Form F-10101 "Wisconsin Medicaid for the Elderly, Blind or Disabled Application Packet" - Wisconsin

What Is Form F-10101?

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-10101 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-10101 "Wisconsin Medicaid for the Elderly, Blind or Disabled Application Packet" - Wisconsin

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WISCONSIN DEPARTMENT OF HEALTH SERVICES
Division of Medicaid Services
F-10101 (02/2020)
WISCONSIN MEDICAID FOR THE ELDERLY, BLIND OR DISABLED
APPLICATION PACKET
HOW TO APPLY
This is an application for health care benefits for people who are 65 years of age or older, blind or have a
disability.
To apply for health care benefits, complete this application and return it to the following address or complete an
application online at access.wi.gov. See below for more information about applying online.
Mail or Fax Applications and/or Proof/Verification to:
If you live in Milwaukee County:
If you do not live in Milwaukee County
MDPU
CDPU
PO Box 05676
PO Box 5234
Milwaukee, WI 53205
Janesville, WI 53547-5234
Fax: 888-409-1979
Fax: 855-293-1822
You can also scan and/or upload any proof online at
access.wi.gov
.
You will need to provide proof of some of your answers. For more information on what you will need to
provide, see the Proof/Verification Section starting on page 4.
If you have questions about Medicaid, need help filling out this application or want to answer the questions in
person or over the phone, contact your agency to set up an appointment. If you need the address and/or phone
number of your agency, see page 6. Information is also available online at
www.dhs.wisconsin.gov/forwardhealth/resources.htm.
If you have a disability and need this information in an alternate format, or if you need it translated to another
language, contact your agency. These services are free of charge.
APPLY ONLINE
ACCESS is an online tool that lets you apply for benefits, check the status of your benefits, report changes or
complete your annual renewal. To visit ACCESS go to access.wi.gov. An online application is the same as a
paper application.
LETTERS AVAILABLE THROUGH THE ACCESS WEBSITE
Members can get letters and information about their benefits online instead of by regular mail. To make this
choice, the member needs to contact their agency, or log into their ACCESS account at access.wi.gov. If a
member does not have an ACCESS account, they must create one to view their letters online.
HOW TO USE THIS FORM
1. Read the Important Information section and all the instructions before completing the application.
2. Print clearly. Use blue or black ink.
3. Write dates in the mm/dd/yyyy format. (Example: April 2, 1958, would be 04/02/1958.)
4. Enter information about you and/or your spouse.
5. Completely fill out the application. There may be a delay in Medicaid benefits if the application is not
complete. (Use the checklist on page 15 to make sure your application is complete.) If your application is not
complete, the agency will contact you for more information.
1
WISCONSIN DEPARTMENT OF HEALTH SERVICES
Division of Medicaid Services
F-10101 (02/2020)
WISCONSIN MEDICAID FOR THE ELDERLY, BLIND OR DISABLED
APPLICATION PACKET
HOW TO APPLY
This is an application for health care benefits for people who are 65 years of age or older, blind or have a
disability.
To apply for health care benefits, complete this application and return it to the following address or complete an
application online at access.wi.gov. See below for more information about applying online.
Mail or Fax Applications and/or Proof/Verification to:
If you live in Milwaukee County:
If you do not live in Milwaukee County
MDPU
CDPU
PO Box 05676
PO Box 5234
Milwaukee, WI 53205
Janesville, WI 53547-5234
Fax: 888-409-1979
Fax: 855-293-1822
You can also scan and/or upload any proof online at
access.wi.gov
.
You will need to provide proof of some of your answers. For more information on what you will need to
provide, see the Proof/Verification Section starting on page 4.
If you have questions about Medicaid, need help filling out this application or want to answer the questions in
person or over the phone, contact your agency to set up an appointment. If you need the address and/or phone
number of your agency, see page 6. Information is also available online at
www.dhs.wisconsin.gov/forwardhealth/resources.htm.
If you have a disability and need this information in an alternate format, or if you need it translated to another
language, contact your agency. These services are free of charge.
APPLY ONLINE
ACCESS is an online tool that lets you apply for benefits, check the status of your benefits, report changes or
complete your annual renewal. To visit ACCESS go to access.wi.gov. An online application is the same as a
paper application.
LETTERS AVAILABLE THROUGH THE ACCESS WEBSITE
Members can get letters and information about their benefits online instead of by regular mail. To make this
choice, the member needs to contact their agency, or log into their ACCESS account at access.wi.gov. If a
member does not have an ACCESS account, they must create one to view their letters online.
HOW TO USE THIS FORM
1. Read the Important Information section and all the instructions before completing the application.
2. Print clearly. Use blue or black ink.
3. Write dates in the mm/dd/yyyy format. (Example: April 2, 1958, would be 04/02/1958.)
4. Enter information about you and/or your spouse.
5. Completely fill out the application. There may be a delay in Medicaid benefits if the application is not
complete. (Use the checklist on page 15 to make sure your application is complete.) If your application is not
complete, the agency will contact you for more information.
