Free Temporary Enrollment for BadgerCare Plus Family Planning Waiver Plan, F-10119A - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-10119A (01/09)

STATE OF WISCONSIN

TEMPORARY ENROLLMENT FOR BADGERCARE PLUS FAMILY PLANNING WAIVER PLAN
This application is only for those persons applying for Temporary Enrollment for the BadgerCare Plus Family Planning Waiver Plan. The Family Planning Waiver Plan provides limited services to women seeking contraceptive management. Both the Family Planning Waiver Plan qualified provider and applicant should complete the application together. Providing or applying for a Social Security Number (SSN) is voluntary; however, any person who wants BadgerCare Plus but does not provide an SSN or apply for one will not be able to enroll in BadgerCare Plus. SSNs and personally identifiable information will be used only for the direct administration of the BadgerCare Plus program. Applicants and members who belong to a recognized religious sect that conscientiously opposes applying for or using an SSN are exempt from meeting the SSN requirements. A person who refuses to apply for or use an SSN due to religious beliefs must provide verification from a church elder or other officer that doing so is against the church doctrine. Once the application has been completed, provide a copy to the applicant, retain a copy for your files and mail or fax a copy to: Wisconsin Medicaid Temporary Enrollment 6406 Bridge Rd Madison WI 53784 Fax: (608) 250-5202 Federal poverty level (FPL) guidelines are updated annually. For current guidelines, go to badgercareplus.org/fpl.htm.

SECTION I --APPLICANT INFORMATION (GENERAL) (Applicant completes this Section) If the applicant prefers information she receives in a language other than English, indicate the preferred language. Line 1: Applicant name, birth date, telephone number Determine if the applicant is age 15 through 44: · · If the applicant will turn 45 during the temporary enrollment period, she may be enrolled up to her 45th birthday. The applicant must be at least 15 years of age on the date that the form is signed.

If the applicant meets the age requirement, go to Line 2. If the applicant does not meet this age requirement, go to Section III and check the box indicating that the applicant cannot be enrolled because she does not qualify under the age guidelines. Follow the instructions for Section III ­ Notice for an Applicant who Cannot be Temporarily Enrolled in the BadgerCare Plus Family Planning Waiver Plan. Line 2: Applicant's residence address and county of residence. If the applicant is a resident of Wisconsin, continue to Line 3. If the applicant is not a Wisconsin resident, go to Section III and check the box indicating that the applicant cannot be enrolled because she does not qualify under the residency guidelines. Follow the instructions for Section III ­ Notice for an Applicant who Cannot be Enrolled in the BadgerCare Plus Family Planning Waiver Plan. Line 3: Are you receiving full-benefit Wisconsin Medicaid or BadgerCare Plus? If the applicant answers "No" on Line 3, go to Line 4. If the applicant answers "Yes" on Line 3, she is already receiving full benefit Medicaid or BadgerCare Plus benefits. Explain that she already has access to the same benefits through the Medicaid and/or BadgerCare Plus programs. Go to

