Free BadgerCare Plus Premium Information, F-10139 - Wisconsin

WISCONSIN DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-10139 (06/09)

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BADGERCARE PLUS PREMIUM INFORMATION
You will have to pay a monthly premium to be enrolled in BadgerCare Plus. Premium amounts are based on your family size and income. Your coverage will not begin until the premium listed below is received. In some instances you may be required to pay more than one month of premiums before your coverage begins. The premium amount(s) below must be paid to the local agency at the address listed below. A check or money order should be made payable to "BadgerCare Plus". Cash will not be accepted. The total premium(s) must be paid; partial payments will not be accepted. Your premiums may increase or decrease depending on changes in your income or family size. After your initial premium has been paid, you will get monthly premium notices from the Wisconsin Department of Health Services (DHS). These payments must be sent to the DHS at the address listed on the premium notice. Do not send these future premium payments to your local agency. Payments are due by the 10th of each month for the current month. If your premium is received late, you will receive a notice saying your BadgerCare Plus enrollment is ending. If DHS gets your payment by the end of the month, your coverage will continue. If DHS gets the premium payment after the first of the following month, you will need to pay two premium payments. Example: Your premium payment for May was not received until June 2nd, you will need to pay the premium for May and June to stay enrolled. If your premium payment is not received by the following month, some or all members of your family are subject to a restrictive re-enrollment period. This means that you will not be able to enroll in BadgerCare Plus for six months. If you wish to re-enroll in BadgerCare Plus after this period, you will be required to pay any past due premiums at the time of reenrollment. You may be able to re-enroll during your six months of restrictive re-enrollment period if your family income drops to a level where you would not have a premium. This following information applies only for your initial premium(s), which must be paid to your local agency. You must pay the Total Due amount listed below before you can get benefits. Case Name Benefit Month Benefit Month Benefit Month Date Due CARES Case Number Premium Amount Due $ Premium Amount Due $ Premium Amount Due $ Total Due $

Tear off at dotted line and send the bottom portion with your payment to the agency address listed below.

Case Name Benefit Month Benefit Month Benefit Month Date Due Make your check or money order payable to BadgerCare Plus. Be sure to write your CARES case number (see above) on the check/money order. Do not send cash. You must pay the Total Due amount.

CARES Case Number Premium Amount Due $ Premium Amount Due $ Premium Amount Due $ Total Due (Agency Address) $

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