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1 to Family Health Care Coverage A Publication of ABC for Health, Inc. Information current through July 2011

2 2

3 About ABC for Health, Inc. Founded in 1994 by public interest attorney Robert A. Bobby Peterson, Advocacy & Benefits Counseling for Health, Inc. offers families and providers a unique combination of counseling, advocacy, and legal services. Mission Statement ABC for Health, Inc. is a Wisconsin-based, nonprofit public-interest law firm dedicated to linking children and families, particularly those with special needs, to health care benefits and services. ABC for Health s mission is to provide the community of both patients and providers with the information, advocacy tools, legal services, and expert support they need to secure health care coverage and services. Vision Statement ABC for Health, Inc., a nonprofit, public-interest law firm, is working to develop a nationally recognized, integrated model of health benefits counseling, legal services, and policy advocacy that promotes a universal system of health care coverage and access for all people. ABC for Health will develop multi-purpose education strategies to inform consumers and providers of health care coverage options, while also advocating directly for individuals disenfranchised from health care coverage and services. ABC for Health will serve as a catalyst in the development of local HealthWatch coalitions, as well as other partnerships and strategic alliances to influence public policy and opinion, while also working to maximize all available health care coverage options for people. 3

4 BadgerCare Plus: The Face of Family Health Care in Wisconsin In 2007, then-governor Jim Doyle announced his plan to reform health care in Wisconsin and extend coverage to more people than ever, including all uninsured children. This program, called BadgerCare Plus, began on February 1, BadgerCare Plus merged three existing programs: BadgerCare, Family Medicaid, and Healthy Start. People who were receiving the benefits of any of these programs were enrolled automatically in BadgerCare Plus. For everyone else, BadgerCare Plus expanded access to health care coverage for a number of groups, including pregnant women and working families. Its creation was an important step toward providing access to health care for everyone in Wisconsin. For more information on BadgerCare Plus, please visit This booklet will tell you how to apply for BadgerCare Plus and other programs, what to do with coverage once you get it, and how to keep that coverage. 4

5 Welcome to the to Family Health Care Coverage Did you know that there is free or low-cost health care coverage available to children and some families and pregnant women in Wisconsin? Wisconsin s BadgerCare Plus program offers comprehensive medical benefits. Best of all, you will not have to worry about how to pay for a visit to your child s doctor. According to Cover the Unisured ( there were more than 50 million uninsured individuals in the United States in 2010, of which 7 million were children. Many uninsured children, families, and pregnant women in Wisconsin are eligible for (but not enrolled in) low-cost or free health care coverage through Medicaid or BadgerCare Plus. The purpose of this kit is to help eligible children, families, and pregnant women get, use, and keep health care coverage. This kit includes information about: Who s eligible, What medical services are covered, How and where to apply, What information you need to apply, How to use and keep your family health coverage, and Where to get help if you have problems. Getting started is easy Begin by looking at Family Health Coverage Facts on page 6 to learn more about who s eligible and what s covered. 5

6 Family Health Coverage Facts Who is eligible for BadgerCare Plus coverage? Children under age 19 Youth ages who are exiting out-of-home care Pregnant women Parents or relative caretakers of children under 19 Parents or relative caretakers whose children have been removed from the home and placed in out-of-home care Spouses of eligible parents Certain self-employed families who are above income limits but who have depreciation and/or amortization What are the income limits? There is no income limit for children under age 19, pregnant women, or youth exiting out-of-home care. There are various income limits for the other groups listed above. Eligibility categories are based on the Federal Poverty Level (FPL), which is determined using your monthly income (before taxes) and the number of people in your family. Family Size (count unborn baby as one) 150 percent FPL 200 percent FPL 300 percent FPL 1 $1, $1, $2, $1, $2, $3, $2, $3, $4, $2, $3, $5, Each additional $ $ $ *These numbers are current through January What services are covered? BadgerCare Plus pays for: Doctor visits Hospital care and emergency care Checkups and immunizations Eyeglasses and hearing aids Prescriptions Mental health services Prenatal care Family planning And more... 6

