State of Wisconsin Department of Health Services

Release 25-02 April 9, 2025

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33.3 SeniorCare Nonfinancial Requirements

33.3.1 SeniorCare Nonfinancial Requirements Introduction

To be non-financially eligible for SeniorCare, an applicantA person who has submitted a request for coverage for whom no decision has been made regarding eligibility must:

1. Be at least 65 years of age.
2. Be a Wisconsin resident. A Wisconsin resident is an individual who meets at least one of the following criteria: A SeniorCare member may temporarily live outside the state of Wisconsin, as long as they maintain permanent residency in Wisconsin. Residency in a Wisconsin nursing home or an assisted living facility will meet this requirement. There is also not a specific period of time the applicant must be a Wisconsin resident before applying for SeniorCare.
   1. Has a permanent residence in Wisconsin
   2. Is considered a Wisconsin resident for tax purposes
   3. Is a registered voter in Wisconsin
3. Be a U.S. citizen or have qualifying immigrant status. (see Section Section 7.1 US Citizens and Nationals). An applicant who is a not a U.S. citizen will need to have a qualifying immigrant status to be eligible for SeniorCare (see Section 7.3 Immigrants). The applicant will need to provide his or her immigration registration number. Verification of the applicant’s immigration status will be made through the U.S. Citizenship and Immigration Services’ Systematic Alien Verification for Entitlements (SAVE) program. In some cases, the individual may need to provide an official government document. For example, if the applicant’s immigration status cannot be verified through SAVE or there are discrepancies between reported and verified data, supporting legal documentation must be provided by the applicant.
   
   If current SSDI, SSI, Medicare, Foster Care, or Adoption Assistance benefits have been verified, the applicant is exempt from documenting their citizenship (see Section 7.2 Documenting Citizenship and Identity).
4. Provide an SSN or be willing to apply for one, unless they are exempt from the SSN requirement (see Section 10.1.1 Social Security Number Requirements).
   
   SeniorCare applicants only need to provide a number, which is verified through the data exchange with Social Security. If the SSN validation process returns a mismatch record, then the applicant must provide the Social Security card or another official government document with the SSN displayed. If an applicant does not yet have a SSN, they must be willing to apply for one.
   
   If an applicant requires assistance in obtaining a SSN, the SeniorCare Program will assist him or her in applying for one. “Assisting the applicant” may include helping with filing the SS-5 SSN Application form, obtaining a birth certificate on behalf of the applicant, or assisting with obtaining another document needed to apply for the SSN.
   
   SeniorCare applications without the SSN or with an incorrect SSN will not be returned. Applicants will be contacted and given an opportunity to provide a valid SSN or apply for one. The SeniorCare program will honor the original application date for individuals who initially provide an incorrect SSN or who need assistance in applying.
   
   If the individual is not willing to provide or apply for an SSN or the proof of application is not received within 30 days of application for the SeniorCare application date, eligibility will be denied and any enrollment fee received will be refunded. The individual can reapply once they are willing to provide or apply for an SSN. The eligibility begin date will be based on the new application receipt date.
   
   The member should be informed if the SSN validation process indicates another individual is using the same SSN. The member should contact the Social Security Administration and request they conduct an investigation. The IM worker cannot provide the member with any information that would identify the individual who is using the member's SSN.
   
   If the Social Security Administration finds that the SSN has been used fraudulently it may: Verify the SSN only once.
   1. Recommend further action be taken
      and/or
   2. Provide the member with the information on the fraudulent action so that the member may pursue action through the legal system.
5. Not be a full-benefit Medicaid member (see Section 21.2 Full-Benefit Medicaid). This includes members who are covered by BadgerCare Plus (see the BadgerCare Plus Handbook).
   
   Individuals are not considered Medicaid members for SeniorCare if they have an unmet Medicaid deductible (see Section 24.2 Medicaid Deductible Introduction) or receive one of the following:
   1. Medicare Savings Program (see Section 32.1 Medicare Savings Programs).
   2. Tuberculosis (TB) Related Medicaid
   3. Family Planning Only Services
6. Not be an inmate of a public institution. An inmate is someone who resides in a public institution on an involuntary basis through operation of law enforcement authorities. For example, a prisoner in a jail, prison, or other correctional facility is considered an inmate.
   
   The following individuals are not considered to be inmates for the purposes of SeniorCare:
   1. A staff person voluntarily residing in a public institution is not considered an inmate.
   2. An individual voluntarily residing in an institution while waiting for other living arrangements to be made that are appropriate to the person’s needs.
   3. An individual who is legally confined to his or her home by a monitoring device, such as an ankle bracelet.
   4. People who are on parole, probation, or have been released to the community pending trial (including those under pre-trial supervision).
   A public institution is an institution that is the responsibility of a governmental unit or over which a governmental unit exercises administrative control. This includes correctional facilities operated by or under contract with a governmental unit. A public institution does not include a medical institution (see Section 27.1 Institutions), a publicly operated community residence that serves no more than 16 residents, or a child care institution in which Foster Care maintenance payments are made under Title IV-E. People residing in these situations are not inmates.
   
