Free Wisconsin Chronic Renal Disease Program Application, F-1186 - Wisconsin

DEPARTMENT OF HEALTH SERVICES DIVISION OF HEALTH CARE ACCESS AND ACCOUNTABILITY F-1186 (02/09)

STATE OF WISCONSIN ss. 49.68 WIS STATS

WISCONSIN CHRONIC RENAL DISEASE PROGRAM APPLICATION
READ INSTRUCTIONS CAREFULLY BEFORE COMPLETING THE FORM SECTION 1. APPLICANT INFORMATION
1. Name ­ Applicant (Last, First, MI) 2. Social Security Number (SSN) (optional)

3. Street Address ­ Applicant

4. Home Telephone

5. City, State, ZIP Code

6. County of Residence

7. Are you currently receiving veteran health care benefits? Yes No

8. Sex Male

9. Date of Birth Female

10. Do you have any dependent family members who are also members of the Chronic Disease Program? Yes No If Yes, indicate the names and Social Security Numbers (SSN) of all dependent family members who are members of the Chronic Disease program. Name ________________________________________________ Name ________________________________________________ 11. Race/Ethnicity (Optional) American Indian or Alaska Native Black (Not of Hispanic Origin) 12. Current Medical Status Incenter Hemodialysis Incenter Peritoneal Dialysis SSN SSN

Asian or Pacific Islander White (Not of Hispanic Origin)

Hispanic (Mexican, Puerto Rican, Cuban, or other Hispanic Culture)

Home Hemodialysis Home Peritoneal or CAPD

Transplant Date this status began__________________

SECTION 2. RESIDENCY INFORMATION
13. Have you lived in Wisconsin for the last 2 years? Yes No If you answered No, indicate the date you moved to Wisconsin. __________________________________________ 14a. Applicants age 19 and over should provide copies of the following documents. · Last year's Wisconsin Income Tax return with all attachments. · The most recent rental agreement or property tax bill. · Wisconsin drivers license with current address OR state identification with current address. · Alien registration card issued by the INS if you are not a U.S. citizen. 15. If you do not have these documents, explain why. 14b. Applicants under the age of 19 should provide copies of the following documents. · Parent or guardian's Wisconsin Income Tax return with all attachments for the last year. · Parent or guardian's most recent rental agreement or property tax bill. · Wisconsin drivers license with current address OR state identification with current address OR school identification. · Alien registration card issued by the INS if you are not a U.S. citizen.

SECTION 3. MEDICARE, WISCONSIN MEDICAID, BADGERCARE PLUS, AND SENIORCARE INFORMATION
16. Do you currently have or have you had Medicare coverage? If yes, indicate your Medicare eligibility dates below. Part A Begin Date Part A End Date · · _____________ _____________ Part B Begin Date ________________ Part B End Date ________________ Part D Begin Date ________________ Part D End Date Yes No

______________

If you are currently eligible for Medicare, attach a copy of your Medicare card. If you are not eligible for Medicare, attach the letter of denial from the Social Security Administration stating the reason you are not eligible for Medicare. You may disregard this, if your transplant was more than 3 years ago.

WISCONSIN CHRONIC RENAL DISEASE PROGRAM APPLICATION F-1186 (02/09)

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17. Were you eligible for Medicare when you received your kidney transplant?

Yes

No

N\A

18. Wisconsin law requires applicants must first complete applications for other health care programs, if they may be reasonably eligible given their financial and non-financial circumstances, before applying to WCDP. Are you currently enrolled in Wisconsin Medicaid, BadgerCare Plus (Medical Assistance, MA, Title 19, T-19), or SeniorCare? Yes No If yes, indicate your Medicaid, BadgerCare Plus,or SeniorCare identification number here._______________________________ 19. If no, have you applied for any of these programs in the past year? Yes No If yes, and you were denied eligibility for these programs, explain why. ________________________________________________________________________________________________________

SECTION 4. SOCIAL WORKER SIGN OFF
This section is to be completed by the social worker if the applicant is not enrolled in Wisconsin Medicaid, BadgerCare Plus, or SeniorCare. 20. Based on my knowledge of _________________________________________________________, I attest that he/she is not eligible for the programs listed above. Explain in the space provided why the applicant would be denied eligibility, where applicable. Medicaid or BadgerCare Plus________________________________________________________________________________ SeniorCare______________________________________________________________________________________________ SIGNATURE ­ Social Worker Facility Name Date Signed

