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STATE OF WISCONSIN DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-10107 (07/08)

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Medicaid Qualified Medicare Beneficiary (QMB) Specified Low-Income Medicare Beneficiary (SLMB) Specified Low-Income Medicare Beneficiary Plus (SLMB+) Negative Decision Notice
Client Name (Last, First, MI) Date

Residence Address (Street, City, State, Zip Code)

Case Number

Because you are entitled to Medicare Part A coverage, we have conducted a review to determine if you are eligible for the State of Wisconsin to pay for some of your Medicare coverage costs. Based on the application information you provided, you are not eligible for the State to pay for some or all of your Medicare coverage as part of Wisconsin's QMB, SLMB, and SLMB+ programs. You are not eligible because (see the box checked below): Your income is higher than the income limits for the Medicare Beneficiary program. (Please refer to the calculation at the bottom of this notice if you have questions about how much income was counted and the income limits used). Your assets are higher than the asset limits of the Medicare Beneficiary program. (Please refer to the calculation at the bottom of this notice if you have questions about the assets was counted and the assets limit used). Your income is higher than the QMB income limit and Medicaid will not pay for your Medicare coinsurance and deductibles. Because your income is still less than the SLMB income limit, Wisconsin's Medicaid program will continue to pay for your Medicare Part B premiums. It takes two months to change monthly federal billing for your Medicare premiums to the state. You will receive additional federal and state notices informing you of when this change will take place. Other: If you believe your eligibility determination has been handled incorrectly, you have the right to appeal the action by requesting a fair hearing. See attached information on fair hearings. If you have questions contact: Name Worker (Last, First, MI)

Worker Number

Telephone Number

FINANCIAL CALCULATION USED TO DETERMINE QMB / SLMB / SLMB+ ELIGIBILITY 1. Total Assets $ 2. QMB / SLMB / SLMB+ Asset Limit $ 3. Gross Earned Income $ 4. Earned Income Disregard 5. Gross Social Security(Social Security check plus Medicare premium) 6. Other Unearned Income 7. Income Deductions 8. $20 Disregard 9. Net Income 10. QMB Income Limit 11. SLMB Income Limit 12. SMLB+ Income Limit
Wisconsin Stats. S. 49.468

-$ +$ +$ -$ -$ =$ $ $ $

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Client and Agency

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MEDICAID/BADGERCARE FAIR HEARING INFORMATION
If you are not satisfied with a Medicaid/BadgerCare decision you may appeal the decision by requesting a Fair Hearing in writing or in person at your local county/tribal social or human services department. You may also write to: The Department of Administration Division of Hearings and Appeals PO Box 7875 Madison, WI 53707-7875 (608) 266-3096 (voice) (608) 264-9853 (TTY) If you need an accommodation for a disability or a language translation, please call (608) 266-3096 (voice) or (608) 264-9853 (TTY). These telephone numbers are only for the administrative hearing process. You, your chosen representative (if any), and the local county/tribal social or human services department will receive written notice at least 10 days before the fair hearing explaining the schedule time, date and place of the hearing. The hearing will be held in the county where you live. If you file an appeal of a discontinuation, termination, or reduction of benefits before the date the change was to take effect, your coverage can continue pending the hearing decision. The appeal should include important facts of the matter and your Medicaid ID number. Your request must be received within 45 days of the action you are appealing.

PREPARING FOR A FAIR HEARING
You have the right to bring witnesses, your own lawyer, or some other advisor to the fair hearing. The agency cannot pay for a lawyer to represent your side of the story, but they may be able to help you find free legal assistance for questions or fair hearing representation. You have the right, both before the hearing and during the hearing, to see the agency's written materials about the case, including your case record, upon which the agency based its decision. You or your representative has the right to question anyone who testifies against you at the fair hearing. You also have the right to your own arguments and bring written materials showing why you think you are 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 cannot speak English or require sign language, you have the right to have an interpreter present at the hearing. The Division of Hearings and Appeals may authorize payment for necessary translation or interpreters if you ask.

CONTINUATION OF BENEFITS
If you ask for a fair hearing before the effective date of the agency's action your Medicaid benefits will not be reduced or terminated until after the results of the fair hearing are known. You are still required to report any changes in your circumstances while your hearing is pending which may affect the level of your benefits. Asking for a fair hearing does not cancel out normally scheduled interview periods.

EFFECTS OF THE FAIR HEARING
If the fair hearing decision is in your favor: No action will be taken against you by the agency. If benefits have been terminated, they will be reinstated. The date of reinstatement will be listed in the copy of the decision you receive, ordering the agency to reinstate your benefits. If the fair hearing goes against you: The agency's action will stand and you may have to pay back the cost of any benefits you received that you should not have received.

REHEARINGS
After you have received the fair hearing decision, you have the right to ask for a rehearing if: You have important new evidence that you could not have made available even if you tried, before the hearing that could change the decision. You feel that there was a mistake in the facts of the decision. You feel that there was a mistake in the legal basis of the decision. If you would like a rehearing, a written request must be received within 20 days from the date of the written decision the Division of Hearings and Appeals. The state hearing's office will decide within 30 days in a rehearing is justified.

APPEALING A FAIR HEARING OR REHEARING DECISION
If you do not 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 have received 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 completed by filing a petition with the Clerk of Courts in your county. It is best to have legal assistance, if you decide to appeal a fair hearing decision in Circuit Court.