   Even though the following institutions may accommodate 16 or fewer residents, they are not considered to be publicly operated community residences. People residing in these institutions may be inmates if they are residing there on an involuntary basis through operation of law enforcement authorities:
   1. Residential facilities located on the grounds of, or immediately adjacent to, any large institution or multiple purpose complex.
   2. Correctional or holding facilities for people who are prisoners, have been arrested or detained pending disposition of charges, or are held under court order as material witnesses or juveniles.
   Some inmates may be allowed to leave jail for various reasons under the Huber Law, also known as the Huber Program. Huber Law prisoners who are released from jail to attend to the needs of their families can become eligible for SeniorCare if both the following are true:
   1. They intended to return to the home.
   2. They continue to be involved in the planning for the support and care of their minor children.
   Huber Law prisoners who are released for a purpose other than attending to the needs of their families are not eligible for SeniorCare.

7. Cooperate with providing information and/or verification necessary to determine eligibility (see Chapter 20 Verification) and for quality assurance purposes.
   
   If a person requires assistance in obtaining the required verification, the SeniorCare program will assist him or her.
   
   If a person is not able to produce the required verification and the SeniorCare program is not able to produce the required verification, the SeniorCare program may not deny assistance.
   
   If a person is able to produce required verification but refuses or fails to do so, the application will be denied.

33.3.2 Enrollment Fee

In addition to the non-financial requirements listed above, each applicant must pay a $30 annual enrollment fee. The enrollment fee must be paid prior to eligibility confirmation. When a member reapplies for a new benefit period, a new enrollment fee is required.

When a SeniorCare enrollment fee check is returned for non-sufficient funds, the applicant or member is mailed a letter and provided ten calendar days to submit a replacement check. If a replacement check is not received, a letter giving another 10 days to replace the fee is sent. If the check is still not replaced, then eligibility is denied or terminated.

33.3.2.1 Refunds

No Application Received

If EM CAPO receives an enrollment fee without an application, a manual notice and application will be sent, if possible, to the individual from whom the enrollment fee was received. If a SeniorCare application is not received by EM CAPO within 45 days of the receipt of the enrollment fee, a refund will be processed at the request of the person who submitted the enrollment fee.

Application Denied

Anytime an application for SeniorCare is denied, a refund of the paid enrollment fee is automatically issued. A refund may be requested prior to eligibility being confirmed or within specified timelines outlined below.

Opt Out

In all opt-out cases, a refund will be issued only if the request to withdraw from the SeniorCare program is received by the later of:

• Ten days following issuance of the eligibility notice, or
• 30 days from the application filing date.

The date by which a request for refund must be received will be printed on the initial eligibility determination notice. Filing of a hearing request will not delay these deadlines for refunds.

Refunds are based on individual participation. A SeniorCare member may receive an enrollment fee refund if he or she received an initial eligibility notification, but has not received any SeniorCare prescription drug benefits or services and requests to withdraw from the program (see Section 33.12.2 Withdrawal).

SeniorCare prescription drug benefits include use of the SeniorCare card to receive discounted drug prices in levels 1, 2a, and 2b. A refund may be issued if such charges are reversed by the pharmacy.  

Use of the SeniorCare card at Level 3 where a spenddown has not been met constitutes receipt of SeniorCare prescription drug services. A refund of the enrollment fee may be issued if such claims are reversed by the pharmacy.

Example 1:

Julie is a SeniorCare member at Level 2b. Julie’s SeniorCare application filing date was October 26th, and her benefit period began November 1st. On November 15th, Julie calls the SeniorCare Customer Service hotline to withdraw from the SeniorCare program and request a refund of her $30 enrollment fee. Julie used her SeniorCare card on November 10th, when she purchased a prescription. Although Julie requested a refund within 30 days of her application filing date, she is not entitled to a refund, because she received her prescription at a discounted cost by using her SeniorCare card.

 

Example 2:

Mike is a Level 3 SeniorCare member. Mike’s SeniorCare application filing date was October 28th and his benefit period began November 1st. On November 20th, Mike requests to withdraw from the SeniorCare program and that his $30 enrollment fee be refunded to him. Mike used his SeniorCare card on November 18th, when he purchased a prescription; however, he had not met his Level 3 spenddown, so he did not receive a discounted price for his prescription. Mike is entitled to a refund of his enrollment fee if the pharmacy reverses this prescription claim. He made the refund request within 30 days of his application filing date and he has not received any SeniorCare prescription drug benefits or services. If the claims are not reversed, Mike is not entitled to a refund.

33.3.2.2 Refunds to Deceased Members

A refund may also be requested by the family memberA recipient of Medicaid; formerly referred to as a "client." of a deceased member when all the following criteria are met:

1. He or she received an eligibility notification, and
2. Death occurs prior to the start of or within 30 days of the beginning of the SeniorCare benefit period, and
3. The request is made within 45 days of the date of death; and
4. He or she had not received any SeniorCare prescription drug benefits or services.

