Read the following statements carefully. Ask about any statements you do not understand. This form is part of your application; you may ask your worker for a copy of the application. Keep this addendum with your important papers and review it when changes occur.
I understand the change reporting requirements below:
Medicaid for the Elderly Blind and Disabled
Report to the agency within 10 days:
- Any changes in income or assets of any member of my household, and
- Any other change in the information I have given on my application that is required to be reported in the “Rights and Responsibilities” pamphlet or the Medicaid change Report form.
If all household members are elderly, blind or disabled and no one has any earned income, report to the agency within 10 days:
- Any new employment.
- Any increase in total child support income of more than $100 per month.
- An increase in total other unearned income of more than $50 per month.
- When someone is born or dies.
- If a person moves in or out of the household.
- Any change in my address and resulting change in my shelter costs.
- Any change in the legal obligation to pay child support.
I understand that for all programs if I fail to report changes, I may be prosecuted for fraud and/or I will be responsible to repay any benefits I receive in error. To report a change, I understand I can use a change report form or I can contact my worker by phone, or in writing. I can also report my changes to the change reporting center or on-line at www.access.wi.gov.
I and all other persons living in my household and applying for aid are citizens or nationals of the United States or are in a satisfactory immigration status. I understand that the immigration status of any person in my household applying for benefits will be verified with the United States Citizenship and Immigration Services (USCIS). Information from USCIS may affect my household’s eligibility and amount of benefits. Immigration status will not be verified with USCIS for people in my household who are not applying for assistance.
Other Medical Coverage
I understand that as a condition of Medicaid eligibility, I must report to the agency any third party who may be liable to pay for medical care for me and my family. I must cooperate by giving information as requested. This also includes any insurance that may be available through an absent parent or an employee’s group health insurance.
Recovery of Medicaid
I understand that Wisconsin state law provides for the recovery of certain Medicaid benefits I receive while age 55 or older and residing in the community. I understand that the law also provides for the recovery of all Medicaid benefits I receive while I am a resident in a nursing home and while I am an inpatient fin a hospital for 30 days or more. I also understand that under limited circumstances a lien my be placed on my home for benefits I receive while I am residing in a nursing home if I am unlikely to return home and my spouse (or a minor/disabled son or daughter does not live in the home).
I understand that I have the right to request a Fair Hearing if I do not agree with the agency’s decision regarding an overpayment, my application or ongoing benefits. I understand that I can ask for a Fair Hearing by writing to: Division of Hearings and Appeals, P.O. Box 7875, Madison WI 53707-7875. I may also contact the office where I applied and ask for assistance with filing a Fair Hearing request. I understand that I can refer to the Fair Hearing pamphlet of my Notice of Decision for more information on the fair hearing process.
Use of Social Security Number/Privacy Act Statement
I understand that providing the information requested in this application, including the Social Security number (SSN) of each household member is voluntary. I understand that I must, by federal law[*], give the agency the SSN for all household members applying for benefits. Failure to provide the SSN for those applying will result in a denial of benefits. Any Social Security numbers that are provided will be used and disclosed in the same manner as Social Security numbers of eligible household members.
My SSN, as well as other information I give the agency, is subject to verification by federal, state and local officials for FoodShare Wisconsin, Badger Care Plus, Medicaid, W-2, Child Care Caretaker Supplement programs and other federal assistance and state programs, such as the School Lunch program. . The Income and Eligibility Verification System and other computer information with the Internal Revenue Service, Social Security Administration Unemployment Insurance Division, and Department of Transportation. The agency may also submit this information to the United States Citizenship and Immigration Services and other agencies for verification. The SSNs are also used to check the identity of household members through program reviews or audits to prevent duplicate participation, and to make sure my household is eligible for assistance. The agency may contact my household’s employers, banks or other parties.
I understand the information provided on this application will be used to determine whether my household is eligible or continues to be eligible to participate in these assistance programs. This information will be verified through computer matching programs. This information will also be used to monitor compliance with program regulations and for program management. This information may be disclosed to other Federal and State agencies for official examination.
I understand that knowingly providing a false SSN or other information may result in criminal or civil action and/or an overpayment of benefits with I will have to repay.
I understand that if I need assistance applying for an SSN for myself or someone in my household, I can contact the agency worker.
Drug Felony/Fleeing Felons
I understand I must report to my worker if I have been convicted of a drug felony for an offense that happened in the last five years. If I refuse to provide this information, I may be denied benefits. If I have been convicted of a drug felony and I am requesting FoodShare benefits, I must submit to a drug screen test. If my drug screen is positive, my benefits will be reduced. If I refuse to submit to a drug screen, I may be found ineligible for benefits.
Fleeing felons and probation/parole violators are ineligible for FoodShare Wisconsin.
I understand information provided on this application may be provided to law enforcement officials for the purpose of apprehending persons fleeing to avoid the law.
I understand that I must pay back any benefits that I receive in error regardless of whether or not it was my fault or an error was made by the agency.
I understand that I must pay back Medicaid benefits that I receive in error under certain circumstances.
I understand that if a FoodShare claim arises against my household, the information on this application, including all SSNs, may be referred to federal and state agencies, as well as private claims collection agencies, for claims collection action.
FoodShare Penalty Warning
I understand that any member of my household who intentionally breaks any of the following rules can be barred from FoodShare Wisconsin for 12 months after the first violation; 24 months after the second violation or for a first violation involving a controlled substance; and permanently for the third violation:
- Giving false information or hiding information to get or continue getting FoodShare benefits;
- Trading, selling, or altering FoodShare benefits;
- Using FoodShare benefits to buy non-food items, like alcohol or tobacco; or,
- Using another person’s FoodShare benefits, identification card or other documentation.
Depending upon the value of misused benefits, the individual can also be fined up to $250,000, imprisoned up to 20 years or both. A court can also bar an individual from the program for an additional 18 months. You will also be permanently disqualified if you are convicted or trafficking FoodShare benefits of $500 or more. You will be ineligible to participate for 10 years if you are found to have made a fraudulent statement or representation with respect to identity and residence in order to receive multiple benefits at the same time.
Any member of your household who has used or received benefits involving the sale of any controlled substance is ineligible for 24 months after the first violation and permanently after the second. Any member of your household who has used or received benefits involving the sale of firearms, ammunition or explosives is permanently ineligible after the first violation.
In accordance with federal law and U.S. Department of Agriculture (USDA) and U.S. Department of Health and Human Services (HHS) policy, this institution is prohibited from discriminating on the basis of race, color, national origin, sex, age, or disability. Under the Food Stamp Act and the USDA policy, discrimination is prohibited also on the basis of religion or political beliefs.
To file a complaint of decimation, contact USDA or HHS write to:
The Department of Children and Families and Department of Health Services are equal opportunity employers and service providers. If you have a disability, you have the right to request this information through a sign language interpreter or in an alternate format. If you do not speak or read English, you have the right to request an interpreter or to have this information translated to another language. For Medicaid and FoodShare please contact (608) 266-3356 or 888-701-1251 TTY.