DEPARTMENT OF HEALTH SERVICES STATE OF WISCONSIN

Division of Medicaid Services

F-10182 (07/2024)

BADGERCARE PLUS APPLICATION PACKET

This is an application for BadgerCare Plus and Family  Read any instructions, before you answer the
Planning Only Services. You can apply: question.

• Online at access.wi.gov. Click Apply now.  Complete all sections of the application that apply to
• By mail or fax: Complete this application, mail, or fax you and your family. You may have a delay in
it to: getting BadgerCare Plus benefits if the application is
not complete.
If you live in Milwaukee County:
MDPU If more room is needed, use an additional sheet of
6055 N 64th St. paper or the blank sheets at the end of the
Milwaukee WI 53218 application.
Fax: 1-888-409-1979
 Enter information about all the people living in your
If you do not live in Milwaukee County home. List all children who live in the home with you
CDPU at least 40% of the time.
PO Box 5234
Janesville, WI 53547-5234  You may need to provide proof of some of your
Fax: 1-855-293-1822 answers. See the Verification/Proof Section on page
4, to see what documents you will need to provide.
• By phone or in-person: You will need to call your Enclose with your application any proof documents,
agency to set up an appointment to apply by phone additional documentation or sheets of paper used to
or in-person. complete the application. Please send copies. Do
not send originals.
If you need help filling out this application or want to
answer the questions in person or by phone, contact  Sign the application and any attachments that
your agency. To get the address or phone number of require a signature. Applications and/or attachments
your agency, call 800-362-3002 or go to without a signature will be returned.
dhs.wi.gov/im-agency.
 If you have a legal guardian of the estate, legal
If you have a disability or need this information guardian of the person and the estate, conservator,
interpreted/translated or in a different format, contact activated durable power of attorney for finances,
your agency. These services are free. attach the legal documentation authorizing the
appointed legal guardian, conservator, or power of
ACCESS - APPLY ONLINE attorney for the applicant. If you have an authorized
ACCESS is an online tool that lets you apply for benefits, representative, attach the Appoint, Change, or
check the status of your benefits, or report changes to Remove an Authorized Representative form (Person
your worker. To visit ACCESS, go to access.wi.gov. form F-10126A or Organization form F-10126B).

On ACCESS, you can also apply for FoodShare  If you want to apply for FoodShare, complete the
Wisconsin, which is a program that helps people buy FoodShare Application, F-16019 on the DHS
nutritious food. For more information about FoodShare, website at dhs.wisconsin.gov/library/collection/F-
go to dhs.wisconsin.gov/forwardhealth/resources.htm. 16019.

HOW TO USE THIS FORM — CHECK LIST

 Read the Important Information, the Rights and
Responsibilities sections before you apply.

 Keep pages 1 through 6 and the Information Change

Report, F-10183, in this application packet, for future
changes.

 Print clearly, using blue or black ink.

BADGERCARE PLUS APPLICATION PACKET
F-10182
Page 2 of 35

IMPORTANT INFORMATION Appoint, Change, or Remove an Authorized

The following is important information you will need to Representative: Organization form, F-10126B
know about applying for BadgerCare Plus. (dhs.wisconsin.gov/library/collection/F-10126B). This will
allow your authorized representative to complete and
• It is important to apply as soon as possible as your sign the application for you.
application date is the date the agency gets your
signed application. To get this form, call 800-362-3002, or go to
• If insurance has not paid for your medical expenses dhs.wisconsin.gov/forwardhealth/representative-
or family planning expenses from the last three types.htm.
months, you can apply for coverage to pay those
expenses. To request this help, fill out Attachment 7: ACCESS TO EMPLOYER GROUP HEALTH
Help Paying for Medical Expenses Request and INSURANCE
send it in with your completed application. If employer-sponsored health insurance is available,
• If you are enrolled in BadgerCare Plus, you will need some children and pregnant women might not be able to
to complete a renewal with your agency every 12 get BadgerCare Plus.
months to stay enrolled.
• Your application for BadgerCare Plus is also an The Department of Health Services will check this
application for help with paying for private health information with your employer before you are enrolled.
insurance through the federal Health Insurance
Marketplace. If you do not meet the rules to enroll in BADGERCARE PLUS DEDUCTIBLE
BadgerCare Plus or Medicaid, your information may If you are a pregnant woman who is a U.S. citizen or
be sent to the Marketplace. If this happens, the qualifying immigrant and you have income over 300% of
Marketplace will contact you and let you know if you the Federal Poverty Level (FPL) or if your child is not
are able to get help with paying for private health able to enroll because they are over the income limit or
insurance. To learn more about the Marketplace, has access to employer-sponsor health insurance where
visit HealthCare.gov or call 1-800-318-2596 or 1- the employer pays 80% or more of the premium, you
855-889-4325 (TTY). may still be able to enroll by meeting a deductible.