7 to Family Health Care Coverage Step 1: Applying for Family Health Coverage I m ready to apply now! You have FOUR choices when it comes to applying for BadgerCare Plus: Mail or fax a paper application Apply online using Complete an application over the phone Apply in person (at the human services office in your county) See Applying for Family Health Coverage on page 8 for instructions. Step 2: Using Family Health Coverage I have a Forward card but don t know what to do next. After you receive your Forward card, call the Managed Care Enrollment Specialists at (800) with questions. See Using Family Health Coverage on page 13 for instructions. Step 3: Keeping Family Health Coverage My family has Medicaid or BadgerCare Plus, and I d like to keep it. You can keep your coverage as long as you remain within program guidelines. See Keeping Family Health Coverage on page 14 for instructions. If you re not sure what you need to do, call the Member Services Hotline at (800)

8 Step 1: Applying for Family Health Coverage First, Collect Your Information The first step in applying is collecting the information you will need to complete the application. You will need: Income information for your household; Birthdates of everyone living in your home; Information about any health insurance you currently have; Information about your income-producing assets; and Social Security Numbers of those applying who are U.S. citizens, or Alien Registration Numbers ( A numbers ) for those applying who are Registered Aliens (qualifying immigrants) Use the Family Record on page 11 to record information for your application. Next, Fill Out the Application You are now ready to complete an application for family health coverage. Contact your county/tribal human service department for locations in your county. There are four ways you can apply: Mail or fax a paper application (INCLUDED WITH THIS KIT). Apply online at (see page 9 for more details). Apply in person at your local county/tribal human or social service department, W-2 agency, or BadgerCare Plus or Medicaid outstation site. Complete an application over the phone (complete listing of phone numbers here: Families who wish to apply for programs such as FoodShare, Child Care Assistance, W-2, or Medicaid for the Elderly, Blind or Disabled (in addition to BadgerCare Plus) may be required to complete an interview or provide additional information. APPLY NOW! The faster you apply, the faster your health coverage can begin. 8

9 Step 1: Applying for Coverage (continued) Help Applying The Department of Health Services (DHS) Website states that community organizations across Wisconsin are available to help you enroll in BadgerCare Plus. For a list of these organizations, visit gethelp.htm. Applying Online Using ACCESS Website The ACCESS Website ( is an online resource that makes applying for and managing low- and no-cost health care easy for anyone who has access to the Internet. With ACCESS, you can: See if you re eligible for Wisconsin public assistance programs, such as BadgerCare Plus, Medicaid, FoodShare, SeniorCare and other programs; Apply for any of these programs; Check on the status of your benefits after you ve qualified for one or more of these programs; Report any residence, employment, or other changes to the local agency; and Renew BadgerCare Plus or Elderly/Blind/Disabled Medicaid benefits. 9

10 Step 1: Applying for Coverage (continued) Creating an Account on the ACCESS Website You are not required to create an account in order to use ACCESS; however, it is useful to do so for several reasons. To create an account, simply follow the instructions on the ACCESS Website. First, you will be asked to choose a user ID and password. This same ID and password can be used to enter Check My Benefits, Report My Changes, and Renew My Benefits. In addition, creating an account in ACCESS means that you do not have to complete the application in one sitting; you can save an incomplete application and finish it at a later date. You will need the following information to create your account: Your name, Your date of birth, and Your Social Security Number. Completing the ACCESS Online Application Using the online application system to complete an application is estimated to take between 30 and 60 minutes. Applicants can complete and submit the application in one sitting, or they can save an incomplete application and finish it at a later time. The applicant signs and submits the application and receives a tracking number, which appears at the top of the page; this is all done electronically. What Happens Next? After submission, the county or tribal agency processes the application. The Economic Support Specialist may request mandatory documents, verify questionable information or require an interview for FoodShare. Requested documents can be mailed, faxed, or personally delivered. 10