1
WISCONSIN MEDICAID FOR THE ELDERLY, BLIND AND DISABLED APPLICATION PACKET
F-10101
IMPORTANT INFORMATION
The following is important information regarding Medicaid for persons who are elderly, blind or have a
disability.
Legal Guardian, Conservator, or Power of Attorney
If you have a legal guardian, conservator, or power of attorney for finances, that person can fill out and submit
this form on your behalf. That person would also need to submit documents about his or her appointment along
with this form.
Authorized Representative
You may have an authorized representative apply for you. To appoint an authorized representative, fill out either
the Appoint, Change, or Remove an Authorized Representative: Person form, F-10126A, or the Appoint,
Change, or Remove an Authorized Representative: Organization form, F-10126B, found in this application
packet. This will allow your authorized representative to complete and sign the application for you.
Application Date
Your application date is the date the Medicaid office gets your signed application. A decision on your Medicaid
will be mailed to you within 30 days of your application date. Unsigned forms will be returned. It is important to
apply as soon as possible since the date your benefits will begin, if you meet all program rules, is based on your
application date.
Backdated Coverage
You may be able to get Medicaid benefits for up to three months before your application date if you provide the
necessary information to show you met the Medicaid rules for those months. If you want help paying for health
care for any of the past three months (backdated coverage), complete the “Medicaid Backdated Coverage
Request” page found in this application packet.
Personally Identifiable Information / Social Security Number
Personally identifiable information and Social Security Numbers are used only for the direct administration of
the Medicaid program.
If someone in your household is not applying for Medicaid, you do not need to provide Social Security Number
(SSN) information for that person. Any person who wants Wisconsin Medicaid, but does not provide their SSN
or apply for one will not be eligible for benefits, pursuant to Wis. Stat. § 49.82(2).
If you are applying only for Emergency Services because of your immigration status, or you are a pregnant
woman applying for BadgerCare Plus Prenatal Services, you do not need to provide SSN information.
Your SSN permits a computer check of your information with government agencies such as the Internal
Revenue Service (IRS), Social Security Administration, Department of Revenue and the Department of
Workforce Development. In addition, the Department of Health Services will match your name and SSN with
information provided by health insurance carriers to determine if you have other health insurance.
Your SSN will not be shared with the United States Citizenship and Immigration Services (USCIS).
Renewals
If you are able to get Medicaid, you will need to complete a renewal at least once every 12 months to see if you
still meet all the program rules for enrollment in Medicaid.
2
WISCONSIN MEDICAID FOR THE ELDERLY, BLIND AND DISABLED APPLICATION PACKET
F-10101
Fair Hearing
Estate Recovery
You may appeal to the Division of Hearings and
If you are enrolled in Medicaid, Wisconsin State
Appeals or your agency if:
law, with limited exceptions, requires the recovery
of certain Medicaid benefits from your estate. The
• Your application for Medicaid was denied in
Estate Recovery Program Handbook (P-13032)
error.
provides you with information on estate recovery.
• Your application was not processed within 30
You may get a copy of the brochure from your local
days from the date the agency received it.
agency or by contacting Member Services at
• You disagree with the agency’s decision to
800-362-3002. Certain benefits you get in the
discontinue, terminate, suspend, or reduce your
community after age 55 and all Medicaid benefits
benefit.
you get while residing in a nursing home or while
• Your request for prior authorization for a
you are an inpatient in a hospital for 30 days or
medical service was denied.
more, are recoverable. Also, if you reside in a
nursing home or are institutionalized in a hospital,
You may request a fair hearing by writing to:
and are not expected to return home to live, a lien
Wisconsin Department of Administration
may be placed on your home. A lien may not be
Division of Hearings and Appeals
placed on your home if you, your spouse or certain
PO Box 7875
other family members reside in the home.
Madison, WI 53707-7875
Rights and Responsibilities
The Request for Fair Hearing form can be found at
Rights
www.dhs.wisconsin.gov/forwardhealth/
State and Federal laws guarantee rights for
resources.htm.
members, which include:
• The right to be treated with respect by state and
If you choose to write a letter instead of using the
county employees.
form, you must include:
• The right to confidentiality of all information
given to agencies to determine eligibility. (This
• Your name.
does not prohibit the use of such records for
• Your mailing address.
program administration.)
• A brief description of the problem.
• The right of access to agency’s records and files
• The name of the agency.
relating to your case, except information obtained
• Your CARES case number.
by the agency under a promise of confidentiality.
• Your signature.
• The right to remain eligible for Medicaid benefits
even if temporarily absent from the state, if you
An appeal must be made no later than 45 days after
remain a Wisconsin resident.
the date of the action.
