 day deadline for processing the application is near. updated May2002 page C-2

16 Application Assistance The Form, Step by Step The Application Form A copy of the application form with numbers corresponding to those in the instructions is attached. Note: A complete application will be processed more quickly. Therefore, try to answer all the questions on this form. It is also helps to identify your agency using the CBO (community-based organization) field in the upper right-hand corner of the form. By doing so, you let the economic support worker know of your involvement in helping the applicant complete the form. #1 If there are medical bills incurred during the three months prior to the month of application, check yes to question #1 for possible payment or reimbursement of these costs. Note: For an applicant who qualifies for BadgerCare, there is no three month backdate period of eligibility. BadgerCare coverage begins the first day of the month in which the application is turned in and all eligibility criteria are met. For all other Medicaid programs, except Healthy Start Presumptive Eligibility, coverage can be backdated up to three months. Applicants must meet all other eligibility requirements in the three months prior to the month of application to get the backdated coverage. The applicant can choose to start coverage the first day of any one of these months prior to the month of application. #2 If any applicant is blind, disabled, or incapacitated and you check yes for this question, proof of disability will be required. Items needed to verify disability include: a favorable disability decision from the Social Security Administration, a decision from the Disability Determination Bureau, or a completed Incapacity Form that can be obtained from a county human service or tribal office. The Incapacity Form must be completed and signed by a health care professional. If an applicant does not have documentation of disability or incapacity, a worker will contact him or her for verification. #3 Notices are available only in English or Spanish. Choose the language in which the applicant wants to receive notices. If a language other than English of Spanish is needed, indicate that in this box so workers will be aware of lanuage barriers and translation services can be arranged. #4 and #5 Write in the home address of the applicant and the mailing address if this is different. Write same in box #5 if the applicant does not have a different mailing address. #6 Write in the applicant s phone number, including area code. If there is no phone, write none. updated May2002 page C-3

17 Application Assistance The Form, Step by Step #7 Indicate if a child is not a full-time student because if there is a teenager in the household who is a part-time student and also working, his or her income must be included in the total household income for the purposes of assessing BadgerCare eligibility. #8 List all of the people living in the household, including those who are not applying for assistance. In the next box write the name of the spouse of the person listed above, or the name of the father/mother of the children living in the household. In the remaining boxes write the names of all other people living in the household (this will usually be the children). If you need more space, attach a second application form and continue to list all members of the household and include all requested information for those additional applicants. Note: You must list ALL members of the household even if they are not applying for coverage. For each person on the application who is applying for Medicaid, check yes under the column Applying for Medicaid? Check no for each person who is not requesting assistance. Complete ALL boxes after the names of each applicant. Do not leave blank boxes unless the person listed is not applying for coverage. Marital status codes are provided under box #8. For documented noncitizens: If any applicant in the household is not a U.S. citizen, attach a photocopy of his or her Alien Registration card to the application. For undocumented noncitizens: Those who are not applying for Medicaid do not have to provide Social Security Numbers, answer the citizenship question, provide date of entry into the U.S., or provide an Alien Registration Number. Those who are applying for Medicaid should check No to the question Are you a U.S. Citizen? They do not have to provide Social Security Numbers or date of entry into the U.S. Indicate ethnicity if the applicant wishes to provide this information. If not, write not applicable in this box. This information will not be used in any way in determining the client s eligibility for Medicaid or BadgerCare. Race and ethnicity codes are provided at the bottom of box #8. Complete the relationship boxes. Indicate the relationship of all people living in the household even if they are not applying for coverage. Examples: spouse, parent, stepparent, boyfriend, girlfriend, stepchild, son, daughter, niece, nephew, grandparent, grandchild, etc. updated May2002 page C-4

