Form F-10182 "Badgercare Plus Application Packet" - Wisconsin

What Is Form F-10182?

This is a legal form that was released by the Wisconsin Department of Health Services - a government authority operating within Wisconsin. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on February 1, 2020;
  • The latest edition provided by the Wisconsin Department of Health Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form F-10182 by clicking the link below or browse more documents and templates provided by the Wisconsin Department of Health Services.

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Download Form F-10182 "Badgercare Plus Application Packet" - Wisconsin

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BadgerCare Plus Application Packet
F-10182 — February 2020
BadgerCare Plus Application Packet
F-10182 — February 2020
DEPARTMENT OF HEALTH SERVICES
STATE OF WISCONSIN
Division of Medicaid Services
F-10182 (02/2020)
BADGERCARE PLUS APPLICATION PACKET
This is an application for BadgerCare Plus and Family
Print clearly, using blue or black ink.
Planning Only Services. You can apply:
Read any instructions, before you answer the
Online at access.wi.gov. Click Apply now.
question.
By mail or fax: Complete this application, mail or fax
it to:
Complete all sections of the application that apply to
you and your family. You may have a delay in
If you live in Milwaukee County:
getting BadgerCare Plus benefits if the application is
not complete.
MDPU
PO Box 05676
If more room is needed, use an additional sheet of
Milwaukee WI 53205
paper or the blank sheets at the end of the
Fax: 1-888-409-1979
application.
If you do not live in Milwaukee County
Enter information about all the people living in your
CDPU
home. List all children who live in the home with you
PO Box 5234
at least 40% of the time.
Janesville, WI 53547-5234
Fax: 1-855-293-1822
You may need to provide proof of some of your
answers. See the Verification/Proof Section on page
By phone or in-person: You will need to call your
4, to see what you will need to provide. Enclose with
agency to set up an appointment to apply by phone
your application any proof, additional documentation
or in-person.
or sheets of paper used to complete the application.
Please send copies. Do not send originals.
If you need help filling out this application or want to
answer the questions in person or by telephone, contact
You may have an authorized representative apply
your agency. To get the address or phone number of
for you. To appoint an authorized representative, fill
your agency, call 800-362-3002 or go to
out either the Appoint, Change, or Remove an
www.dhs.wisconsin.gov/forwardhealth/imagency/
Authorized Representative: Person form, F-10126A,
index.htm.
or the Appoint, Change, or Remove an Authorized
Representative: Organization form, F-10126B. This
If you have a disability or need this information
will allow your authorized representative to complete
interpreted/translated or in a different format, contact
and sign the application for you. To get this form,
your agency. These services are free.
call 800-362-3002, or go to
www.dhs.wisconsin.gov/forwardhealth/
ACCESS - APPLY ONLINE
representative-types.htm.
ACCESS is an online tool that lets you apply for benefits,
check the status of your benefits, or report changes to
Sign the application and any attachments that
your worker. To visit ACCESS, go to access.wi.gov.
require a signature. Applications and/or attachments
without a signature will be returned.
On ACCESS, you can also apply for FoodShare
Wisconsin, which is a program that helps people buy
If you want to apply for FoodShare, complete the
nutritious food. For more information about FoodShare,
FoodShare Wisconsin Registration form, F-16019A,
go to
in this application packet.
www.dhs.wisconsin.gov/forwardhealth/resources.htm.
HOW TO USE THIS FORM — CHECK LIST
Read the Important Information, the Rights and
Responsibilities sections before you apply.
Keep pages 1 through 6 and the Information Change
Report, F-10183, in this application packet, for future
changes.
BADGERCARE PLUS APPLICATION PACKET
F-10182
Page 2 of 33
IMPORTANT INFORMATION
current income guidelines, call 800-362-3002 or go to
www.dhs.wisconsin.gov/forwardhealth/resources.htm.
The following is important information you will need to
know about applying for BadgerCare Plus.
OTHER MEDICAL COVERAGE
As a condition of BadgerCare Plus enrollment, you must
It is important to apply as soon as possible as your
report to the agency any third party who may be liable to
application date is the date the agency gets your
pay for medical care for yourself and your family. You
signed application.
must cooperate by giving information as requested. This
Most pregnant women and people with income
also includes any insurance that may be available
below certain limits, who have medical bills in any of
through an absent parent or an employer's group health
the three months before their application date, may
insurance.
be able to get “backdated coverage”. If you’d like to
request backdated coverage, fill out Attachment 7;
PERSONALLY IDENTIFIABLE INFORMATION/
Request for Backdated Coverage form and send it in
SOCIAL SECURITY NUMBER (SSN)
with your completed application.
If you are enrolled in BadgerCare Plus, you will need
Personally identifiable information and Social Security
to complete a renewal with your agency every 12
Numbers are used only for the direct administration of
months to stay enrolled.
the BadgerCare Plus programs.
Your application for BadgerCare Plus is also an
application for help with paying for private health
If someone in your household is not applying for
insurance through the federal Health Insurance
BadgerCare Plus, you do not need to provide a Social
Marketplace. If you do not meet the rules to enroll in
Security Number (SSN) or immigration information for
BadgerCare Plus or Medicaid, your information may
that person. Any person who wants BadgerCare Plus,
be sent to the Marketplace. If this happens, the
must provide their SSN or apply for one pursuant to Wis.
Marketplace will contact you and let you know if you
Stat. § 49.82(2).
