Benefits for Seniors & Adults with Disabilities

In Marquette County there are two Medicaid program options that are designed to provide you with the services you need to remain living in, or return to, the community.  An individual must be both functionally and financially eligible to enroll into a Long-Term Care Program.

The publicly-funded, long-term care programs are designed to keep people out of the nursing home AND remain independent.  In Marquette County there are two different program options.

• Family Care (Care Wisconsin, Inclusa)
• IRIS (Advocates4U, Connections, First Person, TMG)

Timeline:
The eligibility determination process can take on average 2 to 3 months.

Eligibility Criteria:
An individual must be both functionally and financially eligible to enroll in a long-term care program.

Functional Eligibility:
An ADRC Resource Specialist will complete a Long-Term Care Functional Screen to determine an individual’s functional eligibility. Wisconsin’s Functional Screen system is a web-based application. It is used to confidentially collect information about an individual’s functional status, health, and need for assistance for various programs that serve the frail elderly and people with intellectual, developmental, or physical disabilities.

Financial Eligibility:
An individual must be eligible for Wisconsin Medicaid, also known as Medical Assistance. Medicaid is a form of State insurance that provides healthcare for people who are financially eligible. For someone who is elderly or has a disability, there is a specific type of Medicaid that can help provide care. Financial eligibility is determined by the East Central Consortium.

• Single: The asset limit for a single individual is $2,000 or less, OR already enrolled in the full benefit Medicaid program.
• Married: Special provisions known as spousal impoverishment protections apply to married couples. This rule allows married couples to maintain a higher amount of assets and potentially allocate a portion of his/her income to his/her spouse.  The individual will need to be at or below $2,000 in assets, while his/her spouse may be allowed to maintain a higher amount of assets. This amount is determined by Marquette County Economic Support through a Medicaid application.

Assets:
Countable Assets * Non-Countable Assets

• Checking & saving accounts * Home (if you live in it)
• IRA’s, CD’s, stocks, bonds * One Vehicle
• Some Life Insurance Policies * Personal Belongings
• Irrevocable burial assets
• Spouse’s Retirement
• This is NOT an all-inclusive list

Divestment:
Divestment rules apply to long-term care programs and Institutional Medicaid. The State of Wisconsin will look back five years to see if anything has been divested (given away or sold for less than fair market value). If there was a divestment in the last five years, there could be a penalty that prevents enrollment for a period of time (based on the amount/value divested).

Cost Share:
A monthly amount of money that some individuals pay to remain eligible for the long-term care program while living in the community. This is similar to a health insurance premium. Cost shares are based on income and countable expenses.     ***Not everyone has a cost share***

Patient Liability:
Patient Liability is the amount of money that an individual pays to remain eligible for Institutional Medicaid while living in a nursing home. The patient liability amount is determined based on income and countable expenses.

Estate Recovery:
The process the State of Wisconsin uses to get repayment of certain home health care and long-term care benefits. Estate Recovery can apply to anyone.  But, for those under 55 it typically is when they reside in a hospital or nursing home.
The Program will review remaining assets for recovery after an individual passes away. For married couples, Estate Recovery will take effect after both spouses pass away.  The State may do this by placing a lien on a property or by making a claim against any other part of the estate.
For local assistance with publicly-funded, long-term care programs please contact the Marquette County Aging and Disability Resource Center.

Medicare Coverage

Medicare is a medical insurance program sponsored by the Federal Government. On your 65th birthday (or after 2 years of being determined disabled by Social Security), you will become eligible to receive benefits regardless of your income or health status.  What you pay for Medicare will depend on the number of work credits you have, your coverage choices, and your income and assets.

Under Original Medicare, the government pays directly for health care services an individual receives.  A person can see any doctor that accepts Medicare anywhere in the country.  Unless another choice is made, the person will have original Medicare.  Individuals can choose to get their Medicare benefits from a Medicare approved “Advantage” or “Health” Plan.  These plans must offer the same benefits as Original Medicare but can do so with different rules, costs and restrictions.  Some of these plans may offer drug coverage as well.