LEGAL GUARDIAN, CONSERVATOR, OR POWER OF For a pregnant woman a deductible is the difference
ATTORNEY between your family’s net income and 300% of the
If you have a legal guardian of the estate, legal guardian federal poverty level over a six-month period. For
of the person and the estate, conservator, or activated children, a deductible is the difference between your
durable power of attorney for finances, that person can family’s net income and 150% of the federal poverty
fill out and submit this form on your behalf. That person level over a six-month period. For example, if your
would also need to submit documents about their monthly income is $100 over the 150% federal poverty
appointment along with this form. level, you would have to pay a deductible of $600, to be
able to get benefits. ($100 X 6 months = $600). For
current income guidelines, call 800-362-3002 or go to
When submitting this application, include the legal
www.dhs.wisconsin.gov/forwardhealth/resources.htm.
documentation authorizing the appointed legal guardian,
conservator, or durable power of attorney for finances for
the applicant. OTHER MEDICAL COVERAGE
As a condition of BadgerCare Plus enrollment, you must
A legal guardian of the person can act on your behalf report to the agency any third party who may be liable to
with your BadgerCare Plus eligibility and benefits only if pay for medical care for yourself and your family. You
this power is granted in the court documents appointing must cooperate by giving information as requested. This
the legal guardian of the person. also includes any insurance that may be available
through an absent parent or an employer's group health
A power of attorney for health care does not have the insurance.
ability to act on your behalf with your BadgerCare Plus
eligibility and benefits. PERSONALLY IDENTIFIABLE INFORMATION/
SOCIAL SECURITY NUMBER (SSN)
AUTHORIZED REPRESENTATIVE Personally identifiable information and Social Security
Numbers are used only for the direct administration of
You may have an authorized representative apply for the BadgerCare Plus programs.
you. To appoint an authorized representative, fill out
either the Appoint, Change, or Remove an Authorized
If someone in your household is not applying for
Representative: Person form, F-10126A
BadgerCare Plus, you do not need to provide a Social
(dhs.wisconsin.gov/library/collection/F-10126A) , or the
BADGERCARE PLUS APPLICATION PACKET
F-10182
Page 3 of 35

Security Number (SSN) or immigration information for

that person. Any person who wants BadgerCare Plus,
must provide their SSN or apply for one pursuant to Wis.
Stat. § 49.82(2).

If you are applying for BadgerCare Plus and do not have

an SSN due to religious beliefs or because of your
immigration status, leave the SSN field blank.

Your SSN permits a computer check of your information

with government agencies such as the Internal Revenue
Service (IRS), Social Security Administration,
Department of Revenue, Department of Transportation
and the Department of Workforce Development. In
addition, the Department of Health Services will match
your name and SSN with information provided by health
insurance carriers to determine if you have other health
insurance.

Your SSN will not be shared with the United States

Citizenship and Immigration Services (USCIS).

CHILD SUPPORT COOPERATION

In some situations, you must cooperate with the Child
Support Agency to establish paternity. This means you
must help the agency locate an absent parent, legally
name the absent parent and/or enforce medical support
liability orders. If you do not cooperate with the Child
Support Agency and do not have a good reason to not
cooperate, your benefits may end if you are an adult and
are not pregnant.
BADGERCARE PLUS APPLICATION PACKET
F-10182
Page 4 of 35