SECTION 5. INSURANCE INFORMATION
21. In the last two years have you had or do you currently have private, group, HIRSP, or other health insurance coverage for medical expenses? (Do not include Medicare, Wisconsin Medicaid, BadgerCare Plus, or SeniorCare information here.) Yes No If yes, complete the following information. If you have more than one insurance company, list the second company under Insurance #2. Attach additional information if needed for current and past insurance for the last two years. Insurance #1 Insurance #2 a. Name ­ Insurance Company b. Telephone Number a. Name ­ Insurance Company b. Telephone Number c. Name ­ Policy Holder e. Policy Number g. Coverage Begin Date
d. Relationship of Policy Holder

c. Name ­ Policy Holder e. Policy Number g. Coverage Begin Date

d. Relationship of Policy Holder

f. Group Policy Number
h. Coverage Termination Date

f. Group Policy Number
h. Coverage Termination Date

Indicate whether this insurance covers these services by answering each question. Answer each question. i. Inpatient Hospital Service. Yes j. Outpatient Hospital Service. k. Physician Services. l. Radiology Services. m. Laboratory Services. n. Home Dialysis Supplies. o. Prescription Drugs. Yes Yes Yes Yes Yes Yes

No No No No No No No

Indicate whether this insurance covers these services by answering each question. Answer each question. i. Inpatient Hospital Service. Yes No j. Outpatient Hospital Service. k. Physician Services. l. Radiology Services. m. Laboratory Services. n. Home Dialysis Supplies. o. Prescription Drugs. Yes Yes Yes Yes Yes Yes No No No No No No

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22. If you are enrolled in Wisconsin Medicaid, BadgerCare Plus, SeniorCare, or Medicare Part D, you may skip this question and go to question 23. WCDP is trying to determine if you have insurance that covers drugs that meets Medicare Part D's definition of `creditable coverage'. If you currently have private, group, or other health insurance coverage for medical expenses does it do the following: a. Provide coverage for brand and generic prescriptions; b. Provide reasonable access to retail providers and, optionally for mail order coverage; c. Pay on average at least 60% of your prescription drug expenses; and d. Satisfy at least one of the following criteria below: Yes Yes Yes Yes No No No No

1. The prescription drug coverage has no annual benefit maximum benefit or a maximum annual benefit payable by the plan of at least $25,000; or 2. The prescription drug coverage has an actuarial expectation that the amount payable by the plan will be at least $2,000 per Medicare eligible in 2006; or 3. For plans that have integrated supplemental coverage directly through a specific Part D plan, the integrated health plan has no more than a $250 deductible per year, has no annual benefit maximum payable by the plan of at least $25,000 and has not less than a $1,000,000 life time combined benefit maximum. SECTION 6. FINANCIAL INFORMATION 23. Indicate the number of dependent family members; include yourself if you are a dependent family member.____________________

24. Indicate your current total income by completing items a - m either by

monthly OR annual totals.
a. Gross wages, salaries, tips, etc. b. Net income from non-farm self-employment. c. Net income from farm self employment. d. Social Security and/or Supplemental Security benefits. e. Dividends and interest income. f. Total of estate or trust income, net rental income and royalties. g. Cash public benefits (e.g. W-2 payments). h. Pensions, annuities and/or veteran's pension. i. Unemployment compensation and/or worker's compensation. j. Maintenance, alimony and/or child support. k. Non taxable interest (federal, state or municipal bonds). l. Nontaxable deferred compensation. m. Total Monthly OR Yearly Income.

Average Monthly Totals OR Annual Totals ________ 2 0__ __ 2 0 __ __
Month Year Year

$ $ $ $ $ $ $ $ $ $ $ $

$ $ $ $ $ $ $ $ $ $ $ $

25. Do you expect this income to change significantly from month to month or in the next year? 26. If yes, will your income be less or more than the total above? Explain why. Less More

Yes

No

27. On last year's Wisconsin Income Tax return, what was your total gross family income before taxes?

______________________

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SECTION 7. AGREEMENT AND SIGNATURES FOR CHRONIC RENAL DISEASE PROGRAM APPLICANTS