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Section III and check the box that the applicant cannot be enrolled because she is eligible for full benefit Medicaid or BadgerCare Plus. Follow the instructions for Section III ­ Notice for an Applicant who Cannot be Enrolled in the BadgerCare Plus Family Planning Waiver Plan. Line 4: Are you a U. S. citizen? If the applicant answers "Yes" on Line 4, go to Line 5. If the applicant answers "No" on Line 4, she has indicated that she is not a U.S. citizen, go to Section III and check the box indicating that the applicant cannot be enrolled because she is not a US citizen. Follow the instructions for Section III ­ Notice for an Applicant who Cannot be Enrolled in the BadgerCare Plus Family Planning Waiver Plan.. Inform the applicant you cannot determine her temporarily enrolled, however, she may still be able to enroll for Family Planning Services or BadgerCare Plus, but she must apply through her local county or tribal agency or online at access.wi.gov. A list of these agencies can be found at badgercareplus.org/gethelp.htm or she can contact Member Services at 1-800-362-3002. Line 5: Have you been determined temporarily enrolled in the Family Planning Waiver Plan in the last 12 months? If the applicant answers "No" on Line 5, go to Line 6. If the applicant answers "Yes" on Line 5, she cannot be temporarily enrolled. A woman is only allowed to have one period of temporary enrollment in a 12-month period. To determine if the applicant has been temporarily enrolled in the last 12 months, call Provider Services at 1-800-947-9627. Go to Section III and check the box indicating that the applicant cannot be enrolled because she has been temporarily enrolled in the Family Planning Waiver Plan in the last 12 months. Follow the instructions for Section III ­ Notice for an Applicant who Cannot be Enrolled in the BadgerCare Plus Family Planning Waiver Plan. Explain that she can only be temporarily enrolled once in a 12 month period. Encourage the woman to apply for the Family Planning Waiver Plan or BadgerCare Plus at her local county or tribal agency, or online at access.wi.gov. A list of these agencies can be found at badgercareplus.org/gethelp.htm or by contacting Member Services at 1-800-362-3002. Section II -- Income Information To complete Section II, the qualified provider should work with the applicant to answer the questions regarding her finances. For determining temporary enrollment the financial test is based on anticipated income. For this calculation, use the actual income expected during the month. (For example, a woman applying any time in September will use expected income for September.) Answer all the questions for the individuals counted as part of the group on Line 6, Section II. Line 6: When determining who is in the eligibility group, the provider is required to include certain family members living with the applicant. Count the applicant, her spouse, any non-marital co-parent of any of her minor children who are living in the household, and any natural, step or adopted children that live in the household when determining the group size. For example, if the applicant is a/an: Minor (under age 18) -- Include only the minor female, her spouse, or the non-marital co-parent of any of her children living in the household, and her natural, step or adopted children that live in the household and unborn fetuses of any member of the household. Adult female without a spouse -- Include the adult female, the non-marital co-parent of any of her children living in the household, her minor natural or adopted children living in the household and the number of unborn fetuses of any member of the household. Adult female with a spouse -- Include the adult female, her spouse if he is living in the household, her minor natural, step or adopted children living in the household and the number of unborn fetuses of any member of the household. Enter the number of family members, on Line 6.

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Line 7: To be temporarily enrolled, the applicant must meet the income limits for the appropriate group size. Income includes the spouse's income if the applicant is married, or the income of a non-marital co-parent of any of her children living in the household. Do not count the income of the applicant's parents, if the applicant is a minor. Earned income includes: Wages, Salaries, Tips, Commissions, All other payments resulting from labor or personal service, excluding allowances, and Self-employment. Self employment income is income earned directly from one's own business, rather than earned as an employee with a specified salary or wages from an employer. Do not count the following as monthly earned income: Wages of individuals under 18 years of age Tax refunds, Student financial aids, or Allowances. Add monthly gross earned income (amount of money earned before any deductions) for each member of the group to arrive at the total monthly earned income. Enter this amount on Line 7. Line 8: Add all monthly other income. Other income includes, but is not limited to: Pensions, annuities, insurance benefits, Social Security (use gross amounts), Veterans benefits, military allotments and Workers' Compensation. Payments received for the rental of rooms, apartments, dwelling units, buildings or land (if not reported as selfemployment income). Taxes and the expense of property maintenance may be deducted. Child support payments received. If the applicant is a minor, list the child support payments received for the minor, even if the minor does not directly receive the payments. Money, including allowances provided to someone in the eligibility group by someone outside of the eligibility group. Example: Julia is a 17 year old who applies for Temporary Enrollment for BadgerCare Plus Family Planning Waiver Plan. Julia receives $25 a week or $100 a month as an allowance from her father who no longer lives in the same household. Julia's father also pays child support directly to Julia's mother in the amount of $400. Julia's other income would be $500. This is the amount that is reported on line 9. Do not count the following as monthly other income: Supplemental Security Income (SSI). Student loans or grants, regardless of source, including work study. Reimbursement for expenses which the applicant has incurred or paid, except for reimbursement for normal household living expenses such as rent, clothing or food eaten at home. Foster care or subsidized adoption payments. Life insurance policy dividends. Tax refunds, including Earned Income Tax Credits payments. Governmental (federal, state, or local) rent and housing subsidies, including payments made directly to the applicant for housing or utility costs (e.g., U.S. Department of Housing and Urban Development (HUD) utility allowances). Nutrition-related benefits, such as FoodShare Wisconsin. Enter this amount on Line 8. Line 9: Add the total monthly gross income by adding the applicant's monthly gross earned income (Line 7) and total monthly other income (Line 8). Enter this amount on Line 9.