11 Step 1: Applying for Coverage (continued) Family Record You will need to have information about your family members in order to apply for Medicaid or BadgerCare Plus. Use this Family Record to keep a record of numbers and dates you will need.* For Non-Citizens: Name Birth Date Social Security Number Date you entered the U.S. and Alien Registration Number * If you re pregnant, you will need a statement from your doctor verifying your pregnancy. * You will need to provide information about all of the children s parents, including parents who do not live with you. You don t have to give this information if you re pregnant, if you only want coverage for your children, or if you are the victim of domestic violence. Information About Your Income and Income-Producing Assets Monthly Income (before taxes): Money earned at a job Also include: unearned income such as child support, unemployment, and worker s compensation. Income-Producing Assets: Assets that produce income Information About Health Insurance You Currently Have You may still be eligible even if you have other health insurance coverage. If you currently have employer-sponsored health insurance, you will need to provide the name of the insurance company, the policy number, who the policy covers, and when the coverage started. You also will be asked what percentage of monthly premiums is paid by your employer. 11

12 Step 1: Applying for Coverage (continued) After Applying After you apply, you will receive a notice from your county about your application. Note: Make sure to keep this notice, along with any other letters or documents you get that are related to your BadgerCare Plus application and account. Keep them in the plastic case your 3 Steps Kit came in so you can find them easily when you need them! If some information is missing from your application, you will be contacted by a county worker to complete your application. If your application is complete, the county must make a decision within 30 days about your eligibility. If you do not receive a decision within 45 days, call your county/tribal human service department. You ve Been Approved! You ll receive a Forward card in the mail for each eligible family member. Take these cards with you to all medical appointments and to pick up prescriptions. Note: Take your Forward card with you every time you go to a BadgerCare Plus provider. Providers don t have to see a person who doesn t have their card; if you don t have yours, you may be asked to pay for services. If You re Denied If your application is not successful, the county will send you a letter that tells you the following things: 1. You have been denied, and 2. Why you were denied. If you feel this is not correct, consider contacting your assigned Economic Support Specialist (his/her name will appear on that denial notice) to make sure there has not been an error. If you can t resolve the problem, consider calling ABC for Health at (800) , ext. 229 to talk to an advocate about your options. 12

13 Step 2: Using Family Health Coverage I have my Forward card. What should I do now? You should also receive information on your next step to enrolling in an HMO. If you have questions, call the Managed Care Enrollment Specialists at (800) The enrollment specialist can help you: Choose an HMO that meets your needs; Determine the HMO(s) your doctor or clinic belongs to; Fill out enrollment forms; and Learn how to work within the HMO system. What is an HMO? A health maintenance organization, or HMO, is an organized system of health care delivery. HMOs contract with selected doctors and facilities to provide medical care to their members. When you are enrolled in an HMO, you agree to use their providers for your health care needs. What will happen if I don t enroll right away? If you don t enroll within two weeks of receiving the enrollment packet, a reminder card will be sent to you. If you don t enroll into an HMO within six weeks of receiving your enrollment packet, one will be picked for you. This HMO may not include doctors or clinics you have been using. You will receive a letter telling you which HMO you ve been assigned to. Once you are enrolled in an HMO, you may change your HMO for any reason within the first 3 months. Note: Individuals may avoid enrolling in an HMO for certain reasons. This is called an exemption. There are a variety of reasons why an individual may be granted an exemption for a certain period of time. To find out if you qualify, call the Managed Care Enrollment Specialists. Questions? Call (800) for help with your enrollment questions. 13