18 Application Assistance The Form, Step by Step In cases where two unrelated families are living in the same household, the applicant still must list all household members on the application. In the relationship boxes, indicate that the applicant is not related to them. Some suggested terms are co-tenant or roommate. If both unrelated families are seeking coverage, they need to complete separate applications. #9 This question refers to the parents of children who are applying for coverage. Check yes if any child applying for coverage has a natural or adoptive parent who is not living in the household. Check no if there is no absent parent for any applicant child. If you check no, write not applicable in #10. #10 Complete the absent parent contact information if applicable. (see Exceptions and Waivers below) Child Support Exceptions and Waivers Coverage for a pregnant woman or a child cannot be denied if the applicant does not wish to provide contact information for the absent parent to the county child support office. A pregnant woman s coverage will extend at least 60 days after her pregnancy ends. Her coverage will end on the last day of the month in which the 60 th day falls. At that time, she will no longer be eligible for coverage if she does not cooperate and provide absent parent contact information. If the applicant parent does not know where the absent parent currently resides and does not have contact information, the applicant parent cannot be penalized unless there is a valid reason to suspect this is not true, and it is proven that the applicant does have this information and is not cooperating with the child support office. If it is not known who the biological father of an applicant child is, write unknown in #10. This can be verified by providing a copy of the child s birth certificate without the name of a father who has a legal obligation to the child. If there is an abusive relationship that physically or emotionally threatens an applicant parent or child, a good cause waiver can be claimed. Write good cause requested in #10 and the applicant will be contacted by the economic support worker. If the waiver is granted, she or he will not have to provide absent parent information. Documentation that will be accepted includes: police or hospital records, shelter records, a statement from a physician or nurse, counselor or social worker, a member of the clergy, family member or friend, that documents the abusive relationship. #11 List the names of all applicants living in the household who have income from employment. You must also list income for all people in the household who are legally responsible for any applicant. Check the appropriate box in this section to indicate if any applicant is a migrant worker because their income is calculated differently. It is important to complete all relevant information about any employment income. updated May2002 page C-5

19 Application Assistance The Form, Step by Step Note: If a child under age 19 is a full time student and works part-time (less than 30 hours per week), that student s income does not count. If that child is not a full-time student, his or her income will count towards the household s total income. Summer employment for a full-time student returning to high school in the fall does not count. If the applicant/s checked yes in #1 and they want to have coverage in any of the three months prior to the month of application (retroactive eligibility), you must include employment and salary information for any month in the previous three months for which the applicant wants coverage. If employment and salary are the same in the previous 3 months, simply state that employment and salary for the retroactive eligibility period is the same as currently stated on the form. If employment and salary are different in any or each of the previous three months, attach another sheet of paper and list the employment and salary for each month. #12 Self-employment income and expenses may also be self-declared. If the family has self-employment income, you must also include the amount of the business depreciation from the most recent income tax return. The business depreciation may also be self-declared. You should write the depreciation amount from last year s income tax form in the space called Depreciation Amount Claimed. If the applicant is unsure of the answers to any of these questions, or if their self-employment situation is complex, he or she can attach a photocopy of their most recent income tax return. #13 Unearned Income is any income that is received from a source other than employment. Check yes for any category of unearned income that is received by an applicant in the household and list that amount in the Gross Monthly Amount column. You must also list the name of the applicant member of that household who receives the unearned income. Note: If you are requesting an FFU calculation for a child, put that child s interest income in the Other income box. List the monthly interest or, if it is a new savings account, list the amount of money in the account and the interest rate. Check no for each category of unearned income that is not received by the applicant household. Make sure you have checked yes or no for each type of unearned income listed, and that you have provided all additional required information for those categories that are received by the applicants. Even though there is no asset test, an applicant must include the interest income generated from any assets they own. Include this type of income in the box called Interest/Dividends. updated May2002 page C-6

