Release 19-01

33.10 Changes

33.10.1 SeniorCare Changes Introduction

The following changes must be reported to the SeniorCare program within 10 days:

Address (including a change in mailing address or permanent residency outside of Wisconsin).
Household Composition (including marriage, divorce, separation, or someone moving to a nursing home or other medical facility).
Death.

Changes may be reported by phone to the SeniorCare Customer Service hotline at 1-800-657-2038.

Changes may also be reported by writing to:

SeniorCare

P.O. Box 6710

Madison, WI 53716-0710

Members are asked to include an SSN or case number on any written correspondence.

If an individual reports any changes before the case has been confirmed in CARES, the new information will be used in his or her SeniorCare eligibility determination.

Changes reported after the case has been confirmed in CARES will be applied to the member’s SeniorCare benefits as follows:

Address change:

Reports of address changes within Wisconsin will result in SeniorCare notices being sent to the new address. SeniorCare benefit levels will not change for the current benefit period.
Address changes that result in termination of Wisconsin residency result in discontinuation of SeniorCare benefits. The member will be provided with at least 10 days notice before the effective date of an adverse action .

Note: Reporting an out-of-state address does not necessarily signify that an applicant is not a Wisconsin resident (see Section 33.3 SeniorCare Nonfinancial Requirements).

Death

A member’s death ends SeniorCare eligibility on the date of death. A 10-day notice for adverse action is not required when an adverse action is the result of a participant‘s death. The “early termination date” for the member should be equal to the member’s date of death.

If a member’s spouse dies, the member will remain eligible at the same benefit level through the current SeniorCare benefit period. The member may wish to re-apply to establish a new benefit level if the spouse’s death will result in a reduction in income.

Change in household composition

If a member experiences a change in household composition, the SeniorCare benefit level will not change through the remainder of the SeniorCare benefit period. The member may wish to re-apply to establish a new benefit level if the change in household composition will result in a better level of participation.

Inmate of a Public Institution (See General Medicaid Application Process for Inmates of State Correctional Institutions).

An inmate of a public institution is ineligible for SeniorCare on the date incarceration begins. The member will be provided adequate notice before the effective date of the adverse action. The “early termination date” is equal to the notice mailing date.

If a member’s spouse is an inmate of a public institution the member benefit level will remain eligible as the same benefit level through the current SeniorCare benefit period. The member may wish to re-apply to establish a new benefit level if the spouse’s incarceration will result in a better level of participation.

5. Change in Circumstance

If an applicant needs to correct their application, or has a change in circumstances during the application processing period, he or she may need to report this information before their eligibility is determined in order to have the change impact their SeniorCare eligibility and participation level.

Depending on the nature of a client-reported error or agency-discovered error, a member’s eligibility will be redetermined (see Section 33.10.2 Correction of Errors). The member will be provided with at least 10 days notice before the effective date of an adverse action.

If the case has already been confirmed in CARES, and the individual reports a change in circumstances since they applied (for example, a job loss), eligibility will not be redetermined. The applicant may opt out and reapply if he or she so desires.

Example 1: Sally and Fred are husband and wife and applied for SeniorCare in July. Both Sally and Fred were found eligible at Level 2a with a deductible for August. In September, Fred loses his job. He reports the change to the SeniorCare program. This change will not affect Sally or Fred’s SeniorCare benefits, because Fred reported the change after his case had been confirmed in CARES.

If Fred had reported the change prior to his case being confirmed in CARES, the change would have been applied to Sally and Fred’s eligibility determination, and they would have paid the co-payment amounts for prescription drugs. If Fred and Sally wish, they may request to file a reapplication (see Section 33.11 Re-Application) and submit enrollment fees to have their eligibility redetermined and change their benefit level. Without the income from Fred’s job, Sally and Fred would be able to purchase prescription drugs at the co-payment level, if a reapplication is filed.

33.10.2 Correction of Errors

All errors made on the SeniorCare Application (F -10076) must be reported by the member or his or her Authorized Representative , POA, or Guardian to the SeniorCare Customer Services hotline at 1-800-657-2038 (TTY and translation services are available) or in writing to:

SeniorCare

P.O. Box 6710

Madison, WI 53716-0710

An error may include, but is not limited to:

Doubling of income (for example, totaling income on the application incorrectly).
Incorrect entries (for example, income amounts are off by a factor of 100 due to the lack of decimal point).
Application processing errors.

