Free Negative Notice, HCF 16001 - Wisconsin


File Size: 311.0 kB
Pages: 3
Date: March 10, 2009
File Format: PDF
State: Wisconsin
Category: Health Care
Author: DHCAA-BOC
Word Count: 1,570 Words, 9,902 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://dhs.wisconsin.gov/forms/F1/F16001.pdf

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STATE OF WISCONSIN, DEPARTMENTOF HEALTH SERVICES, Division Of Health Care Access and Accountability DEPARTMENT OF WORKFORCE DEVELOPMENT, Division Of Workforce Solutions F-16001 (07/08)

NOD
Date

NEGATIVE NOTICE
Applicant / Member Name (Last, First MI) Case Number

Address (City, State, Zip Code)

See Explanation of Action section for more details. Child Care Assistance Your application for Child Care Assistance has been denied. Your Child Care Assistance will be terminated effective . Your application for Child Care Assistance has been cancelled because you have withdrawn the application. We have not made a decision on your Child Care Assistance application because . FoodShare Wisconsin Your application for FoodShare benefits has been denied. Your monthly FoodShare benefits will decrease from $ effective . . . to $

Your FoodShare benefits will be terminated effective

(member) will no longer receive FoodShare benefits effective Your application for FoodShare benefits has been cancelled because you have withdrawn the application. We have not made a decision on your FoodShare application because

. Medicaid / BadgerCare Plus Your application for Medicaid/BadgerCare Plus for the months of because Your Medicaid/BadgerCare Plus benefits will be terminated effective because . has been denied .

Your application for Medicaid/BadgerCare Plus has been denied because your income exceeds the legal maximum by $ per month. If you incur six times this amount ($ ), in medical bills, you

may be able to enroll. Contact your worker for details. Your Medicaid/BadgerCare Plus premium, patient liability or cost share has increased to $ month, effective because . Your application for Medicaid/BadgerCare Plus has been cancelled because you have withdrawn the application. We have not yet made a decision on your Medicaid/BadgerCare Plus application because . OVER per

NEGATIVE NOTICE F-16001 (07/08)

NOD
W-2, Job Access Loan or Emergency Assistance (Check one program

Wisconsin Works (W-2) Your application has been denied for only). Your W-2 benefits will be terminated effective because . Your W-2 payment will decrease from $ to $ effective .

Your application for W-2 has been cancelled because you have withdrawn the application. We have not made a decision on your W-2 application because . Other Your application/review for Your application/review for (program) has been denied, effective (program) has been denied, effective . .

Additional Comments / Explanation of Action(s). Please include income and expenses used in the eligibility determination. (For Medicaid and BadgerCare Plus cases include the appropriate legal citation for this action.)

If you do not agree with your Medicaid/BadgerCare Plus, FoodShare benefits or Child Care Assistance decision, you can request a fair hearing. Please see the enclosed for information about fair hearings. If you disagree with a W-2 decision, you can ask for a Fact Finding Review. You must ask for the review within 45 days from the date of the notice, or within 45 days from the effective date of the decision announced in this notice, whichever is later. If you have questions, please contact County/tribal or W-2 agency

Distribution:

Member / Applicant original

Case file copy

RESET FORM

STATE OF WISCONSIN DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-10150 (07/08)

STATE OF WISCONSIN DEPARTMENT OF WORKFORCE DEVELOPMENT Division of Workforce Solutions

