Medicaid Katie Beckett Program Application and Recertification

DEPARTMENT OF HEALTH SERVICES STATE OF WISCONSIN Division of Medicaid Services Federal Regulation 42 CFR § 435.225 & 435.913 (a) F-20582 (10/2017) Wisconsin Statutes § 49.82 (2) MEDICAID – KATIE BECKETT PROGRAM APPLICATION AND RECERTIFICATION Application (Date of Wisconsin Residency: )

Recertification

Answer the following two questions only if this child resides in Adams, Columbia, Dane, Green, Jackson, Jefferson, Kenosha, La Crosse, Lafayette, Marquette, Monroe, Ozaukee, Racine, Rock, Walworth, Washington, or Waukesha County. For which program(s) are you applying? (Check all that apply.) Katie Beckett Program Medicaid Children’s Community Options Program Children’s Long-Term Support Waiver

Would you be willing to participate in a short survey regarding your experiences with this application process? Yes No

Child’s Last Name Child’s First Name Child’s MI Date of Birth (mm/dd/yyyy) Sex M F

Race/Ethnicity Asian Black or African American Hispanic American Indian Native Hawaiian/Other Pacific Islander

White Other:

Social Security Number (Required) Child’s Signature if 14 or over. Check here if unable to sign

Street Address City State ZIP Code

County Phone Number (include area code)

Is the child a U.S. Citizen? Yes No Alien Registration Number

(If no, include the Alien Registration Number and attach a copy of the front and back of their card.) Does this child speak English? Yes No If no, what language does this child speak? Federal law requires that all U.S. citizens applying for or receiving Medicaid benefits must show proof of their U.S. citizenship and identity. If you are applying for Medicaid through the Katie Beckett Program, you will have 30 days from the date of your application home visit, to provide proof of your child’s U.S. citizenship and identity. Alien status (or proof of being a lawfully admitted Permanent Resident) is also verified with the U.S. Department of Homeland Security for all immigrants who apply for Medicaid benefits. Immigration status will not be verified for people in your household who are not applying for Medicaid. Any person who wants Wisconsin Medicaid but does not provide their SSN or apply for one will not be eligible for benefits pursuant to Wisconsin Statute § 49.82 (2).

I understand the questions and statements on this application form. I understand the penalties for giving false information or breaking rules. I certify, under penalty of false swearing, that all my answers are complete to the best of my knowledge. I understand that persons or organizations listed in this form may be contacted to obtain the necessary proof of this child’s eligibility and level of benefits. Application for the Katie Beckett Program is voluntary. Failure to sign this form will prevent the processing of the eligibility determination. Person Completing Form - Name SIGNATURE Date Completed

Relationship – A copy of guardianship/adoption papers is required if you are not the child’s birth parent.

Complete the following if different that the child’s Information Street Address City State ZIP Code

Home Phone Number (include area code) Cell Phone Number (include area code) Work Phone Number (include area code)

Other Parent/Guardian MEDICAID – KATIE BECKETT PROGRAM APPLICATION/RECERTIFICATION F-20582 Page 2 Name Relationship

Street Address City State ZIP Code

Home Phone Number (include area code) Cell Phone Number (include area code) Work Phone Number (include area code)

Who may be contacted for questions?

Do both parents have legal custody? Yes No If no, explain. Add additional pages if needed for any section. Include the name of the section(s) for which you are adding additional information. INCOME OF CHILD Does this child have any personal monthly income? Yes No If yes, list the source and amount. DIAGNOSES INFORMATION 1. Diagnoses: What are the child’s current diagnoses? Diagnosis Who made the diagnosis? Date of diagnosis?

