Free SeniorCare Instructions for Application Form, HCF 10076A - Wisconsin

DEPARTMENT OF HEALTH AND FAMILY SERVICES Division of Health Care Access and Accountability HCF 10076A (05/08)

STATE OF WISCONSIN Section 49.688, Wis. Stats.

Instructions for Application Form

The SeniorCare application form is only for persons applying for the SeniorCare Prescription Drug Program. This is not an application for any other benefit program. For help with this form, contact the SeniorCare Customer Service Hotline at 1-800-657-2038 (TTY and translation services are available.) Help may also be available at your local aging office, Senior Center or aging resource center. Information is available on the Department of Health and Family Services' web site at: http://dhfs.wisconsin.gov/seniorcare. IMPORTANT INFORMATION · Your application date is the date the completed and signed application form is received by the SeniorCare program. A decision on your SeniorCare enrollment will be mailed to you within 4-6 weeks. Incomplete or unsigned applications will not be processed and will be returned to you. · Enclose the $30 enrollment fee for each applicant ($60 if you and your spouse are both requesting SeniorCare). Your enrollment begin date may be delayed if your full enrollment fee is not received at the time of your application. If you are not able to enroll in SeniorCare, your enrollment fee will be returned within 6-8 weeks. · Complete, sign and mail the application form with the enrollment fee to the address on the form. · If you wish to authorize a representative to apply for you, contact the SeniorCare Customer Service Hotline at 1-800-657-2038. The appropriate form and information will be mailed to you. HOW TO USE THIS FORM 1. Print CLEARLY using CAPITAL letters. Use ONLY blue or black ink. Shade in the circles next to the appropriate answers by coloring in the circles completely. 2. Complete both sides of the application and submit the appropriate enrollment fee. If your application is not complete or correct, a SeniorCare Customer Service Representative may contact you for more information. This may cause a delay in the processing of your SeniorCare application. 3. Provide information on the application form for you and your spouse (if you have a spouse living in your household). Do not include information about other persons in your household.