An applicant who wishes to report a change in circumstances from what was on his or her submitted application may do so, but to impact eligibility, this change should be reported prior to eligibility being confirmed in CARES (see Section 33.10.1 #5 Change in Circumstance).

If a member has been found eligible for either an incorrect SeniorCare benefit level or spenddown amount due to an error, action will be taken to correct the mistake. The effective date of the correction is based on whether the error is determined to be due to agency error or Applicant /Member error, as follows.

33.10.2.1 Agency Error

Agency errors for SeniorCare will be determined on a case by case basis. If the error resulted in an overpayment, past benefits are not recoverable. If the error resulted in an underpayment, corrected benefits will be restored back to initial eligibility date of the current benefit period.

33.10.2.2 Applicant or Member Error

If an applicant or member error resulted in an overpayment, benefit recovery will be pursued, and the correction is processed with an effective date based on adverse action notice. The member will be provided with at least 10 days notice before the effective date of an adverse action.

If the error resulted in an underpayment and he or she reported the error within 45 days of the mail date of the notice of decision, corrected benefits should be restored back to the initial eligibility date of the benefit period. If the error is not reported within 45 days of the notice of decision mail date, the effective date of the correction is the first of the month in which the error is reported.

Example 2: In August, Charlie lost this job at the Burger Palace. In September, Charlie applied for SeniorCare. In his application, Charlie erroneously reported income of $1150 per month from the Burger Palace job. Charlie’s notice of decision had a mail date of October 1, and stated that Charlie had a $1500 spenddown.

Depending on when Charlie reports this error, his benefits may be corrected back to the eligibility begin date or the first month in which the error was reported (see Section 33.10.2 Correction of Errors).

If he reported the error by November 15, within the first 45 days after the notice of decision mail date, his benefits would be corrected back to the original effective date.

If he reported the error November 16 or later (more than 45 days after the notice of decision mail date), the benefit level change would be made effective the first of the month in which the error was reported.

Example 3: Eric applied for SeniorCare in July and was determined eligible at level 1 effective August 1. Prior to applying for SeniorCare, Eric got a part-time job that had begun in June. When Eric applied for SeniorCare, he neglected to report his anticipated part-time earnings on the SeniorCare application.

Eric receives his notice of decision, dated August 8. The notice informs him that he is eligible at level 1. Eric reviews the income used in his eligibility determination that is printed in the notice and realizes that he forgot to report the earnings from his part-time job. He calls the SeniorCare Customer Service hotline on August 21 to report his error.

Eric indicates that he is working 10 hours per week and earns $10 per hour. He plans to keep the job as long as possible. He estimates that his earnings will be $5,200 for his 12-month benefit period. The only other income that Eric receives is Social Security. His earnings in addition to the annual Social Security income move him from level 1 to level 2b.

Since the income correction will result in a negative impact on his eligibility, the effective date of the corrective benefit is October 1, providing Eric with a 10-day notice of the negative action in his case.

Prior to reporting this mistake, Eric had purchased several prescriptions at the copayment levels with his SeniorCare card. Since the correction resulted in Eric’s eligibility at level 2b, he must now meet an $850 deductible between October 1 and July 31 (the end of his 12-month benefit period). SeniorCare will have overpaid Eric’s benefits and could seek recovery of the overpaid amount.

33.10.3 Fraud

Fraud is defined as intentionally getting or helping another person get benefits to which he or she is not entitled. Penalties for fraud include a fine of up to $10,000, imprisonment up to one year, or both, and suspension from the SeniorCare program.

Fraudulent acts include:

Intent to provide misleading, fraudulent, omitted, or incomplete information on the SeniorCare application;
Not reporting an event that knowingly affects initial or continued eligibility for SeniorCare;
Applying for SeniorCare on behalf of another person and use of any part of the benefit for oneself;
Allowing another person to use someone else’s card to get prescription drugs.