Free Wisconsin Hemophilia Home Care Program Financial Need Statement, F-1187 - Wisconsin

DEPARTMENT OF HEALTH SERVICES DIVISION OF HEALTH CARE ACCESS AND ACCOUNTABILITY F-1187 (02/09)

STATE OF WISCONSIN ss. 49.685 WIS STATS

WISCONSIN HEMOPHILIA HOME CARE PROGRAM FINANCIAL NEED STATEMENT
READ INSTRUCTIONS CAREFULLY BEFORE COMPLETING THE FORM SECTION 1. APPLICANT INFORMATION
1. Name ­ Applicant (Last, First, MI) 2. Social Security Number (SSN) (optional)

3. Street Address ­ Applicant

4. Home Telephone

5. City, State, ZIP Code

6. County of Residence

7. Sex Male 9. Female

8. Date of Birth

Do you have any dependent family members who are also members of the Chronic Disease Program? Yes No If Yes, indicate the names and Social Security Numbers (SSN) of all dependent family members who are members of the Chronic Disease program. Name _________________________________________________ Name _________________________________________________ SSN SSN

10. Race/Ethnicity (Optional) American Indian or Alaska Native Black (Not of Hispanic Origin)

Asian or Pacific Islander White (Not of Hispanic Origin)

Hispanic (Mexican, Puerto Rican, Cuban, or other Hispanic Culture)

SECTION 2. RESIDENCY INFORMATION
11. Have you lived in Wisconsin for the last 2 years? Yes No _________________________________________ 12b. Applicants under the age of 19 should provide copies of the following documents. · Parent or guardian's Wisconsin Income Tax return with all attachments for the last year. · Parent or guardian's most recent rental agreement or property tax bill. · Wisconsin drivers license with current address OR state identification with current address OR school identification. · Alien registration card issued by the ISN if you are not a U.S. citizen. Note: If you are unable to provide either of the following documents, you may have your treatment facility social worker sign the residency verification. · A copy of the most recent rental agreement or property tax bill. · A copy of your Wisconsin drivers license with current address OR state identification with current address OR Student ID (only for applicants under age 19). If you answered No, indicate the date you moved to Wisconsin. 12a. Applicants age 19 and over should provide copies of the following documents. · Last year's Wisconsin Income Tax return with all attachments. · The most recent rental agreement or property tax bill. · Wisconsin drivers license with current address OR state identification with current address. · Alien registration card issued by the ISN if you are not a U.S. citizen.

Note: If you are unable to provide either of the following documents, you may have your treatment facility social worker sign the residency verification. · A copy of the most recent rental agreement or property tax bill. · A copy of your Wisconsin drivers license with current address OR state identification with current address OR Student ID (only for applicants under age 19). 13. If you do not have these documents, explain why.

WISCONSIN HEMOPHILIA HOME CARE PROGRAM FINANCIAL NEED STATEMENT F-1187 (02/09)

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SECTION 3. MEDICARE, WISCONSIN MEDICAID, BADGERCARE PLUS, AND SENIORCARE INFORMATION
14. Do you currently have or have you had Medicare coverage? If yes, indicate your Medicare eligibility dates below. Part A Begin Date Part A End Date _____________ _____________ Part B Begin Date ________________ Part B End Date ________________ Part D Begin Date ________________ Part D End Date Yes No

______________

15. Wisconsin law requires applicants must first complete applications for other health care programs, if they may be reasonably eligible given their financial and non-financial circumstances, before applying to WCDP. The department may waive the requirement for an applicant who requests a waiver for religious reasons under 49.687 (1m) (b) of the Wisconsin State Statutes. Are you currently eligible for Wisconsin Medicaid, BadgerCare Plus (Medical Assistance, MA, Title 19, T-19), or SeniorCare? Yes No

If yes, indicate your Medicaid, BadgerCare Plus, or SeniorCare identification number here.______________________________ 16. If no, have you applied for any of these programs in the past year? If yes, and you were denied eligibility for these programs, explain why. ________________________________________________________________________________________________________ Yes No

SECTION 4. SOCIAL WORKER SIGN OFF
This section is to be completed by a healthcare professional if the applicant is not enrolled in Wisconsin Medicaid, BadgerCare Plus, or SeniorCare. 17. Based on my knowledge of _________________________________________________________, I attest that he/she is not eligible for the programs listed above. Explain in the space provided why the applicant would be denied eligibility, where applicable. Medicaid or BadgerCare Plus_________________________________________________________________________________ SeniorCare_______________________________________________________________________________________________

SIGNATURE ­ Social Worker

Facility Name

Date Signed

SECTION 5. INSURANCE INFORMATION
18. In the last two years have you had or do you currently have private, group, HIRSP, or other health insurance coverage for medical expenses? (Do not include Medicare, Wisconsin Medicaid, BadgerCare Plus, or SeniorCare information here.) Yes No If yes, complete the following information. If you have more than one insurance company, list the second company under Insurance #2. Attach additional information if needed for current and past insurance for the last two years. Insurance #1 Insurance #2 a. Name ­ Insurance b. Telephone Number a. Name ­ Insurance b. Telephone Number Company Company c. Name ­ Policy Holder e. Policy Number g. Coverage Begin Date
d. Relationship of Policy Holder

c. Name ­ Policy Holder e. Policy Number g. Coverage Begin Date

d. Relationship of Policy Holder

f. Group Policy Number h. Coverage Termination Date

f. Group Policy Number h. Coverage Termination Date

Indicate whether this insurance covers these services by answering each question. Answer each question. i. Inpatient Hospital Service. Yes No j. Outpatient Hospital Service. k. Physician Services. l. Radiology Services. m. Laboratory Services. Yes Yes Yes Yes No No No No Yes Yes No No

Indicate whether this insurance covers these services by answering each question. Answer each question. i. Inpatient Hospital Service. Yes No j. k. l. n. o. Outpatient Hospital Service. Physician Services. Radiology Services. Yes Yes Yes Yes No No No No Yes Yes No No

m. Laboratory Services.

n. Hemophilia home care products and supplies. o. Prescription Drugs.