YOUR RIGHTS AND RESPONSIBILITIES FOR WISCONSIN WORKS (W-2) SERVICES, CHILD CARE ASSISTANCE, MEDICAID, BADGERCARE PLUS AND FOODSHARE WISCONSIN
YOU HAVE THE RIGHT TO A WRITTEN NOTICE from this agency before any action is taken to stop or reduce your FoodShare, Medicaid or BadgerCare Plus benefits. For most actions, a notice will be mailed to you at least 10 days before the action is taken. A written 10 day notice will be mailed to you before action is taken to stop your Child Care benefits. (This does not apply to Wisconsin Works (W-2) payments.) YOU MAY REQUEST A FAIR HEARING FOR FOODSHARE, MEDICAID, BADGERCARE PLUS OR CHILD CARE BENEFITS if you disagree with any agency's action including your FoodShare benefit amount. You may request a fair hearing in writing or in person with the agency listed on the front of this notice. You may also request a fair hearing by writing to the Department of Administration, Division of Hearings and Appeals, PO Box 7875, Madison, WI 53707-7875 or by calling 1-608-266-7709. Your request must be received (1) within 45 days of the action's effective date for Medicaid, BadgerCare and Child Care and, (2) within 90 days of the action's effective date for FoodShare Wisconsin. In most cases, if your Fair Hearing request is received by the Division of Hearings and Appeals prior to the action's effective date, your Medicaid, BadgerCare Plus and/or FoodShare benefits will not stop or be reduced. The benefits will continue at least until the decision on your appeal is made. During this time, if another unrelated change occurs, your Medicaid, BadgerCare Plus or FoodShare benefits may change. If another change occurs, you will receive a new notice. If you are not satisfied with the fair hearing decision, you may appeal and request a second fair hearing. If the fair hearing decision ends or reduces your benefits, you may have to repay any benefits you receive while your appeal was pending. You may ask not to receive continued benefits. YOU MAY REQUEST A W-2 FACT FINDING REVIEW if you do not agree with a W-2 decision. This request must be separate from any Fair Hearing request for Medicaid/BadgerCare Plus, FoodShare or Child Care benefits. You must request the Fact Finding within 45 days from the date you are notified of the decision or within 45 days from the effective date of the decision whichever is later. You can request a Fact Finding Review by calling or writing your worker or W-2 agency. A W-2 Fact Finder will review your case. The Fact Finder will review W-2 service issues such as employment positions or Emergency Assistance. Depending on the situation, W-2 services may not be continued pending the Fact Finding decision. If you or your representative fail to appear at the Fact Finding without good cause, your request is considered abandoned and will be dismissed. YOU MAY REPRESENT YOURSELF OR BE REPRESENTED at the hearing, conference or Fact Finding by an attorney, friend or anyone else you choose. We cannot pay for your attorney. However, free legal services may be available to you if you qualify. If you fail to appear, or your representative fails to appear at the hearing or Fact Finding without good cause, your appeal is considered abandoned and will be dismissed. IF YOU ARE RECEIVING W-2 OR FOODSHARE BENEFITS, you must complete all assigned activities, including Learnfare requirements, to receive a full benefit or payment. Any hours missed without good cause may result in a reduction in the payment or benefits. IF YOU ARE RECEIVING W-2, MEDICAID, BADGERCARE PLUS, CHILD CARE OR FOODSHARE BENEFITS, you must cooperate with the Child Support Agency, unless you have a good cause reason. Your worker can provide more information about child support cooperation. Even if you are not eligible for programs such as W-2, Medicaid, BadgerCare Plus, Child Care or FoodShare Wisconsin, help is available to get or increase your child support payments. Contact your county Child Support Agency for more information. COMPUTER CHECK: If you work, the wages you report are checked by the computer against the wages your employer reports to the Department of Workforce Development. The Internal Revenue Service, Social Security Administration, Unemployment Insurance Division and Department of Transportation may also be contacted about income and assets you may have. IF YOU RECEIVE MEDICAID OR BADGERCARE PLUS, present your ForwardHealth card to your Medicaid or BadgerCare Plus providers such as, physicians, hospitals, druggist, dentist, etc. each time you go to a provider. For some services, you may have to pay a co-payment to the provider. The amount depends on how much the service costs. Your provider should tell you if a co-payment is required or if a specific service is not covered by Medicaid or BadgerCare Plus. Your worker will answer any questions you may have about the Medicaid and BadgerCare Plus programs. IF YOU RECEIVE BENEFITS OR SERVICES, you must follow these rules: DO NOT give false information or hide information to get or continue to get benefits. DO NOT trade or sell FoodShare benefits or ForwardHealth cards. DO NOT alter cards to get benefits you are not entitled to receive. DO NOT use FoodShare benefits to buy ineligible items, like alcohol or tobacco. DO NOT use someone else's FoodShare benefits or ForwardHealth card. Anyone in your household who intentionally breaks any FoodShare Wisconsin rule can be barred from receiving FoodShare Wisconsin benefits for 12 months after the first violation, 24 months after the second violation and permanently after the third violation. The individual can also be fined up to $250,000, imprisoned up to 20 years or both. A court can also bar a person from receiving FoodShare Wisconsin benefits for an additional 18 months. The person may also be subject to further prosecution under the applicable laws. Any member of your household who intentionally breaks any program rule for the purpose of getting or keeping W-2 eligibility or to increase the amount of W-2 payments to the family, can cause a reduction or termination of W-2 services. After three (3) Intentional Program Violations occur, the individual and entire W-2 group may be permanently barred from the W-2 program. The same rules apply to the Child Care Program. RE: Federal Regulations Wisconsin Statutes

7 CFR 273, 42 CFR 431, 42 CFR 433, 42 CFR 435 49.141, 49.161, 49.22, 49.45, 49.49, 49.95