Free Medicaid Income Allocation Notice, F-10097 - Wisconsin

WISCONSIN DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-10097 (02/09)

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MEDICAID INCOME ALLOCATION NOTICE
Instructions: The Income Maintenance worker should complete form and provide a copy to the member, community spouse and the case file. Member Name (Last, First, MI) Spouse's Name (Last, First, MI)

The above named Medicaid member has been determined eligible for Medicaid. The above named spouse is designated as the community spouse of the Medicaid member. If the community spouse has monthly income less than $ the Medicaid member may allocate some of his/her income to bring the community spouse income up to a maximum of $ a month or higher if ordered by a fair hearing or court order. The Medicaid member may also allocate some of his/her income to any dependent family member living with the community spouse to bring each dependent family member's income up to $ a month. The community spouse and dependent family members must report any change in monthly income within 10 days of the change to the local county or tribal agency. Subtract the following amounts from the Medicaid member's gross monthly income: 1) A personal allowance which the member can keep to pay for personal need items not covered by Medicaid; 2) The amount of income actually given to the community spouse; 3) The income allowance for each dependent living with the community spouse whether or not it is given to them. The amount of the Medicaid member's income remaining after deductions will be the amount of income that the Medicaid member must contribute towards the cost of his/her medical care. These calculations are shown below: Community Spouse l. Maximum Monthly Income Allowance 2. Minus Actual Monthly Income of Community Spouse 3. Equals Maximum Income Amount that Medicaid Member can allocate to the Community Spouse Medicaid Member 1. Gross Monthly Income 2. Minus Personal Allowance 3. Minus Actual Allocated Amount to the Community Spouse (Amount listed from #3 above) 4. Minus Dependent Allowance Minus Other Deductions Equals Cost of Care Contribution = = Amount

Amount

MEDICAID INCOME ALLOCATION NOTICE F-10097 (02/09) Page 2 of 4

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The Medicaid member and community spouse has the right to appeal a Medicaid decision by requesting a fair hearing concerning: 1) The ownership and availability of income. 2) The computation of the community spouse's monthly income allocation and other dependent income allowance. 3) The amount of the community spouse's income allocation. 4) An increase in the community spouse's monthly income due to exceptional circumstances. Please see the attached fair hearing information. SIGNATURE ­ Agency Representative Do not complete shaded area. Case Name

Date Signed

Case Number

Agency Name

WI Stats. s. 49.455, Federal Public Law 100-360 Attachment

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MEDICAID INCOME ALLOCATION NOTICE F-10097 (02/09) Page 3 of 4

MEDICAID / BADGERCARE PLUS FAIR HEARING INFORMATION Any time your benefits are denied, reduced or ended, and you think the county or tribal office made a mistake, contact the local agency. If the local agency does not agree, you can ask the local office worker to help you in asking for a fair hearing. Fair Hearing A fair hearing gives you the chance to tell why you think the decision about your application or benefits were wrong. At the hearing, a hearing officer will hear from you and the local agency to find out if the decision was right or wrong. You may bring a friend or family member with you to the hearing. You may also get free legal help. (See Legal Help to learn more.) How to Ask for a Fair Hearing Ask your local agency to help you file for a fair hearing or write directly to: Department of Administration Division of Hearings and Appeals PO Box 7875 Madison WI 53707-7875 Or call (608) 266-3096 If you have access to the internet, the Fair Hearing Request form can be found at dhfs.wisconsin.gov/em/customerhelp. If you chose to write a letter in place of the form, you must include the following: Your name, Your mailing address, A brief description of the problem, The name of the local agency that took the action or denied the service, Your Social Security Number, and Your signature. Your request should include the important facts of the matter and your BadgerCare Plus identification number. An appeal must be made no later than 45 days after the date of the action. Your latest notice will have the date by which you must request a hearing. If you need an accommodation for a disability or an interpreter services, please call 1-608-266-3096. This telephone number is only for the administrative hearing process. You or your chosen representative (if any), and the local agency will get written notice of the time, date and place of the hearing at least 10 days before the fair hearing. The hearing will be held in the county where you live. Preparing for a Fair Hearing You have the right to bring witnesses, your own lawyer or other advisor to the fair hearing. The agency can't pay for a lawyer to represent you, but they may be able to help you find free legal help for any questions you may have or to represent you at the fair hearing. (See Legal Help to learn more.) You have the right, both before the hearing and during the hearing, to see the local agency's written materials about the case, including your case record, on which the local agency based its decision.

MEDICAID INCOME ALLOCATION NOTICE F-10097 (02/09) Page 4 of 4

You or your representative, have the right to question anyone who testifies against you at the fair hearing. You also have the right to present your own arguments and bring written materials showing why you think you're right. If the fair hearing is about whether you are or are not incapacitated or disabled, you have the right to present medical evidence for proof, paid for by the agency. If you can't speak English or use sign language, you have the right to have an interpreter at the hearing. The Division of Hearings and Appeals may allow payment for translation or interpreters if you ask. You Can Keep Getting Benefits If you ask for a fair hearing before the effective date of the local agency's action, you can ask that your benefits not be reduced or ended until after the results of the fair hearing are known. If the fair hearing isn't in your Effects of the Fair Hearing If the fair hearing decision is in your favor: No action will be taken against you by the local agency. Benefits will be reinstated if they were ended. The date of reinstatement will be listed in the copy of the decision you get, ordering the local agency to reinstate your benefits. If the fair hearing decision isn't in your favor: The local agency's action will stand and you will have to pay back any benefits that you shouldn't have gotten. Rehearings After you get the fair hearing decision, you have the right to ask for a rehearing if: You have new evidence that you couldn't have made available before the hearing, even if you tried, that could change the decision, You feel that there was a mistake in the facts of the decision, or You feel that there was a mistake in the legal basis of the decision. The Division of Hearings and Appeals must get a written request for a rehearing within 20 days from the date of the written decision. The state hearing agency will decide within 30 days if a rehearing is justified. If the office doesn't issue a written response to the request in 30 days, it is assumed your request is denied. Appealing a Fair Hearing or Rehearing Decision If you don't agree with the fair hearing or rehearing decision, it is still possible for you to appeal to the Circuit Court in your county. This must be done within 30 days after you get the written decision about the fair hearing or within 30 days of the denial of the rehearing request. An appeal to the Circuit Court must be done by filing a petition with the Clerk of Courts in your county. It's best to have legal help, if you decide to appeal a fair hearing decision in Circuit Court. Legal help Legal help may be available through Wisconsin Judicare, Inc. or Legal Action of Wisconsin, Inc (LAW). To find the office closest to you, call: Judicare at (715) 842-1681 or www.judicare.org/, or LAW at 1-888-278-0633 or badgerlaw.net.