20 Application Assistance The Form, Step by Step You may have more than one applicant in the household who is receiving interest income. If you would like to list these individually, you can use the two boxes called Other Income for this purpose. If there is not enough room to list information for all applicants, you can attach an additional sheet of paper or another application form with that information on it. Miscellaneous #14 This question refers only to health insurance coverage, not to dental insurance, life insurance, or car or house insurance. Make sure to answer the question about who is covered. In many instances, not everyone in the household will be covered by the private insurance policy. Note: Families may believe that their private insurance makes them ineligible for Medicaid. It is important to let them know that all Medicaid programs except BadgerCare are available to them even if they have private insurance coverage. Medicaid can fill in gaps such as deductibles and co-payments that a family will otherwise pay when they only have their private insurance. When in doubt, encourage a family with private health insurance to apply for Medicaid. It is important to complete information in the box that shows the end date of private insurance coverage because if an applicant family is found to be eligible only for BadgerCare, they will be denied coverage if it is not clear that the private insurance if no longer in effect. Note: Check the reason for loss of insurance coverage because waiver provisions may apply that will allow the family to access immediate coverage without a 3 month wait. #15 This is an important question because if an applicant pays for care for a family member, there is a deduction from gross income that can help an applicant family become eligible for Medicaid or BadgerCare coverage. If you check yes to question #15, be sure to complete all the necessary information requested so the simplified form can be processed without delay. #16 If you check yes to the question about child support, complete all additional requested information about child support income that is going out of the applicant household. If an applicant is court-ordered to make payments to support others, that court-ordered amount must be deducted from the household income. The child support deduction only applies if the payment is court-ordered. A voluntary child support payment to another parent will not be deducted. updated May2002 page C-7

21 Application Assistance The Form, Step by Step #17 If anyone in the household is pregnant, the fetus counts as an additional family member and can help a family meet the income guidelines for eligibility. If multiple births are expected, be sure to note this in #17 because each fetus will be counted as one additional family member. Required verification: Attach a signed and dated statement from a medical provider certifying the pregnancy, the number of fetuses, and the expected due date. #18 - Make sure the form is signed and dated. The filing date is the date the application is received by the economic support agency as long as it contains the individual s name, address and signature. If you fax the form to economic support, the filing date becomes the date the fax is printed at the local agency. You have now completed the simplified application. Make a photocopy for your records and one for the applicant. Mail or fax the completed application to your county or tribal social or human services office promptly. Be sure you verify that you are using the fax number where applications are accepted and also confirm that the fax has gone through. You may contact your local county or tribal agency for assistance. If you still have questions, call ABC for Health for technical assistance statewide at or in Madison at (608) Helpful Attachments for Application Submission The application form does not cover all eligibility situations. If you ve already collected information on the family s needs that would helpful for the economic support worker to know and that can t be recorded on the form, you can use one of the sample attachments. These attachments can be copied as needed and filled out to let the worker know that this family requests one or more of the following: Backdated eligibilty A Medicaid Deductible calculated An FFU calculated Medicaid for Emergency Services There are places on these attachments to supply additional information needed to assess backdated eligibility. The Medicaid for Emergency Services attachment can be used to let the worker know what type of medical service the applicant needed, and when that care was given. Note: ABC for Health created these forms for internal staff use and has found them to be quite helpful. Their use is entirely optional. updated May2002 page C-8

22 Attachment for Family Medicaid/BadgerCare Application Please note the following additional information and request for assessing eligibility: I request backdated eligibility for: 1 month 2 months 3 months My income for the past 3 months is the same as stated on this application. My income for the past 3 months varied. I ve listed my income for each month below: Name of month Name of month Name of month Income $ Income $ Income $ My household composition was the same for the last 3 months. My household composition was different in the last 3 months. Please calculate a Medicaid Deductible. Please calculate a Family Fiscal Unit (FFU) assessment of individual eligibility. This group has: A pregnant woman A child with his/her own income 1. Savings Account (child s name and acct #) 2. Savings Account (child s name and acct #) 3. Savings Account (child s name and acct #) 4. Savings Account (child s name and acct #) A stepparent A non-marital co-parent A non-legally responsible relative caregiver

