|
|
State of Wisconsin Department of Health Services BadgerCare + Eligibility Handbook Release 9-06, November 05, 2009 |
|
|
State of Wisconsin Department of Health Services BadgerCare + Eligibility Handbook Release 9-06, November 05, 2009 |
9.9.1.2 BC + Emergency Services
9.9.5 Power of Attorney and Guardianship
9.9.6 Access To Employer Provided Health Insurance
9.9.6.1 Employer Verification of Health Insurance (EVHI) database
9.9.6.2 Other Forms of Health Insurance Access Verification
The following items must be verified for BC+:
Citizenship and Identity (Chapter 4.2)
Immigrant Status (9.9.2)
Pregnancy, if eligibility is based on the pregnancy (9.9.3)
Medical Expenses (for deductibles only) (9.9.4)
Documentation for Power of Attorney and Guardianship (9.9.5)
Migrant worker’s (eligibility in another state) (12.3)
Income
Health Insurance Access (Chapter 7)
Health Insurance Coverage (Chapter 7)
Family Re-unification plan for Child Welfare Parents (Chapter 10)
The placement status of a YEOHC (Chapter 11) on his/her 18th birthday
Unless determined questionable, self declaration is acceptable for all other items.
Social Security Numbers (SSNs) need to be furnished for household members requesting BC +, but are not required from non-applicants.
An applicant A person who has submitted a request for enrollment in BC+ for whom no decision has been made regarding the person or group's eligibility for enrollment. is not required to provide a document or social security card. S/he only needs to provide a number, which is verified through the CARES Client Assistance for Re-employment & Economic Support. `This system supports the Income Maintenance operations for DHFS and DWD. CARES is used to determine eligibility, issue benefits, track premium payments and manages support for BC+, EBD Medicaid, W-2, Child Care and Work Programs SSN validation process.
If the SSN validation process returns a mismatch record, the member must provide the social security card or another official government document with the SSN displayed. If an applicant does not yet have an SSN s/he must be willing to apply for one.
Assist the member in applying for an SSN for any group member who doesn’t have one (IMM, Ch. I, Part C).
Do not deny benefits pending issuance of an SSN if you have any documentation that an SSN application A request for BadgerCare Plus coverage. The request may be a signed and dated application form or any other signed and dated request containing the applicant's name and address. The applicant must submit a signed and completed application form to complete the application process. was made. At the next review, check to see if an SSN has been issued.
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 can not 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:
Recommend further action be taken.
and/or
Provide the member with the information on the fraudulent action so that the member may pursue action through the legal system.
Verify the SSN only once.
A parent of a newborn may begin an SSN application on the newborn’s behalf while still in the hospital.
Do not require an SSN to be furnished or applied for on behalf of a newborn determined continuously eligible (8.2) for BC +. Accept the mother’s statement about the existence and residence of the newborn.
The BC+ fiscal agent receives notification of children born to BC+ members from hospitals and HMOs. The fiscal agent certifies newborns who are eligible for Continuously Eligible Newborn status in the MMIS Management Information System and sends a letter to both the mother of the newborn and to the certifying agency. This newborn letter received from the fiscal agent is a reported change. For purposes of BC+, the worker should add the newborn to CARES entering that pseudo SSN on the Household Members Page in CWW CARES Worker Web. The web based pages used in the CARES operations. screen ANID. No further verification is required.
Do not require or verify SSNs of members who receive BC+ Emergency Services only (Chapter 39).
Women applying for the BC+ PP do not need to apply for or provide an SSN. See 41.1 BC+ Prenatal.
A member who indicates s/he is not a citizen must provide an official government document that lists his/her immigrant registration number. Verification of the individual’s immigration status The legal status conferred on a non-citizen by immigration law is done through the Systematic Alien Verification for Entitlement (SAVE) system. Women applying for BC+ Prenatal Program (Chapter 41) and persons applying for Emergency Services (Chapter 39) who do not provide proof of immigration status can still qualify for those benefits.
An immigrant that presents documentation of his/her immigrant status and meets all other eligibility criteria is eligible while any secondary verification of immigrant status is taking place.
Verification of immigrant status is not needed if the person already provided proof when s/he applied for an SSN.
Do not re-verify immigrant status unless the member reports a change in citizenship or immigrant status.
If a woman wants to be considered pregnant for a BC+ or BC+ Prenatal Program (Chapter 39) eligibility determination, documentation from a health care professional attesting to the pregnancy is required. Fetus count and the expected pregnancy end date are not mandatory verification items.
Verification sources for pregnancy are:
Physician's statement.
Physician assistant's statement.
Licensed nurse practitioner's statement.
A written statement from a registered nurse (RN) working in a:
Healthy Birth Identification of Pregnancy Project (EDP).
Publicly funded family planning project.
Certified Nurse Midwives.
A valid BC+ Temporary Enrollment card.
Medical expenses used to meet a deductible Either the amount of health care expenses an insured person is required to incur before benefits are payable under a health insurance plan. must be verified. The expense amount, any third party liability amount and date of service must all be verified.
Verify power of attorney and any guardianship type as specified by the court. Ask for any documentation regarding durable power of attorney or court-ordered guardianship.
Verification of access to health insurance is required at the following times, unless the individual has already verified health insurance access within the last 12 months with the same employer:
BC+ Application and Review.
Person Add - if adult (age 18 or over) is employed and part of the BC+test group.
When an adult (age 18 or over) in the BC+ test group gets a new job.
When a change is processed causing total income to exceed 150% FPL (generating a request for premium payment) for the BC+ assistance group.
It is not the client’s responsibility to verify access to employer-sponsored health insurance. For the majority of BC+ applicants and members the EVHI database will be used to verify insurance access. Information gathered from employers is stored in the database. The verification will be returned based on the employer details entered on the employment page. It will be critical for Income Maintenance workers to enter the correct FEIN number and all other employment details for each employment sequence so that all employers are correctly identified in the EVHI database.
If the employment details are not complete enough to verify access, the applicant will be sent a letter from the State requesting more information and the case will pend.
|
Example 1: Mary’s employer has verified that permanent full-time employees have access to health insurance, however temporary employees do not. Mary did not indicate whether she is a permanent or temporary employee. Since that information is necessary to verify access to health insurance using the database, she will be sent a letter requesting the information. |
If the employer has not provided information about the health insurance they offer to their employees, the BC+ eligibility will pend and a request will be sent from the State to the employer requesting that the information be provided.
BC+ eligibility can pend up to the end of the 30 day application processing period. At that point, regardless of whether the employer has responded or not, eligibility must be confirmed. If the employer has not responded assume there is not access to employer sponsored health insurance.
BC+ will not be terminated or denied due to an employer failure to respond to a request for verification of health insurance access. If BC+ eligibility begins and an employer later responds to the verification request indicating that health insurance access is available to the employee, BC+ eligibility will be terminated with adequate notice of adverse action The last day of the month a change can be made in CARES to affect eligibility for the following month. Adverse Action is usually 13 days prior to the last day of the month to allow for a timely notice to be generated.. There will be no overpayment liability for the applicant.
Other types of verification can be used to document access to employer sponsored health insurance. If a BC+ applicant or member needs medical services, agencies may use other contacts with employers in these situations to speed the verification process. Other forms of verification include:
EVF-H form
Employer statement
Collateral Contact with the employer
This page last updated in Release Number: 07-02
Release Date: 11/19/07
Effective Date The begin date of a specific action such as an approval, denial, closure or other change in eligibility or coverage.: 02/01/08