2. Overall Summary: How do these diagnoses affect the child’s ability to perform normal daily activities?

3. Mental Health Related Behaviors: Describe any behavior or symptom the child has that result in harm to others, self or serious damage to property. What action is taken when this Where does this occur? (home, school, How often does occurs? (Time-out, supervision, Behavior / Symptom community) this occur? medical/ professional input, emergency services)

Does the child require any of the following supports for their behaviors or mental health needs? Clinical Case Management and Service Coordination

Criminal Justice System

Mental Health Services (check all that apply)

Psychiatric Medication checks with Psychiatrist or other Physician

Counseling Sessions with Psychologist or Licensed Clinical Social Worker

Inpatient Psychiatric Treatment

Day Treatment – either partial or full day

Behavioral Treatment for Children with Autism Spectrum Disorders under the supervision of a mental health professional

In Home Psychotherapy under the supervision of a mental health professional

Substance Abuse Services MEDICAID – KATIE BECKETT PROGRAM APPLICATION/RECERTIFICATION F-20582 Page 3 In-school Supports for Emotional and/or Behavioral Problems Enter the Provider Name, Address, and Phone Number for any support checked above. For In-school supports include the school name and contact person at the school. Provider Name Address Phone Number (include area code)

Approximately how many hours each week are required for all of the services checked above? 4. Self-Care: Describe the child’s abilities, need for assistance, equipment or adaptive aids for the following activities. Activity Description Bathing Grooming Dressing Eating Toileting Mobility

5. Therapy: List any therapies in which the child participates. Place of Therapy Number of Type of Therapy Provider Name and Address (home, school, clinic) Sessions / Week

6. Communication and Understanding: Describe how the child communicates and understands. Does the child communicate verbally, non-verbally, age appropriately or use communication aids?

Communication (Speech and Language) Testing: Include a copy of testing if available. Expressive Receptive Test Name Date of Test Language Language Name and Address of Person Administering the Test Score Score

7. Learning: Is the child performing at grade level? Yes No

If ‘no’ and the child is five years of age or older, describe the types of skills they are working on currently. For example, describe their ability in sequencing, following rules or a schedule, providing personal identifying information or time/money skills. If the child is less than five years of age describe the types of toys they enjoy playing with or skills they are working on currently. For example, describe their ability in naming body parts, counting, matching shapes, or identifying objects in pictures.

Learning Testing: Include a copy of testing if available. Test Name Date of Test Full Scale IQ Name and Address of Person Administering the Test

School: Does the child have an Individualized Education Program (IEP) or Individual Family Service Plan (IFSP)? Yes No MEDICAID – KATIE BECKETT PROGRAM APPLICATION/RECERTIFICATION F-20582 Page 4 Is the child enrolled in Special Education? Yes No

If yes to either question, include a copy of the most recent IEP or IFSP. School Name Grade Level Teacher/Provider Name(s), Address, Phone

Answer the following questions related to school. Question Answer How much school time does the child miss as a result of their disability? Does the child require assistance at school related to their disability? If yes, describe the type and amount of assistance required. Does the child participate in after school activities? If yes, describe the activity. 8. Social Competency (Skills) and Relationships: Describe the child’s relationships with family members, others in the home, teachers and peers in school and in the neighborhood. For example, does the child have a special friend, participate in group activities or do they understand the feelings of others.

9. Hospitalizations: Has the child been in the hospital in the past two years? Yes No

Reason for Hospitalization Admission Date Discharge Date Name and Address of Hospital

10. Other Providers (Physicians, Psychologists, Home Health, and Social Service): List all current providers along with their address and phone number. Include notes from the previous year for each provider. Include all genetic testing results. Provider Name Phone Number (include area code) Address

11. Current Medications: List all prescription medications (including chemotherapy) the child takes on a routine basis. Name of Medication How Often How Taken Describe any Significant Side Effects The child is Having

12. Current Medical/Nursing Care Needs: For each section, check and describe the cares needed, how often they are required, start date and amount of help the child needs or if the child is independent with the needed care. Care Needed How Often Start Date Help Child Needs Apnea monitor Nebulizer Oxygen Suction Tracheostomy care Ventilator Other IV line indwelling Total Parenteral Nutrition (TPN) MEDICAID – KATIE BECKETT PROGRAM APPLICATION/RECERTIFICATION F-20582 Page 5 Other Bowel program Dialysis Ostomy care Tube feeding Urinary catheter care Other NAME – Consultant SIGNATURE – Consultant Intake/Filing Date Home Visit Request Date Home Visit Date