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If the applicant's total monthly gross income (Line 9) exceeds 200% of the federal poverty level for the appropriate group size, go to Line 10. If the applicant's total monthly gross income (Line 9) is at or below 200% of the federal poverty level for the appropriate group size, and all non-financial requirements have been met, she is temporarily enrolled. Check "Yes" on Line 12 and go to Section III. The federal poverty level (FPL) guidelines are updated annually. For current FPL guidelines go to badgercareplus.org/fpl.htm. Line 10: When determining the enrollment of a woman who has been ordered by a court to pay child support, (i.e., support for a child not living in the same home as the parent paying child support), enter the amount ordered by the court on Line 10. Line 11: Subtract the monthly amount of court ordered child support (Line 10) from the total monthly gross income (Line 9). Enter this amount on Line 11. Line 12: Compare total net monthly income (Line 11) to the monthly income limit for the appropriate group size using the FPL guidelines. Countable income must be at or below 200% of the FPL for the appropriate group size. If countable monthly income is at or below 200% of the FPL for the appropriate group size, and all other non-financial requirements have been met, the applicant is temporarily enrolled. Complete Section III ­ Notice for an Applicant who is Temporarily Enrolled in the BadgerCare Plus Family Planning Waiver Plan. If countable monthly income exceeds 200% of the FPL for the appropriate group size, the applicant cannot be temporarily enrolled. Complete Section III of the application and check the appropriate box indicating that the applicant cannot be enrolled because she does not qualify under the income guidelines. Follow the instructions for Section III ­ Notice for an Applicant who Cannot be Enrolled in the BadgerCare Plus Family Planning Waiver Plan. Inform the applicant that she may still be able to enroll in the Family Planning Waiver Plan or BadgerCare Plus, but she must apply through her local county or tribal agency or online at access.wi.gov. A list of these agencies can be found at badgercareplus.org/gethelp.htm or by contacting Member Services at 1-800-362-3002. Section III -- Notice Line 13: Applicant who is Temporarily Enrolled in the BadgerCare Plus Family Planning Waiver Plan If the applicant is temporarily enrolled, qualified providers are required to do all of the following: 1. Check the appropriate box and enter the provider's name, address (street, city, state, zip code) and provider number information. If the provider is a large organization with a number of local sites, please use the specific local site address where the applicant was served. Sign and date the Temporary Enrollment for BadgerCare Plus Family Planning Waiver Plan application. Do not use an agency's name. The signature must be legible. 2. Inform the applicant that her temporary enrollment for the BadgerCare Plus Family Planning Waiver Plan lasts from the date of application until the end of the second month following the month that she is temporarily enrolled. To continue receiving family planning benefits after the temporary enrollment end date, the applicant must apply for BadgerCare Plus or the Family Planning Waiver Plan at the local agency or online at access.wi.gov. A list of these agencies can be found on the Department of Health Services' web at badgercareplus.org/gethelp.htm or by contacting Member Services at 1-800-362-3002. 3. Explain to the applicant that a temporary enrollment determination does not guarantee that her local county or tribal agency will be able to enroll her in BadgerCare Plus or the Family Planning Waiver Plan because of other requirements that may apply. She will have to provide verification of her citizenship and identity, and verify any counted income. The applicant may fill out a BadgerCare Plus Application Packet (F-10182), furnished by the qualified provider, the qualified provider may refer her to her local county or tribal agency, or she can apply online at access.wi.gov.

