Free Wisconsin Chronic Renal Disease Program Financial Need Statement Cover Memo, F-1194 - Wisconsin

DIVISION OF HEALTH CARE ACCESS AND ACCOUNTABILITY WISCONSIN CHRONIC DISEASE PROGRAM FINANCIAL SERVICES P O BOX 6410 MADISON WI 53716-0410

Jim Doyle Governor Karen E. Timberlake Secretary

State of Wisconsin Department of Health Services

Telephone: 800-362-3002 FAX: 608-224-6318 TTY: 866-824-3753

www.forwardhealth.wi.gov

DATE: TO:

March 25, 2009 All Wisconsin Chronic Disease Program (WCDP) Members Chronic Renal Disease (CRD) Program Wisconsin Chronic Disease Program (WCDP)

FROM:

Please complete the enclosed Financial Need Statement [F-1189 (02/09)] and return it to the Wisconsin Chronic Disease Program before May 31, 2009. Please also note that Wisconsin Medicaid has undergone a name change and is now also referred to as BadgerCare Plus. There is no longer a BadgerCare plan. IMPORTANT: Please do NOT throw out your current ForwardHealth ID cards. You will NOT receive another card after you send in your new financial needs information. However, you must provide all information requested. We will return incomplete forms to you. If you do not return your completed Financial Need Statement, claims for services after June 30, 2009, will not be paid and your ForwardHealth card will be deactivated for WCDP coverage. REQUIRED ENROLLMENT IN MEDICARE PART D FOR CHRONIC RENAL DISEASE MEMBERS People entitled to Medicare Part A and/or enrolled in Medicare Part B are eligible for the new Medicare Part D prescription drug benefit that began January 1, 2006. If you are eligible for Medicare Part D, you are required to enroll in Medicare Part D. You should choose the Medicare Part D Prescription Drug Plan (PDP) that best meets your needs. WCRDP will not provide coverage for drugs not covered by your PDP. If you are eligible for Medicare Part D and choose not to enroll, you will not be eligible for drug coverage under WCRD Program. You are exempt from this requirement if you are enrolled in SeniorCare or another form of creditable drug coverage. Creditable drug coverage is drug coverage that is at least as good as standard Medicare Part D drug coverage. You should ask your drug-coverage insurer if your plan is creditable coverage. You will need to submit documentation of enrollment in Part D, SeniorCare or another form of creditable drug coverage with your Financial Needs Statement. WCRDP has not provided full drug coverage since May 1, 2006, but still provides wraparound coverage. Wraparound coverage will provide assistance for out-of-pocket drug expenses, like deductibles and coinsurance.

Wisconsin.gov

Remember, if you choose not to enroll in Medicare Part D, SeniorCare or another form of credible drug coverage, WCRDP will not provide any drug coverage for you. INDIVIDUALS WHO ARE NOT ELIGIBLE FOR MEDICARE If you are not eligible for Medicare, you will not be eligible for the Medicare Part D drug benefit. However, as in past years, you must submit proof that you are not eligible for Medicare by May 31, 2009 in order to continue to receive full drug coverage from WCRDP. OTHER ITEMS TO NOTE Please pay particular attention to the following items. If necessary, staff at your hospital or dialysis center will be able to assess your particular case and advise you in completing and mailing this form. SECTION 5. INSURANCE INFORMATION - You must provide accurate, current insurance information. If your insurance has changed, please indicate the date your old insurance terminated and your new insurance began. If you have more than one insurance policy, list the second insurance company under Insurance #2. Please attach additional sheet(s) of paper with your insurance information if needed. Incomplete insurance information may cause your claims to be rejected. SECTION 6. FINANCIAL INFORMATION. Item 20. CURRENT MONTHLY/YEARLY FAMILY INCOME - Your eligibility will be determined by current monthly or annual family income. You must report all items (a. through l.) for all your immediate family to determine your total family income.
SUBMIT ADDITIONAL INFORMATION. You will need to submit the following items with the Financial Need Statement:

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Copy of last year's Wisconsin Income Tax return with all attachments. Copy of the most recent rental agreement OR property tax bill. Copy of your Wisconsin drivers license with current address OR State identification with current address OR Student ID (only for applicants under age 19). Copy of your Alien registration card issued by the INS if you are not a U.S. citizen. Copy of your Medicare Part A, Part B and Part D cards OR a copy of the letter of denial for Medicare from the Social Security Administration.

The Residency and Health Care Benefits Verification [F 1143 (Rev. 02/09)] has been created to enable WCDP to determine member eligibility. This form should be completed by a county / facility social worker or transplant clinic financial counselor. The social worker / financial counselor will fill out this form, sign it and send it to the member. After the member has the completed form, it should be sent to WCDP with the member's completed Financial Need Statement. It is the member's responsibility to ensure that sections 1,2,5,6 and 7 on the Financial Need Statement are completed. Do not mail the Financial Need Statement to the social worker / financial counselor. Please send your completed materials to: Wisconsin Chronic Disease Program Attention: Eligibility Unit P.O. Box 6410 Madison, WI 53716-0410
F-1194 (02/09)