23 Attachment to Simplified Application Medicaid for Emergency Services This applicant is a non-citizen. Please process this as an application for Medicaid for Emergency Services. This applicant is a pregnant woman or a woman who recently gave birth. Date of baby s birth Dates of hospital stay I am pregnant and applying for Medicaid prior to the birth of my baby, therefore I want a pregnancy extension. I required a c-section due to complications during delivery. I was injured or ill and was treated at the emergency room. Date of emergency room visit Dates of hospitalization (if required) I request backdated eligibility for: 1 month 2 months 3 months My income for the past 3 months is the same as stated on this application. My income for the past 3 months varied. I ve listed my income for each month below: Name of month Name of month Income $ Income $ Name of month Income $ My household composition was the same for the last 3 months. My household composition was different in the last 3 months. Please calculate a Medicaid Deductible. Please calculate a Family Fiscal Unit (FFU) assessment of individual eligibility. This group has: A pregnant woman A child with his/her own income/assets 1. Savings Account (child s name and acct #) 2. Savings Account (child s name and acct #) 3. Savings Account (child s name and acct #) 4. Savings Account (child s name and acct #) A stepparent A non-marital co-parent A non-legally responsible relative caregiver

24 Fact Sheets BadgerCare Who can get coverage? BadgerCare is a Wisconsin Medicaid Program that provides affordable health care for Wisconsin s low- to moderate-income families with children. BadgerCare provides coverage for: families who do not have health insurance; families who can t afford to purchase health insurance; families who are working in a job where family health insurance coverage is not offered; or families who experience a temporary job layoff or job loss. Note: Parents in BadgerCare families do not have to be employed to qualify for coverage. The following is a list of people that can get coverage through BadgerCare: children under the age of 19 (marital status does not affect eligibility); a natural or adoptive parent with a child under age 19 living in the household; spouses of parents with a child under 19 living in the household (stepparent); a non-marital co-parent with a child under 19 living in the household; and a family who is not currently covered by a comprehensive healthcare plan. Note: You must be a U.S. citizen to qualify for BadgerCare. Insurance coverage and access to health care coverage have very complicated rules that can affect BadgerCare eligibility. Please call ABC for Health at to talk with a Health Benefits Counselor about what effect private insurance may have on eligibility. Monthly FPL Chart (May 2002 April 2003) Are there income limits? Family 150% 185% 200% Size To qualify for BadgerCare, a family must be below 2 $ 1492 $ 1840 $ % Federal Poverty Level (FPL). There are specific 3 $ 1877 $ 2315 $ 2503 deductions that a family is allowed to take from 4 $ 2262 $ 2790 $ 3016 household income that will lower a family s countable 5 $ 2647 $ 3265 $ 3530 income and increase the chance that they will be found 6 $ 3032 $ 3740 $ 4043 eligible for BadgerCare. Once a family is in the BadgerCare program, they can keep coverage until their income goes over 200% FPL (see chart). There is no asset test for BadgerCare. updated May 2002 Fact Sheet 1

25 Fact Sheets BadgerCare There is no three-month backdated coverage in the BadgerCare program. Therefore, it is very important that a family submit a BadgerCare application as soon as possible. Always turn in the application before the end of the current month. Eligibility for BadgerCare coverage will begin the first day of the month that the family is found eligible for coverage. If a BadgerCare family has an income between % FPL, they will be required to pay a modest premium for BadgerCare. Premiums for many families range from $30-45 per month. Applying for coverage Applicants must be prepared to provide information about his or her and the children s: Social Security Numbers; dates of birth; monthly income and sources of this income; and recent or current private health insurance coverage. Steps for applying Complete the Family Medicaid/BadgerCare Application. Mail, fax or deliver the application (applications can be taken over the phone, but the date of eligibility will be determined based on when the signed application is received at the county human or social service department, not the date of the phone request). An individual or family can also apply in person at their county/tribal human or social service department, W-2 agency or Medicaid outstation site. Contact your local human or social service department for details. What services are covered? BadgerCare provides comprehensive coverage for a wide range of medical services. Some examples include: doctor visits, hospitalization costs, prescription drugs, ambulance charges, emergency medical care, dental and vision care, therapies, and counseling services. For help with coverage questions, call statewide / in Madison ABC for Health provides free health benefits counseling to families anywhere in Wisconsin. Benefits advocates will talk with you about health coverage options. updated May 2002 Fact Sheet 1

