DEPARTMENT OF HEALTH AND FAMILY SERVICES Division of Health Care Financing HCF 13024A (12/01)
STATE OF WISCONSIN
MEDICAID PURCHASE PLAN PREMIUM EMPLOYER WAGE WITHHOLDING INFORMATION AND INSTRUCTIONS
The Wisconsin Medicaid Purchase Plan requires information to enable the Medicaid Purchase Plan to authorize and pay for medical services provided to eligible recipients. Recipients are required to give providers full, correct, and truthful information for the submission of correct and complete claims for Medicaid reimbursement. This information shall include but is not limited to information concerning eligibility status, accurate name, address, and Medicaid identification number (HFS 104.02 , Wis. Admin. Code). Under s. 49.45 (4), Wis. Stats., personally identifiable information about Medicaid applicants and recipients is confidential and is used for purposes directly related to the Medicaid program administration such as payment of premiums by recipients. Failure to supply the information requested by the form may result in denial of Medicaid payment for services. INSTRUCTIONS: Medicaid Purchase Plan Recipients Your employer should fill out this form if you want your Medicaid Purchase Plan (MAPP) premium payment to be taken out of your paycheck. If you choose this option, fill in your MAPP Case Number found on your MAPP premium notice. Give the Employer Wage Withholding Form, along with the Electronic Funds Transfer (EFT) form, to your employer. You may also have your employer call 1-888-907-4455 to request that the forms be mailed to the employer. Employer Instructions for Completing This Form Fill out the employee's last and first name, Social Security Number, and monthly MAPP premium amount. You may pay the employee's MAPP premiums either by EFT or by direct payment.
· Electronic Funds Transfer
If you (the employer) choose to pay by EFT, complete the Recipient/Employer Electronic Funds Transfer form. Send the form to the address listed at the bottom of the EFT form. MAPP will then take the entire premium amount out of your checking account once per month. If you choose to fax the form, you may fax it to 1-608-221-8185.
· Direct Payment
If you choose to make a direct payment each month, you will receive a premium notice each month. Send your payment with the premium notice and completed Employer Wage Withholding form to: Medicaid Purchase Plan P.O. Box 6738 Madison, WI 53716-0738.
· Employer Information
Fill out employer's name and address. If you have any questions regarding the above information, please call 1-888-907-4455.
DEPARTMENT OF HEALTH AND FAMILY SERVICES Division of Health Care Financing HCF 13024 (12/01)
STATE OF WISCONSIN
MEDICAID PURCHASE PLAN PREMIUM EMPLOYER WAGE WITHHOLDING
INSTRUCTIONS: Type or print clearly. Before completing this form, read Information and Instructions on the reverse side of this form. Complete this form for your employee (and Electronic Funds Transfer (EFT) form, if applicable). If you have any questions, call 1-888-907-4455.
Employee Information Name -- Employee's (Last, First, Middle Initial) Medicaid ID Number of Case Head Enrolled in MAPP
Social Security Number -- Employee's
Monthly Premium Amount
Electronic Funds Transfer If you want to pay the premium via monthly EFT, complete the Recipient / Employer EFT form. You can fax it to 1-608-221-8185. Direct Payment If you want to pay the premium via direct payment, send your payment, payable to Medicaid Purchase Plan (MAPP), and this completed form to the address listed below. Do not send cash.
Employer Information Name -- Employer's Telephone Number
Address -- Employer's
SIGNATURE -- Employer
DISTRIBUTION: Mail completed form along with direct payment to: Medicaid Purchase Plan P.O. Box 6738 Madison, WI 53716-0738 Telephone: 1-888-907-4455 Fax: 1-608-221-8185