Under Original Medicare individuals can go to the Doctor or Hospital when they think they need care.  No permission is required.  There are limits on how much doctors and hospitals can charge.  Persons pay a coinsurance for services they receive.  Often, people have supplemental insurance or the coinsurance costs can be high for people paying out-of-pocket.

If you continue to work or get your health insurance through your spouse’s employment there are specific rules about what and how much Medicare will cover if you have additional insurance. Persons may be automatically enrolled in a Medicare private health plan if their employer sponsors one when they become eligible for Medicare.  It is important to understand your employer’s or retiree insurance and when that coverage will end.  Check with your employer’s human resources department when you turn 65 or when you plan to retire about coverage.

There are specific timelines on when you can enroll in Original Medicare or a Medicare Advantage/Health Plan. There are also situations where you may wish to decline certain parts of Medicare if you have credible insurance coverage in place already. It is important to understand all of your options.

The    “ABC’s”  of Medicare

PART A:   Hospital Insurance. Part A covers hospitals, skilled nursing facilities, hospice care and some home health services. Most people receive Part A without having to pay a premium. There is an out of pocket deductible for inpatient hospital stays. This amount is $1600 for 2023 for each benefit period.

PART B:     Medical Insurance. Part B covers medical services, outpatient procedures, ambulances, emergency rooms, tests and durable medical equipment.  You must pay a monthly premium to receive coverage.  For most people the premium amount is $164.90 a month for 2023.  Part B generally pays 80% of covered medical expenses after the annual deductible of $233 is met.  If you do not enroll with Part B when you are first eligible to do so you may have a penalty to pay for each month you delayed your enrollment.  There are Medicare Savings Programs that can help pay the monthly premium.  Eligibility depends on a person’s income and assets.

PART C:    Advantage or Health Plans. Part C plans are Medicare-approved private insurance plans that provide equal or sometimes more coverage than Original Medicare.  Some plans also cover prescription coverage.  In addition to any premiums you may be required to pay by the Part C provider, you must still pay any required premiums for Part A and B and any required co-pays for services.

PART D:    Prescription Drug Coverage. Part D plans are offered by Medicare-approved private insurance providers.  These plans have a premium and can also have a deductible.  Out-of-pocket co-payments for prescriptions are required as well.  If you do not enroll in a Part D plan when you are first eligible to do so, you may have to pay a penalty for each month you delay enrolling if you enroll later.  Senior Care (state-based prescription drug benefit) can be an alternative to a Part D plan for those 65 and older. Extra help is available for Part D coverage under the Part D Low-Income Subsidy.  Eligibility depends on a person’s income and assets.

Please click the highlighted to access Videos on Medicare

For additional information please call the ADRC and ask to be connected to the Elder Benefit Specialist (people 60+) or the Disability Benefit Specialist (people 18-59). 

Social Security

Social Security includes: Disability, Retirement, Medicare Cards, My Social Security Accounts, and more. For more detailed information please visit www.ssa.gov or call your local Social Security.

My Social Security Account:  Receive personalized estimates on future benefits, see your latest statements or letters that were sent to you, review your earning history, request a replacement Social Security Card, check the status of your applications, and report your income.

Disability: Ways to apply include calling your local Social Security Administration, visiting www.ssa.gov, or by calling your local ADRC and requesting assistance. Disability through the Social Security Administration focuses on a person’s ability to work and what level of work they can do.

There are Five Sequential Steps that the Social Security Administration takes a disability application through.

1. Is the claimant work? Each year the amount a person can earn before they don’t qualify for disability increases. Blind/visually impaired claimants have different limits. If you earn over the set limits without any accommodations being made for you, your application will be denied.
2. How severe is your condition? Has it been 12 months, will it last 12 months, or will it result in death? If it is determined that your condition is not severe you will be denied.
3. Is the impairment on the list of impairments? This is a list that has been established by the Social Security Administration that determines if a person’s condition is so severe that they should automatically qualify for disability. If you are determined disabled at this step, then you don’t need to continue to step 4.
4. Can you do the type of work that you did before? Here the Social Security Administration asks if your condition prevents you from doing the type of work that you have done in 15 years prior to the start of your condition. If it is determined that you could return to some type of work, you had done before your application will be denied.
5. Can you do any other type of work. The Social Security Administration will look at your age, education, skill level, and the restrictions from your conditions to determine if you could do any type of job in the national economy. If you can do some other type of employment your application will be denied.

