Free ForwardHealth Issuer of Annuity - Notice of Obligation, F-10190 - Wisconsin

WISCONSIN DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-10190 (01/09)

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ISSUER OF ANNUITY - NOTICE OF OBLIGATION
DESIGNATION OF PREFERRED REMAINDER BENEFICIARY
Wisconsin Statutes §49.47(4)(cr), require the annuity owner(s) named below to designate the Wisconsin Department of Health Services (DHS) as preferred remainder beneficiary* of the annuity described below.

INSTRUCTIONS
1. Initiate the process to designate DHS as the preferred remainder beneficiary of the annuity identified below. 2. Follow the language provided on the attached Annuity Beneficiary Designation form (F-10191) to designate DHS the remainder beneficiary. 3. Complete the Confirmation/Status of Request section of this notice and fax a copy of this form to the county agency contact listed on the reverse side of this form. 4. Complete the issuer responsibilities in Sections A and B below as they occur. If you have questions about how to comply with this request, contact the local county agency listed on page 2. Name ­ Annuity Company

Address

City

State

Zip Code

Name ­ Annuity Owner(s)

Contract Number

Name ­ Spouse of Annuity Owner

*Preferred Remainder Beneficiary means the individual or entity to whom benefits must first be paid under this annuity. Under state and federal law, DHS must be named as the preferred remainder beneficiary in the first position unless a spouse not living in a medical institution, minor child, or disabled child is the designated preferred remainder beneficiary in the first position. DHS is in the next preferred position after any of the above persons.

ISSUER RESPONSIBILITIES
A. The issuer of the annuity must notify the county agency, at the address on the reverse side: (1) Confirm that a preferred remainder beneficiary designation has been made (2) When a change occurs to the amount of income or principal being withdrawn from the annuity on or after the date the annuity owner signed the enclosed Annuity Information Disclosure form (F-10192). (3) When the owner requests a beneficiary change after DHS has been named preferred remainder beneficiary; include the name of the new beneficiary B. The issuer of the annuity must also notify the state agency, at the address below, when the death benefit becomes payable, as follows: (1) Request in writing that DHS provide a statement of the total amount of MA paid on behalf of the annuity owner and/or their spouse. (2) If the death benefit is payable to someone other than DHS, provide the name and date of birth of the individual(s) to allow DHS to verify primary beneficiary status

NOTICE OF OBLIGATION F-10190 (01/09)

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DHS will respond to the request within 45 days of receipt and will confirm if payout is due to a beneficiary(s) meeting certain requirements. The issuer must subsequently pay DHS an amount equal to the lesser of the amount payable under the annuity or the total amount of Medicaid paid on behalf of the person(s).

Name and Address of Local County or Tribal Agency

DHS (Beneficiary) Estate Recovery Unit Department of Health Services Estate Recovery Program P.O. Box 309 Madison, WI 53701-0309

Telephone Number

Fax Number

CONFIRMATION/STATUS OF REQUEST TO NAME DHS BENEFICIARY OF ANNUITY
Within 30 days of the date of this notice, the annuity issuer must provide the following Confirmation/Status Reply to the county worker identified above: DHS has been named a preferred remainder beneficiary of this annuity as required by law. DHS has been named the remainder beneficiary, as provided by law, after the annuity owner's spouse, who is not living in a medical institution, or after an annuity owner's minor child(ren) or disabled child(ren). The beneficiary change is in process; expected date of completion . Notice will be provided to the county worker when change is completed. The annuity owner(s) has not returned the requested information (owner's name) (date requested). No death benefit is available under this annuity Other (describe) Name ­ Person Completing this Form Date Telephone Number (Include Area Code)

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