Eligibility for state reimbursement exists only insofar as certified by the Department of Health Services (herein called the Department) or its fiscal agent upon: a) determination of the member's Wisconsin residency; b) payment of Medicare part B premiums, if eligible for Medicare; c) receipt of a completed application, including verification by a nephrologist or transplant surgeon from an approved facility of having end stage renal disease. End stage renal disease is defined in Administrative Code 152 as "That stage of renal impairment which is virtually irreversible, and requires a regular course of dialysis or kidney transplantation to maintain life." Pursuant to the authority of Wisconsin Statute 49.68 and 49.687 and the rules promulgated thereunder, the Department or its fiscal agent will, subject to the conditions named, reimburse an approved dialysis or transplant facility in the state or a dialysis or transplant center which is approved as such in a contiguous state, on behalf of the member, for part of the cost of medical treatment specifically relating to chronic renal disease. Reimbursement will be made only for that portion of the allowable cost of medical services and medication remaining after all payment from other state programs, federal programs, and private health insurance coverage have been received and the member's liability and deductibles have been determined. The member's liability and deductibles will be based on income and family size. If insufficient aid is available from other sources, the state shall pay the difference between the allowable cost and the sum of payment received and member liability and deductibles. State payment shall be appropriately reduced if federal, state, private or other health insurance becomes available during the benefit period. The member must inform the Department or its fiscal agent of all health insurance coverage and eligibility date. The Department, the State of Wisconsin, and its officers or agents are released and discharged of and from all manner of action and actions, cause and causes of actions, suits, sums of money, judgment, claims, and demands whatsoever in law or in equity which the claimant, or his/her heirs, executors or assignees might have, or may hereinafter have, by reason of any injury or worsening of condition or death of the member due to chronic renal disease, treatment or lack of treatment. In order to establish my eligibility for state benefits, I authorize the medical facility (28) ________________________ to disclose information relating to my health condition or payment made for my health care to the Chronic Renal Disease Program. I certify, to the best of my knowledge, all information provided on this form is true, correct, and complete. I understand that I will be denied reimbursement if I withhold information, provide inaccurate information, or refuse to provide information. I authorize release of any medical and financial information including certification for General Assistance, Wisconsin Medicaid, BadgerCare Plus, SeniorCare, or Medicare to the Wisconsin Chronic Disease Program necessary for processing claims and verifying services under the program. I agree to notify the Department or its fiscal agent in writing within 30 days of any change in name, address, income by more than 10%, insurance coverage, or family size. I agree to accept responsibility for the program's copayments and deductibles. I have read and consent to the above. I understand that if I have not had a kidney transplant and I no longer require a regular course of dialysis to maintain life, I will not be eligible for benefits of the Wisconsin Chronic Renal Disease Program as of the date of my last dialysis. I will not be eligible for benefits until such time that I receive a kidney transplant or require a regular course of dialysis to maintain life. I also understand that if I am eligible for Medicare Part B, I must continue to pay Part B premiums in order to remain eligible for the Chronic Renal Disease Program. I understand that benefits issued through the Wisconsin Chronic Disease Program are eligible for estate recovery as defined in HFS 152.065(7). I understand that only Wisconsin residents are eligible for the Chronic Disease Program. By signing this form I am attesting that I am a Wisconsin resident as set forth in HFS 152.02(25).
29. SIGNATURE ­ Applicant (or applicant's representative if applicant is a minor) Date Signed

WISCONSIN CHRONIC RENAL DISEASE PROGRAM APPLICATION F-1186 (02/09)

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SECTION 8. CHRONIC RENAL DISEASE PATIENT MEDICAL INFORMATION Section 8 is to be completed by a Nephrologist or Transplant surgeon at an approved facility
30. Name ­ Patient (Last, First, MI) 31. Patient's primary diagnosis (Use ICD-9-CM
code)

32. Date patient started on regular course of chronic maintenance dialysis __________________________ 33. For the above patient, please indicate dates of hospitalization for initial diagnosis of chronic renal disease (if applicable) and all types of treatments and dates of each treatment. Treatments may include disease transplant, home peritoneal dialysis, home hemodialysis, in-center peritoneal dialysis, or in-center hemodialysis. Hospitalization for Initial Diagnosis or Type of Treatment Date this type of treatment began (The date entered should correspond with Item 30). Date this type of treatment terminated

34. Name ­ Treating Facility

35. Wisconsin Medicaid/BadgerCare Plus Provider identification number of facility

36. Address ­ Treating Facility

I certify that the above patient has been diagnosed to have end stage renal disease as defined in the Wisconsin Administrative Code as "that stage of renal impairment which is virtually irreversible, and requires a regular course of dialysis or kidney transplantation to maintain life." I have read and determined that the dates in item 31 and 32 as well as other information on this page is true and correct.
37. SIGNATURE ­ Nephrologist or Transplant Surgeon Date Signed

Send completed application to:

Chronic Disease Program Attn: Eligibility Unit P.O. Box 6410 Madison, WI 53716-0410

OFFICE USE ONLY. DO NOT WRITE IN THIS SPACE.