Once you are determined disabled you may be eligible for multiple programs. It is possible for some to be eligible for both programs.

Supplement Security Disability Income (SSDI)

• The amount of financial assistance received is based on how much the disabled individual has paid into FICA taxes.
• The person determined disabled will become Medicare Eligible after receiving 24 months of payments from the program.
• This program has no asset limit.
• If incarcerated for more than 30 days financial benefits will stop but will start the month following release – so long as Social Security is notified, and a copy of release papers are provided.

Supplemental Security Income (SSI)

• This program is a needs-based program, it is for those who have little to no work history, minimal assets and minimal household income.
• The person who is determined disabled will be eligible for Medicaid, a health insurance similar to Badgercare.
• The Federal amount received varies depending on household income, and your over all living situation (paying rent, living with parents, etc). The maximum amount from Federal Government increases yearly, in 2022 the amount is $841.00 per month, additionally the State pays $83.78.
• If incarcerated the disabled persons payments are suspended. They can be reinstated the month you are released if you are incarcerated less than 12 consecutive months, you notify the Social Security Administration, and your release papers are provided. If longer than 12 months a new disability application will need to be filed with the Social Security Administration.

Misc. Info:

• Everyone determined disabled will be reviewed periodically to see if they are still disabled or if they can return to the work force.
• Any changes in your situation (employment, inheritance, death) should be reported to the Social Security Administration immediately.
• A person must have their old Account information if they are going to be opening a new direct deposit account over the telephone.
• If you have a difficult time managing your funds, an appointed financial representative (rep-payee) can be established.
• You can work and still receive benefits – there is a liaison at the Social Security office who works with those who are interested in working.

Retirement: Full retirement age is the age where a person may be entitled to full or unreduced retirement benefits. You can start receiving retirement benefits at the age of 62, but the amount you receive will be reduced.

• If you were born before 1937 full retirement age is 65
• 1938 full retirement age is 65 and 2 months
• 1939 full retirement age is 65 and 4 months
• 1940 full retirement age is 65 and 6 months
• 1941 full retirement age is 65 and 8 months
• 1942 full retirement age is 65 and 10 months
• 1943 – 1954 full retirement age is 66
• 1955 full retirement age is 66 and 2 months
• 1956 full retirement age is 66 and 4 months
• 1957 full retirement age is 66 and 6 months
• 1958 full retirement age is 66 and 8 months
• 1959 full retirement age is 66 and 10 months
• 1960 or later full retirement age is 67

Applications: Can be completed at www.ssa.gov, or by calling your local Social Security Office.

• An online retirement application can be completed in as little as 15 minutes.
• You can apply for both retirement and Medicare or just Medicare.
• Those who want to apply for retirement or benefits as a spouse:
  • must be at least 61 and 9 months old;
  • not currently receiving benefits on their own Social Security record;
  • have not already applied for retirement benefits, and
  • want their benefits to start no more than 4 months in the future.

The Wisconsin Home Energy Assistance Program (WHEAP) administers the federally funded Low Income Home Energy Assistance Program (LIHEAP) and Public Benefits Energy Assistance Program. LIHEAP and its related services help approximately 230,000 Wisconsin households annually. In addition to regular heating and electric assistance, specialized services include:
Emergency fuel assistance, 
Counseling for energy conservation and energy budgets, 
Pro-active co payment plans, 
Targeted outreach services, 
Emergency furnace repair and replacement. 
Call (608) 297-3124 for more information or to make an appointment. For your convenience we have attached a copy of the forms you may use to apply as well as the income guidelines.

Income Guidelines for 2018-2019 WHEAP with Income chart

Please fill out this form if you have never applied before or your last name is A-K or if  you have any other income besides SSI or SSDI :  LONG FORM Home Energy Plus Program 2018-2019

Please use the Short Form ONLY if your name starts with: L-Z  and you have previously applied for energy assistance in the past and been approved, your only income is SSDI or SSI, and you have no minor children: 

Short Form Energy Application 2018-2019

Please refer to the checklist for items to complete the application:WHEAP Checklist