Hemophilia home care products and supplies. Prescription Drugs.

WISCONSIN HEMOPHILIA HOME CARE PROGRAM FINANCIAL NEED STATEMENT F-1187 (02/09)

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SECTION 6. FINANCIAL INFORMATION
19. Indicate the number of dependent family members; include yourself if you are a dependent family member. ___________________

20. Indicate your current total income by completing items a - m either by

monthly OR annual totals.
a. Gross wages, salaries, tips, etc. b. Net income from non-farm self-employment. c. Net income from farm self employment. d. Social Security and/or Supplemental Security benefits. e. Dividends and interest income. f. Total of estate or trust income, net rental income and royalties. g. Cash public benefits (e.g. W-2 payments). h. Pensions, annuities and/or veteran's pension. i. Unemployment compensation and/or worker's compensation. j. Maintenance, alimony and/or child support. k. Non taxable interest (federal, state or municipal bonds). l. Nontaxable deferred compensation. m. Total Monthly OR Yearly income.

Average Monthly Totals OR ________ _______
Month Year

Annual Totals ___________
Year

$ $ $ $ $ $ $ $ $ $ $ $ $ Yes

$ $ $ $ $ $ $ $ $ $ $ $ $ No

21. Do you expect this income to change significantly from month to month or in the next year? 22. If yes, will your income be less or more than the total above? Explain why. Less More

23. On last year's Wisconsin Income Tax return, what was your total gross family income before taxes? _______________________

WISCONSIN HEMOPHILIA HOME CARE PROGRAM FINANCIAL NEED STATEMENT F-1187 (02/09)

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SECTION 7. AGREEMENT AND SIGNATURES FOR HEMOPHILIA HOME CARE APPLICANTS Eligibility for state reimbursement exists only insofar as certified by the Department of Health Services (herein called the Department) or its fiscal agent upon: a) recipient of completed application, including verification by the physician director of the member's successful participation in a hemophilia home care or self-infusion training program and maintenance program; and c) existence of a written agreement, as designated by the Department or its fiscal agent, between the patient and a certified comprehensive treatment center for compliance with the maintenance program. Pursuant to the authority of Wisconsin Statute 49.685 and 49.687 and the rules promulgated thereunder, the Department or its fiscal agent will, subject to the conditions named, reimburse a certified comprehensive hemophilia treatment center or an approved source, on behalf of the member, for part of the cost of hemophilia home care blood products and infusion supplies. Reimbursement will be made only for that portion of the allowable cost of home care blood products and infusion supplies remaining after all payment from other state programs, federal programs, and private health insurance coverage have been received and the member's liability and deductibles have been determined. The member's liability and deductibles will be based on income and family size. Wisconsin Administrative Code 153 specifies the methodology for provider reimbursement. Charges in excess of what the Hemophilia Home Care Program allows are the individual responsibility of the member. If insufficient aid is available from other sources, the state shall pay the difference between the allowable cost and the sum of payment received and member liability and deductibles. State payment shall be appropriately reduced if federal, state, private or other health insurance becomes available during the benefit period. The member must inform the Department or its fiscal agent of all health insurance coverage and eligibility date. The Department, the State of Wisconsin, and its officers or agents are released and discharged of and from all manner of action and actions, cause and causes of actions, suits, sums of money, judgment, claims, and demands whatsoever in law or in equity which the claimant, or his/her heirs, executors or assignees might have, or may hereinafter have, by reason of any injury or worsening of condition or death of the member due to treatment of hemophilia or lack of treatment. In order to establish my eligibility for state benefits, I authorize the medical facility (24)__________________________ to disclose information relating to my health condition or payment made for my health care to the Hemophilia Home Care Program. I certify, to the best of my knowledge, all information provided on this form is true, correct, and complete. I understand that I will be denied reimbursement if I withhold information, provide inaccurate information, or refuse to provide information. I authorize release of any medical and financial information including certification for General Assistance, Wisconsin Medicaid, BadgerCare Plus, SeniorCare, or Medicare to the Wisconsin Chronic Disease Program necessary for processing claims and verifying services under the program. I agree to notify the Department or its fiscal agent in writing within 30 days of any change in name, address, income by more than 10%, insurance coverage, or family size. I agree to accept responsibility for the program's copayments and deductibles. I have read and consent to the above. I understand that benefits issued through the Wisconsin Chronic Disease Program are eligible for estate recovery as defined in HFS 153.07(5). I understand that only Wisconsin residents are eligible for the Chronic Disease Program. By signing this form I am attesting that I am a Wisconsin resident as set forth in HFS 153.02(17).
25. SIGNATURE ­ Applicant (or applicant's representative if applicant is a minor) Date Signed