26 Fact Sheets Healthy Start Who can get coverage? Healthy Start provides payment of health care costs for: pregnant women; newborns (a child born to a mother on Healthy Start or any other Medicaid category will be continuously eligible for his or her first 12 months regardless of income; however, parents must report the birth of the child to their economic support worker); children up to age six; and children age 6 to 19 (children in this category must meet stricter income eligibility requirements. For more coverage options for children in this age group see the BadgerCare fact sheet). Are there income limits? Pregnant women and children under age 6 must have an income at or below 185% FPL. Children ages 6 to 19 must have an income at or below 100% FPL (see chart). For pregnant women, the fetus is counted for the purpose of income eligibility. For example, a pregnant woman with no other children is a family of two and must have a monthly income at or below $1,789. Additional methods of income eligibility calculations exist that make these income guidelines more generous. For more information see the Medicaid Deductible and Family Fiscal Unit fact sheets. There is no asset test for Healthy Start and eligibility may be backdated to include up to three months preceding the month of application. Applying for coverage Applicants must be prepared to provide information about his or her and the children s: monthly income; Social Security Number; date of birth; and verification of pregnancy (a woman must provide written verification, signed by a medical provider that includes the expected due date and the number of fetuses). Steps for applying Complete the Family Medicaid/BadgerCare Application Monthly FPL Chart (May 2002 April 2003) Family Size 100% 185% 2 $ 995 $ $ 1251 $ $ 1508 $ $ 1765 $ $ 2021 $ 3740 updated May 2002 Fact Sheet 2

27 Fact Sheets Healthy Start Mail, fax or deliver the application (applications can be taken over the phone, but the date of eligibility will be determined based on when the signed application is received at the county human or social service department, not the date of the phone request). An individual or family can also apply in person at their county/tribal human or social service department, W-2 agency or Medicaid outstation site. Contact your local human or social service department for details. Advocacy Tip: Always apply before the end of the month to gain the most benefits possible. Waiver provisions for pregnant women and children Pregnant women applying for Healthy Start will be asked to provide contact information for the baby s father. There are specific circumstances under which the pregnant woman does not have to answer these questions. Coverage for a pregnant woman or child cannot be denied if the applicant does not provide the contact information for the absent parent to the county child support office. A pregnant woman will remain covered until the last day of the month 60 days after the birth of the baby. After the Healthy Start coverage ends, the woman will not be eligible for any other Medicaid program if she does not provide the contact information for the absent parent, however, her child will remain eligible. If the pregnant woman does not know where the father currently resides and does not have contact information for him, the pregnant woman cannot be penalized unless it is proven that the pregnant woman is not cooperating (such as concealing the father s location). The pregnant woman cannot be penalized for not providing absent parent information if she does not know who is the father of the child. If there is an abusive relationship that physically or emotionally threatens the pregnant woman applying for Healthy Start or her children, a waiver can be requested so that the contact information for the absent parent does not have to be provided. A form will be sent to the pregnant woman from the child support office in her county. She must complete this form and return it, and a decision will be made as to whether or not the circumstances meet the waiver criteria. Documentation that will be accepted includes: police or hospital records, shelter records, a statement from a physician or nurse, counselor/social worker or member of the clergy, family member or friend, that documents the abusive relationship. What services are covered? Healthy Start pays for doctor visits, hospital costs, prescription drugs, delivery costs, medical, dental, vision and counseling services for pregnant women, newborns and children up to age 19. For pregnant women, Healthy Start coverage ends on the last day of the month 60 days after the birth of the baby. For help with coverage questions, call statewide / in Madison ABC for Health provides free health benefits counseling to families anywhere in Wisconsin. Benefits advocates will talk with you about health coverage options. updated May 2002 Fact Sheet 2