Example 3:

Henry was a SeniorCare member at Level 1 whose benefit period began December 1st. Henry passed away on December 4th. His daughter reported Henry’s death to the SeniorCare program on December 10th, and requested a refund of his $30 enrollment fee. Henry’s SeniorCare card had been used on December 1st to purchase a prescription; however, the pharmacy had reversed those charges on December 5th, since Henry’s prescription had not been picked up. The $30 enrollment fee should be refunded in this case since Henry did not receive any SeniorCare prescription drug benefits or services.

 

Note:

If all of the above conditions are met, a refund will be issued even if the death is reported beyond the refund deadline date.

33.3.2.3 Opt-In

Once the opt-out of eligibility is confirmed, the participant will have 30-days to contact the EM CAPO if he or she chooses to “opt in” to the program.  He or she would need to send another enrollment fee if the original enrollment fee has been refunded.  A new application is not required to opt in.

A participant who decides after the 30-day period that he or she wants to rejoin the program will need to complete a new application and submit the enrollment fee.

33.3.3 Age Limitation

SeniorCare is for people who are 65 years of age or older. The earliest SeniorCare eligibility can begin is the month after an applicant’s 65th birthday.

A single applicant should apply for SeniorCare no sooner than the calendar month of his or her 65th birthday.

When a couple applies where one spouseA spouse is that person recognized by Wisconsin law as another person's legal husband or wife. Wisconsin does not recognize common law marriage. is 65 or older and the other is under 65 at the time of application, only the spouse that is 65 or older can be determined eligible.  If both apply, the younger spouse would be denied SeniorCare unless they are turning 65 within the current or next calendar month.  If the younger spouse will turn 65 within the 12-month enrollment period, they will receive a notice pending their eligibility for the enrollment fee approximately one month prior to their 65th birthday.

33.3.4 Other Insurance

Except for people enrolled in full-benefit Medicaid, applicants who have prescription drug coverage under other health insurance plans, including Medicare Parts B and D, may enroll in SeniorCare. SeniorCare is the payer of last resort except for state-funded-only programs, such as WCDPWisconsin Chronic Disease Program.

SeniorCare will coordinate benefit coverage with all other health insurance coverage. SeniorCare may also coordinate benefits with pharmacies that accept discount cards. Questions about individual health insurance coverage should be directed to the health insurance company. Questions regarding insurance carriers should be directed to:

Office of Commissioner of Insurance
Bureau of Market Regulation
P.O. Box 7873
Madison, WI 53707-7873
1-800-236-8517

33.3.5 Creditable Coverage

Wisconsin’s SeniorCare prescription drug assistance program is considered to be creditable prescription drug coverage. This means SeniorCare meets or exceeds the standard Medicare Part D plan. If an individual chooses to enroll in SeniorCare instead of Medicare Part D, they will not have a penalty for Medicare Part D.

If an individual is enrolled in SeniorCare, they can keep SeniorCare and not pay extra if they decide to enroll in Medicare Part D later. However, if their SeniorCare coverage ends and they do not enroll in a Medicare Part D plan right away, they may have to pay more to enroll in Medicare Part D at a later date.

If an individual goes without creditable prescription drug coverage for 63 days or longer, their monthly premium for Medicare Part D will go up at least one percent for each month they did not have creditable coverage. For example, if they go nine months without coverage, their premium will always be at least nine percent higher that if they had enrolled in Medicare Part D right away.

If individuals enroll in a Medicare Part D plan, their coverage will typically begin about a month after they enroll. If they need help paying for their prescription drugs and they are enrolled in SeniorCare, they may choose to remain enrolled in SeniorCare until their Medicare Part D coverage begins.

If an individual does not enroll in a Medicare Part D plan when they are eligible, they may have to wait until the next enrollment period before they can enroll. The enrollment period is from October 15 through December 7 each year, and coverage begins January 1.

Individuals with limited income and resources may be able to get extra help paying premiums, deductibles, and copayments for Medicare Part D. They can apply or get more information about Extra Help, also called the Low Income Subsidy, by calling the Social Security Administration at 800-722-1213 or visiting www.socialsecurity.gov/extrahelp.

If applicants have questions about SeniorCare and Medicare Part D, or need help choosing which prescription drug plan is best for them, they should be referred to a benefits specialist at their local aging and disability resource center (ADRC) or the Wisconsin Medigap Part D and Prescription Drug Helpline at 1-855-677-2783.

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The information concerning the Medicaid program provided in this handbook release is published in accordance with: Titles XI and XIX of the Social Security Act; Parts 430 through 481 of Title 42 of the Code of Federal Regulations; Chapters 46 and 49 of the Wisconsin Statutes; and Chapters HA 3, DHS 2, 10 and 101 through 109 of the Wisconsin Administrative Code.

Notice: The content within this manual is the sole responsibility of the State of Wisconsin's Department of Health Services (DHS). This site will link to sites outside of DHS where appropriate. DHS is in no way responsible for the content of sites outside of DHS.

Publication Number: P-10030