14 Step 3: Keeping Family Health Coverage What am I responsible for? You must report all changes to your county economic support worker within 10 days. Some examples include: Change in address Change in income Change in family size/birth of a baby Change in employment status If you are required to pay premiums, you must pay them on time. Failure to pay premiums on time may result in a temporary loss of benefits. It is very important that you keep medical, dental and vision appointments. Make sure you call and cancel an appointment if you can t be there. How do I keep my coverage? It is important that you renew your coverage when you receive a Notice of Review and Reapplication from your county. Read this notice carefully. It will tell you how to renew your coverage by mail, telephone, online or by making an appointment. The renewal process might require you to submit verifications of income and insurance, among other things. Have this information handy to avoid delays. Note: Mark the date on your calendar that is one month before your renewal is due. This way, you ll have plenty of time to gather the documents you ll need to verify income, insurance, and other information. Your health coverage will be renewed if you are still eligible. If you do not reply to the notice, you may lose your coverage and have to apply again. After you renew your eligibility, call the Managed Care Enrollment Specialists at (800) with questions or concerns about continuing in your current HMO. What are my rights? If you lose your Medicaid or BadgerCare Plus, you will be sent a letter telling you this 10 days before it happens. If you receive this notice, do not wait: Contact your county Economic Support Specialist or request a Fair Hearing if you believe you are still eligible. (See Handling Common Problems on page 15 for more information.) 14

15 Handling Common Problems I think I make too much money to qualify. What should I do? Do not decide on your own that you do not qualify for BadgerCare Plus. There are different types of income that are considered Disregarded Income and which will not count toward the income amount used in your determination. When in doubt, apply! There is no limit to the number of times you may apply. Remember, the more complete your application is, the better your chances are to get an accurate determination from the county. What should I do if I have problems applying? You should never be told over the phone that you are not eligible for coverage. You can mail or fax an application, you can apply by phone, or you can apply online. You can also apply in person at your county/tribal human service office or outstation. You should never be discouraged from applying using any of these options. Contact an advocate as soon as possible if you have problems completing or filing an application. What should I do if I lose my Forward card? If you can t find your Forward card, call the Managed Care Enrollment Specialists at (800) A representative will help you get a replacement. You should still go to any medical appointments you have scheduled. Your HMO can check on your coverage for you. What should I do if I get denied? Things to remember if you receive a denial for eligibility or for payment of services: Keep copies of all notices and other letters from the county in your file. If something about your denial does not seem right, request a Fair Hearing. You must request a Fair Hearing within 45 days of the date the denial was issued. Do not miss this deadline. In order to preserve your benefits during the appeal process, you must request the hearing within 10 days of the date the denial was issued. If you are looking for an advocate but the 45-day appeal deadline is near, file the Fair Hearing request yourself before the 45 days are up. There are instructions included with the denial on how to file the request for a Fair Hearing. Find an advocate as soon as possible. It s a good idea to have someone who knows about these programs help you with your appeal. Call and talk with an advocate at ABC for Health at (800) , ext

16 Contact Log Keep a Record of the Contacts You Make Keep copies of everything you receive about your application. Also, list any calls you make concerning your family coverage on this log. Use it to make a record of the people you have talked with and the information you have been given. Date & Time Phone Number Who did you talk to? What did you talk about? 16

17 Notes 17

18 Notes 18

19 More Questions? If you have more questions, you may find these resources helpful: ABC for Health, Inc. (800) Statewide benefits counseling and legal services for families with children having problems financing health care. ACCESS Website (800) ACCESS Website allows Wisconsin residents to check whether or not they may be eligible for FoodShare, Medicaid, BadgerCare Plus, SeniorCare, and other programs, as well as apply for these programs online. Users can also check on their benefits status and report changes online. BadgerCare Plus (800) BadgerCare Plus is Wisconsin s new initiative in health care; it began on February 1, 2008, and merged three existing programs: BadgerCare, Family Medicaid, and Healthy Start, while extending coverage to a greater number of children and families across Wisconsin. Disability Rights Wisconsin (800) Protection and advocacy for persons with developmental or physical disabilities and people with mental illness. Wisconsin Department of Health Services (608) The Wisconsin Department of Health Services, or DHS, promotes health and safety in Wisconsin and helps peopling living in Wisconsin get connected to a number of different programs and services 19

20 This publication is a production of ABC for Health, Inc., and Copyrighted Please do not duplicate this publication without permission. ABC for Health devotes significant staff time and resources to be able to research and produce information and educational materials. ABC for Health is able to produce these documents with the assistance of unique funding sources and able to distribute them for purchase at a reasonable cost. Please contact ABC for Health if you would like more information on publications and education services available. 20

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