• The right to a speedy determination of eligibility
status and prior notice of proposed changes in
You may also contact the agency where you applied
such status.
and ask for help filing a Fair Hearing request. Refer
• The right to emergency medical care.
to the ForwardHealth Enrollment and Benefits
• The right to request reasonable accommodation
Handbook (P-00079) to learn more about the fair
to participate in the program for a disability-
hearing process. You will get a handbook when the
related reason, or the right to request interpreters
agency gets your application or you can find the
or translators to participate in the program.
handbook at
www.dhs.wisconsin.gov/forwardhealth/
• The right to appeal any action taken concerning
resources.htm.
your Medicaid application or ongoing benefits
that you do not agree with by requesting a fair
If you have questions about the fair hearing process,
hearing.
you can call the Division of Hearings and Appeals at
608-266-7709.
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WISCONSIN MEDICAID FOR THE ELDERLY, BLIND AND DISABLED APPLICATION PACKET
F-10101
Responsibilities
States Citizenship and Immigration Services
(USCIS) for people in your household who are not
Reporting Changes
applying for assistance. If someone in your
Report to the agency within 10 days:
household is not applying for Medicaid, you do not
• Any changes in income of any member of your
need to answer this question for that person.
household.
• Any other change in the information you have
Note: Undocumented immigrants are only eligible
given on your application that is required to be
for coverage of emergency health care services if
reported on the Medicaid Change Report form,
they would otherwise be eligible for Medicaid.
F-10137, located in this application packet.
Pregnant immigrants may be able to enroll in
BadgerCare Plus Prenatal Services.
Note: If you are in a Medicaid HMO and you move
out of state but do not report this move, you will be
Examples of what you can use to prove both
responsible to repay Wisconsin Medicaid any
citizenship and identity are:
payment they made to your HMO. For example, if
• U.S. passport
Wisconsin Medicaid paid your HMO $175 per
• Certificate of U.S. Citizenship
month for you and your spouse, the amount of
• Certification of U.S. Naturalization
overpayment you would have to repay Wisconsin
• A state-issued enhanced driver’s license
Medicaid is $350, for each month the HMO was
• Tribal identification documents
paid after you moved out of state, even if you did
not use your Forward card.
Examples of what you can use to prove
citizenship are:
Changes can be reported online at access.wi.gov, by
• U.S. birth certificate
calling your agency or you can use the Medicaid
• U.S. State Department Report of Birth Abroad
Change Report form, F-10137, in this application
• U.S. citizen ID card
packet. Do not send this form with your
application; keep it for future use.
• Adoption papers showing U.S. birth
• Hospital record of U.S. birth
Verification/Proof
• U.S. military record of service or draft record
showing U.S. birth
You will need to provide verification/proof of
certain information. Some of these include:
• Life or health insurance record showing U.S.
birth
Citizenship / Identity
• Nursing home admission papers showing U.S.
Federal law requires that all U.S. citizens applying
birth
for, or getting Medicaid benefits must show proof of
their U.S. citizenship and identity unless they are
Examples of what you can use to prove identity
exempt. Exempt people include recipients of Social
are:
Security Disability Insurance (SSDI), Supplemental
• State driver’s license
Security Income (SSI), Medicare, Foster Care, and
• ID card issued by federal, state, or local
Adoption Assistance. If you are applying for
government
benefits, you will have at least 95 days, from the
• School ID card with photo
date of your application, to provide proof to the
• U.S. military dependent ID card
agency. If you have provided this information in the
• U.S. military ID card
past,, it may already be on file; your agency will let
• For children under age 18, a signed Statement of
you know if more proof is needed.
Identity form, F-10154
We also verify with the U.S. Department of
Homeland Security the immigration status of all
immigrants who apply for benefits for themselves.
Immigration status will not be verified with United
4
WISCONSIN MEDICAID FOR THE ELDERLY, BLIND AND DISABLED APPLICATION PACKET
F-10101
Assets
You will be required to provide proof of all your
assets. Examples of proof include a copy of your
bank statement showing the value of your bank
account on the date the application is completed,
property tax bill, vehicle title/registration, or
something that shows the face value and cash value
of your life insurance policy. If married and
applying for Institutional Medicaid, an Asset
Assessment will be required for both the applicant
and spouse.
Other
Your worker may also ask for proof of the
following:
• Medical expenses to meet a deductible,
• Physician’s certification (verbally or in writing)
that the person is likely to return to the home or
apartment within 6 months for institutionalized
persons maintaining a home or property and who
may be entitled to a home maintenance
allowance. If allowed, expenses will need to be
verified,
• Documentation for Power of Attorney and
Guardianship, and/or
• Disability.
If you have these items available on the day you
submit this application, provide a copy of them with
your application. You will be contacted by the
agency and be asked to provide proof of missing,
conflicting or vague information, if the information
would affect the decision about your Medicaid
enrollment.
Do not send original documents in the mail. You
may bring in original documents or send
photocopies of these items with your application. If
you are having trouble getting what you need to
provide proof, contact your agency and ask for help.
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