are able to get help with paying for private health
insurance. To learn more about the Marketplace,
If you are applying for BadgerCare Plus and do not have
visit
healthcare.gov
or call 1-800-318-2596 or 1-855-
an SSN due to religious beliefs or because of your
889-4325 (TTY).
immigration status, leave the SSN field blank.
ACCESS TO EMPLOYER GROUP HEALTH
Your SSN permits a computer check of your information
INSURANCE
with government agencies such as the Internal Revenue
Service (IRS), Social Security Administration,
If employer-sponsored health insurance is available,
Department of Revenue, Department of Transportation
some children and pregnant women might not be able to
and the Department of Workforce Development. In
get BadgerCare Plus.
addition, the Department of Health Services will match
your name and SSN with information provided by health
The Department of Health Services will check this
insurance carriers to determine if you have other health
information with your employer before you are enrolled.
insurance.
BADGERCARE PLUS DEDUCTIBLE
Your SSN will not be shared with the United States
If you are a pregnant woman who is a U.S. citizen or
Citizenship and Immigration Services (USCIS).
qualifying immigrant and you have income over 300% of
the Federal Poverty Level (FPL) or if your child is not
CHILD SUPPORT COOPERATION
able to enroll because he or she is over the income limit
In some situations, you must cooperate with the Child
or has access to employer-sponsor health insurance
Support Agency to establish paternity. This means you
where the employer pays 80% or more of the premium,
must help the agency locate an absent parent, legally
you may still be able to enroll by meeting a deductible.
name the absent parent and/or enforce medical support
liability orders. If you do not cooperate with the Child
For a pregnant woman a deductible is the difference
Support Agency and do not have a good reason to not
between your family’s net income and 300% of the
cooperate, your benefits may end if you are an adult and
federal poverty level over a six-month period. For
are not pregnant.
children, a deductible is the difference between your
family’s net income and 150% of the federal poverty
level over a six-month period. For example, if your
monthly income is $100 over the 150% federal poverty
level, you would have to pay a deductible of $600, to be
able to get benefits. ($100 X 6 months = $600). For
BADGERCARE PLUS APPLICATION PACKET
F-10182
Page 3 of 33
RECOVERY OF BADGERCARE PLUS
You disagree with the agency’s decision to
discontinue, terminate, suspend, or reduce your
Wisconsin state law provides for the recovery of certain
benefit.
BadgerCare Plus benefits you get in error. The law also
Your request for prior authorization was denied.
requires the recovery of certain Medicaid benefits from
your estate or the estate of your surviving spouse. The
Wisconsin Estate Recovery Program Handbook (P-
You may request a fair hearing by writing to:
13032) provides you with information on estate recovery.
You may get a copy of the publication from your agency,
Wisconsin Department of Administration
by contacting Member Services at 800-362-3002 or at
Division of Hearings and Appeals
www.dhs.wisconsin.gov/publications/p1/p13032.pdf.
PO Box 7875
Certain benefits you get in the community after age 55
Madison, WI 53707-7875
and all benefits you get after age 55 while you are
participating in a long-term care program, living in a
The Request for Fair Hearing form can be found at
nursing home or while you are an inpatient in a hospital
www.dhs.wisconsin.gov/forwardhealth/resources.htm.
for 30 days or more, are recoverable.
If you choose to write a letter instead of using the form,
RIGHTS
you must include:
State and federal laws guarantee rights for anyone
applying for or enrolled in BadgerCare Plus. These rights
Your name.
include the right to:
Your mailing address.
A brief description of the problem.
Be treated with respect by state and county
The name of the agency.
employees.
Your CARES case number.
Confidentiality of all information given to local
Your signature.
agencies to determine enrollment. (This does not
prohibit the use of such information for program
An appeal must be made no later than 45 days after the
administration.)
date of the action.
Have access to agency records and files relating to
your case, except information obtained by the local
You may also contact the agency where you applied and
agency under a promise of confidentiality.
ask for help filing a Fair Hearing request. Refer to the
The right to remain enrolled in BadgerCare Plus
ForwardHealth Enrollment and Benefits Handbook
even if temporarily absent from the state, if you
(P-00079) to learn more about the fair hearing process.
remain a Wisconsin resident.
You will get a handbook when the agency gets your
Be notified if you can be enrolled in BadgerCare
application or you can find the handbook at
Plus within 30 days from the day the agency
www.dhs.wisconsin.gov/forwardhealth/resources.htm.
receives your application for BadgerCare Plus.
Be notified in advance of changes in your benefits or
If you have questions about the fair hearing process, you
enrollment status.
can call the Division of Hearings and Appeals at
608-266-7709.
Ask for reasonable accommodation to participate in
the program for a disability-related reason, or the
RESPONSIBILITIES
right to request interpreters or translators to
participate in the program.
Report Public Assistance Fraud — Go to
Appeal any action taken concerning your
https://www.reportfraud.wisconsin.gov/ or call
BadgerCare Plus application or on-going benefits
1-877-865-3432 (toll-free).
that you do not agree with by asking for a Fair
Hearing.
You have the responsibility to provide truthful and
complete information on this application, attachments or
FAIR HEARING
any other form(s) needed for BadgerCare Plus and
Family Planning Only Services enrollment.
You may appeal to the Division of Hearings and Appeals
or your agency if:
Your application for BadgerCare Plus was denied in
error.
Your application was not processed within 30 days
from the date the agency received it.