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Applicant and Spouse Information (SECTION I AND II) - SeniorCare enrollment will be based on your income and your spouse's income, if your spouse lives with you. If your spouse lives with you, complete the parts of the application form for you and your spouse, even if your spouse is not requesting SeniorCare. Remember: The "Spouse Information" portion of the application form needs to be completed only if your spouse lives with you. Income of other members of your household is not counted for SeniorCare. Wisconsin Resident Enrollment in SeniorCare is possible even if you are temporarily living outside the State of Wisconsin if: · You have a permanent residence in Wisconsin, · You are considered a Wisconsin resident for tax purposes, or · You are a registered voter in Wisconsin. U.S. Citizen If you (or your spouse living with you) are applying for SeniorCare and are not a U.S. citizen, please enclose a copy of both sides of your alien registration card to verify your immigration status and alien registration number. Race/Ethnicity (Optional) Shade in the circle that best describes race or ethnic origin of you and your spouse. This information is voluntary and will not be used to determine your enrollment. Marital Status and Living Arrangement If you are not married, shade in the appropriate marital status. If you are married and your spouse is living with you, shade in the circle next to the appropriate marital status and shade in the circle next to "Living w/Spouse". If you no longer have a spouse living with you, shade in the circle next to "Not Living w/Spouse". Social Security Number Enter your Social Security Number (SSN) and your spouse's if you are both applying for SeniorCare. If your spouse is not applying for SeniorCare, you are not required to enter your spouse's SSN. The SSN and other personally identifiable information are required by sections 49.688 and 49.82(2) of the Wisconsin Statutes. Failure to supply the information may result in denial of your application for benefits. The SSN and personally identifiable information will be used only for the direct administration of the SeniorCare program. Your SSN permits a computer check of your information with other government agencies such as the Internal Revenue Service (IRS), Social Security Administration (SSA) and the Department of Workforce Development (DWD). In addition, the Department will match your name and SSN with a file provided by health insurance carriers to determine if you have other insurance. If you have a health insurance plan, SeniorCare will coordinate benefit coverage with your plan.
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Mailing Address (SECTION III) Address Print the address where you would like information regarding your SeniorCare enrollment to be sent. This may be your current address OR the current address of your representative, legal guardian or power of attorney. Shade in the circle that indicates if the address in the Mailing Address Section is your residence, different than your residence, or the address of your representative, legal guardian or power of attorney. Expected Annual Income (SECTION IV) SeniorCare enrollment is based on your income and your spouse's income if you have a spouse who lives with you. Enter anticipated income amounts for the next 12-month period. Do not enter monthly amounts. Provide your best estimate for each of the following types of income (always round to nearest dollar). A worksheet is included at the end of these instructions to assist you in calculating your income to enter on the application form. Gross Social Security (Estimated 12-month total) Enter expected annual gross Social Security payments for both you and your spouse including Medicare premiums if they are withheld from your benefit check or any Electronic Fund Transfers. Gross Wages (Estimated 12-month total) Enter estimated annual gross salary, wages, bonuses, and commissions (do not include selfemployment or partnership earnings here) received from work for both you and your spouse. Enter the amount before any deductions are taken out of your earnings. You may use your tax return or W-2 form from last year to estimate your earnings taking into considering whether or not you expect to work the same amount, more, or less in the next 12 months. Do not use your adjusted gross income. Interest and Dividends and Capital Gains (Estimated 12-month total) Enter estimated annual interest, dividends and capital gains for both you and your spouse. You must include amounts that are earned even if you do not receive that income. For example, Certificate of Deposit (CD) interest earned and rolled directly back into the CD principal must be included. Net Self-Employment Income (Estimated 12-month total) Enter estimated net annual self-employment income for both you and your spouse. Self-employment includes farming or a business that you or your spouse owns solely or with others. Deduct your business costs, business losses, depreciation on business assets and any other deductions the IRS allows you to take on your self-employment income. You may look at your taxes from last year to get an idea of what you earned and what you were allowed to deduct. You cannot use a loss in self-employment to offset other types of income. A loss must be reported as zero. Retirement Income (Estimated 12-month total) Enter estimated annual gross pensions, Veterans and Railroad Retirement benefits, taxable portions of Individual Retirement Accounts (IRAs) and annuities for both you and your spouse that provide regular periodic payments.
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Other Income (Estimated 12-month total) Enter all other expected annual income for you and your spouse. Other income includes cash assistance, Unemployment or Workers' Compensation, alimony payments, support money and rental income minus operating expenses. Include any income you receive from a spouse who is not living with you. DO NOT INCLUDE any income you may receive from any of the sources listed below: 1. Supplemental Security Income (SSI). SSI is a federal income supplement program designed to help aged, blind or disabled persons who have little or no money. 2. Major disaster and emergency assistance payments. 3. Payments from an Individual Development Account. 4. Reimbursements you receive from expenses incurred either while you worked as a volunteer or expenses for your job or training. 5. Claims settlement payments approved by federal law for Native Americans. 6. Income or benefits from some special programs including: · Homestead Tax Credit. · Low income energy assistance and emergency fuel assistance programs. · Community service programs such as Retired Senior Volunteer program, Service Corporation of Retired Executives and Volunteers in Service to America. · Government subsidy programs for rent, housing or food. · Federal Emergency Management Assistance (FEMA). · Agent Orange Settlement Funds. · The Foster Grandparents Program. Other similar kinds of income may be excluded. If you have questions, contact the SeniorCare Customer Service Hotline 1-800-657-2038. Grand Total (Optional - Estimated 12-month total) You may enter the grand total of amounts from all income here, but it is not required. If you do not enter the grand total, it will be calculated for you when the form is received by the SeniorCare program. Signature of Applicant (SECTION V) The applicant or applicant's representative must sign the application form. If you are a representative, legal guardian or power of attorney who has completed this application form on behalf of someone else, you must sign in the space provided. Forms without a signature will not be processed and will be returned to you. Enrollment Fee (SECTION VI) If the correct enrollment fee is not enclosed with this form, your SeniorCare enrollment may be denied or delayed.
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Enrollment Fee Enclosed Shade in the $30 circle if only one person is applying. Shade in the $60 circle if you and your spouse are both applying for SeniorCare. Enclose the correct dollar amount with the completed application. Payment may be made by money order, cashier's check or personal check payable to "State of Wisconsin". The check or money order must also include your name and SSN and the SSN of your spouse if your spouse is also applying for SeniorCare. If the name of the applicant does not appear on the payment, write the applicant's name and SSN on the check or money order. DO NOT INCLUDE CASH. If you are not able to enroll in SeniorCare, your enrollment fee will be returned within 6-8 weeks. Other Program Information If you would be interested in other programs such as Medicare Premium Assistance or Foodshare Wisconsin contact Member Services at 1-800-362-3002. The Medicare Premium Assistance program helps eligible people pay for Medicare co-insurance and premiums for Part A and Part B. FoodShare Wisconsin helps eligible people buy food. Additional information will be needed if you decide to apply for these programs. To see if you might be able to get health, nutrition and other programs, contact your local county or tribal agency or visit access.wi.gov. This is an internet tool that will ask between 6 and 25 questions and will take about 15 minutes. Once you are done, ACCESS will tell you if you might be able to get health, nutrition and other programs and how to apply. YOUR RIGHTS AND RESPONSIBILITIES Changes such as death, mailing address, change in permanent residence outside of Wisconsin and household composition changes (marriage/divorce/separation) that affect you and/or your spouse must be reported to the SeniorCare Customer Service Hotline at 1-800-657-2038 within 10 days. Your signature on the application (Section V on this form) means that you authorize the Wisconsin Department of Health and Family Services to request any additional information that is appropriate and necessary for the proper administration of the SeniorCare program. By signing your name or by signature of a person signing on your behalf, you agree that information given by you or your representative is true and correct. You and your representative are responsible for incorrect information or errors. Penalties for providing fraudulent information could be a fine of not more than $10,000 or imprisonment of not more than one year, or both. You have the right to request a fair hearing if you do not agree with any action taken concerning your application or ongoing benefits. You may request a fair hearing by writing to: Wisconsin Department of Administration Division of Hearings and Appeals P.O. Box 7875 Madison, WI 53707-7875
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The Department of Health and Family Services is an equal opportunity employer and service provider. If you have a disability and need to access this information in an alternate format, or need it translated to another language, please contact (608) 266-3356 or (888) 701-1251 TTY. All translation services are free of charge. To file a complaint of discrimination, contact: Civil Rights Compliance Office Wisconsin Department of Health and Family Services Office of Affirmative Action and Civil Rights Compliance 1 W. Wilson Street, Room 561 P.O. Box 7850 Madison, WI 53707-7850 Telephone (608) 266-9372 (Voice) or (888) 701-1251 (TTY) or FAX (608) 267-2147 CHECKLIST Is the application complete? Did you sign or have your representative, legal guardian or power of attorney, sign the application? Did you enclose your enrollment fee? ($30 for one person; $60 if you and your spouse are applying) Did you remember to write your SSN and/or your spouse's SSN on your check or money order for the enrollment fee? Did you read the Rights and Responsibilities section? Send the application form to: SeniorCare P.O. Box 6710 Madison, WI 53716-0710