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4. Inform the applicant that her local county or tribal agency may extend her temporary enrollment. This may be done, only when the applicant files an application on or before the last day of the temporary enrollment period and her application cannot be processed before her temporary enrollment period ends. 5. Check the appropriate box indicating that the applicant is temporarily enrolled. Have her read the statement and sign the Temporary Enrollment for BadgerCare Plus Family Planning Waiver Plan application. Give the applicant a copy of the application. 6. Inform the applicant that she is only covered for family planning related services, but she may be able to enroll in full-benefit BadgerCare Plus if she has minor dependent children and meets certain other enrollment requirements. Encourage her to apply for full-benefit BadgerCare Plus if she would like to receive more than family planning related services, by mail, telephone, online at access.wi.gov, or in person through her local county or tribal agency. 7. Inform applicants with children under age five that she and/or her children may be able to enroll in the Special Supplemental Food Program for Women, Infants and Children (WIC) and provide her with a copy of the WIC pamphlet. Go to Section IV. Line 14: Applicant who Cannot be Enrolled in the BadgerCare Plus Family Planning Waiver Plan. If the applicant cannot be enrolled in the BadgerCare Plus Family Planning Waiver Plan, qualified providers are required to do all of the following: 1. Check the appropriate box in Section III indicating the reason the applicant is not able to enroll. 2. Sign and date the application. 3. Have the applicant sign and date the application indicating that she understands that, even though the qualified provider cannot temporarily enroll her in the BadgerCare Plus Family Planning Waiver Plan, she may still be able to enroll in the BadgerCare Plus Family Planning Waiver Plan or BadgerCare Plus by mail, telephone, online at access.wi.gov, or in person through her local county or tribal agency. 4. Detach and destroy the temporary card on the last page of the application and provide the applicant with a copy of the Temporary Enrollment for BadgerCare Plus Family Planning Waiver Plan application. This will serve as the applicant's notice of denial. Give the applicant a copy of the application, retain a copy for your files and fax or mail a copy, within 5 days, to: Wisconsin Medicaid Temporary Enrollment 6406 Bridge Rd Madison WI 53784 Fax: (608) 250-5202 5. Inform applicants with children under age five that she and/or her children may be able to enroll in the Special Supplemental Food Program for Women, Infants, and Children (WIC) and provide her with a copy of the WIC pamphlet.

Section IV -- Temporary Identification Card Complete the following items on the temporary card if the applicant is temporarily enrolled: 1. Card Effective Dates: Temporary enrollment begins on the first day of enrollment and continues through the last day of the second month following the month in which temporary enrollment began (e.g., a woman who is temporarily enroll on June 6 is enrolled through the end of August).

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Inform the applicant that, in order to receive coverage through the BadgerCare Plus Family Planning Waiver Plan beyond the temporary enrollment end date, she must apply for BadgerCare Plus by mail, telephone, online at access.wi.gov, or in person through her local county or tribal agency. 2. Identification Number: Enter the applicant's Social Security Number (SSN). When entering an applicant's SSN add a zero to the end of the number. If the applicant does not have an SSN or does not know the number, qualified providers are required to call (608) 221-4746 ext. 80218, to obtain a pseudo number. BadgerCare Plus will contact the qualified provider if an SSN or pseudo-number is not recorded on the Temporary Enrollment. BadgerCare Plus requires this number on all applications. Note: The applicant will have to provide a valid SSN or apply for one to be enrolled in the BadgerCare Plus Family Planning Waiver Plan through her local county or tribal agency. 3. Agency Code: Enter the agency code number assigned to the qualified provider. 4. Applicant Information: Print or type the applicant's full name and address in the box provided at the bottom of the card. If the applicant is concerned about other household members receiving her confidential information regarding this program, encourage her to indicate a mailing address other than her residence address where she can receive Family Planning Waiver Plan information in care of another person. It is imperative that notices are received in a timely manner. If a woman does not receive the annual review notice or her receipt of the notice is delayed, there may be a gap in her enrollment and coverage. Therefore, if a member has chosen her provider's mailing address for her correspondence the provider must have a reliable way of contacting her to promptly give her the BadgerCare Plus Family Planning Waiver Plan notices and ForwardHealth card. 5. Detach the bottom portion of the application for the applicant to use as a temporary BadgerCare Plus Family Planning Waiver Plan ID card. This temporary ID card entitles the applicant to family planning-related services provided by a BadgerCare Plus certified provider.