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Example Income Calculation Worksheet (Optional) This worksheet is to assist you in calculating the income values to enter on the SeniorCare Application. This worksheet is yours to keep. On the SeniorCare Application enter whole dollar amounts, no cents. See Section IV of these instructions for descriptions of the income types. Gross Social Security 1. Monthly Social Security amount: (include Electronic Fund Transfers) 2. Medicare Part B premium (if withheld from your check) TOTAL Gross Social Security Gross Wages 1. Estimated monthly earnings. Use gross amounts shown on your wage statements (amounts before taxes and deductions). 2. Repeat for all types of earnings you receive. + Applicant $__________ x 12 months = ___________ + $__________ x 12 months = ___________ + Spouse $__________ x 12 months = ___________ $__________ x 12 months = ___________

$__________ x 12 months = ___________ Applicant $__________ x 12 months = ___________

$__________ x 12 months = ___________ Spouse $__________ x 12 months = ___________

$__________ x 12 months = ___________ $__________ x 12 months = ___________ +

$__________ x 12 months = ___________ $__________ x 12 months = ___________

TOTAL Gross Wages Interest Dividends and Capital Gains 1. Amount of interest dividend and capital gains you receive times the frequency with which you receive payments during the year. 2. Add amounts withheld from the payments such as taxes. Repeat for all types of interest dividends and capital gains you receive. TOTAL Interest Dividends and Capital Gains

$__________ x 12 months = ___________ Applicant $__________ x _________ = ___________ frequency $__________ x _________ = ___________ frequency + $__________ x _________ = ___________ frequency +

$__________ x 12 months = ___________ Spouse $__________ x _________ = ___________ frequency $__________ x _________ = ____________ frequency $__________ x _________ = ___________ frequency

$__________ x _________ = ___________ frequency

$__________ x _________ = ___________ frequency

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Net Self-Employment Income 1. Estimated net monthly self-employment or partnership income. 2. Repeat for all types of self-employment or partnership income you receive. +

Applicant $__________ x 12 months = ___________ $__________ x 12 months = ___________ $__________ x 12 months = ___________ +

Spouse $__________ x 12 months = ___________ $__________ x 12 months = ___________ $__________ x 12 months = ___________

TOTAL Net Self-Employment Income Retirement Income 1. Retirement income you receive times the frequency with which you receive that income. 2. Add amount withheld from your income such as taxes or insurance premiums. TOTAL Retirement Income Other Income 1. Other income you receive times the frequency with which you receive that income. 2. Add amount withheld from your income such as taxes or insurance premiums. TOTAL Other Income GRAND TOTAL (Optional) Add all totals. Round income to the nearest dollar.

$__________ x 12 months = ___________ Applicant $__________ x _________ = ___________ frequency + $__________ x _________ = ___________ frequency $__________ x _________ = ___________ frequency Applicant $__________ x _________ = ___________ frequency + $__________ x _________ = ___________ frequency $__________ x _________ = ___________ frequency Applicant $ ____________

$__________ x 12 months = ___________ Spouse $__________ x _________ = ___________ frequency + $__________ x _________ = ___________ frequency $__________ x _________ = ___________ frequency Spouse $__________ x _________ = ___________ frequency + $__________ x _________ = ___________ frequency $__________ x _________ = ___________ frequency Spouse $ _____________

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