RECOVERY OF BADGERCARE PLUS • Your request for prior authorization was denied.
Wisconsin state law requires the recovery of certain
Medicaid benefits from your estate or the estate of your You may request a fair hearing by writing to:
surviving spouse. The Wisconsin Estate Recovery
Program Handbook (P-13032) provides you with Wisconsin Department of Administration
information on estate recovery. You may get a copy of Division of Hearings and Appeals
the publication from your agency, by contacting Member PO Box 7875
Services at 800-362-3002 or at Madison, WI 53707-7875
dhs.wisconsin.gov/publications/p1/p13032.pdf. Certain
benefits you get in the community after age 55 and all The Request for Fair Hearing form can be found at
benefits you get after age 55 while you are participating www.dhs.wisconsin.gov/forwardhealth/resources.htm.
in a long-term care program, living in a nursing home or
while you are an inpatient in a hospital for 30 days or If you choose to write a letter instead of using the form,
more, are recoverable. you must include:

RIGHTS • Your name.

State and federal laws guarantee rights for anyone • Your mailing address.
applying for or enrolled in BadgerCare Plus. These rights • A brief description of the problem.
include the right to: • The name of the agency.
• Your CARES case number.
• Be treated with respect by state and county • Your signature.
employees.
• Confidentiality of all information given to local An appeal must be made no later than 45 days after the
agencies to determine enrollment. (This does not date of the action.
prohibit the use of such information for program
administration.) You may also contact the agency where you applied and
• Have access to agency records and files relating to ask for help filing a Fair Hearing request. Refer to the
your case, except information obtained by the local ForwardHealth Enrollment and Benefits Handbook
agency under a promise of confidentiality. (P-00079) to learn more about the fair hearing process.
• The right to remain enrolled in BadgerCare Plus You will get a handbook when the agency gets your
even if temporarily absent from the state, if you application or you can find the handbook at
remain a Wisconsin resident. www.dhs.wisconsin.gov/forwardhealth/resources.htm.
• Be notified if you can be enrolled in BadgerCare
Plus within 30 days from the day the agency gets If you have questions about the fair hearing process, you
your application for BadgerCare Plus. can call the Division of Hearings and Appeals at
• Be notified in advance of changes in your benefits or 608-266-7709.
enrollment status.
• Ask for reasonable accommodation to participate in RESPONSIBILITIES
the program for a disability-related reason, or the Report Public Assistance Fraud — Go to
right to request interpreters or translators to www.reportfraud.wisconsin.gov or call 877-865-3432
participate in the program. (toll-free).
• Appeal any action taken concerning your
BadgerCare Plus application or on-going benefits You have the responsibility to provide truthful and
that you do not agree with by asking for a Fair complete information on this application, attachments, or
Hearing. any other form(s) needed for BadgerCare Plus and
Family Planning Only Services enrollment.
FAIR HEARING
You may appeal to the Division of Hearings and Appeals
or your agency if:

• Your application for BadgerCare Plus was denied in

error.
• Your application was not processed within 30 days
from the date the agency received it.
• You disagree with the agency’s decision to
discontinue, terminate, suspend, or reduce your
benefit.
BADGERCARE PLUS APPLICATION PACKET
F-10182
Page 5 of 35

REPORTING CHANGES already provided proof of U.S. citizenship and/or identity,

BadgerCare Plus you do not need to provide it again.
If you are enrolled in BadgerCare Plus, you must report
these changes within 10 days: U.S. CITIZENS
If you are a U.S. citizen, examples of what you can use
• You move to a new address or out of state and to prove citizenship and identity are in List 1:
become a resident of that state (see Note below).
• Anyone moves in or out of your home, or becomes List 1
pregnant or gives birth. • U.S. passport
• Your living arrangement changes (example: you go • Certificate of U.S. Citizenship
into a nursing home or other institution). • Certification of U.S. Naturalization
• Your monthly income goes over the program limit for • A state-issued enhanced driver’s license
your family size. • Tribal identification documents
• You get married or divorced.
• You have a change in health insurance coverage. If you do not have one of the items in List 1, you must
• You have a change in expected tax filing status or give one item from List 2 and one from List 3.
tax dependents.
• You no longer have a tax-related deduction you told List 2
us about. • U.S. birth certificate
• You are now in jail or prison or were released from • U.S. State Department Report of Birth Abroad
jail or prison. • U.S. citizen ID card
• Adoption papers showing U.S. birth
If you have a change in income and your gross monthly • Hospital record of U.S. birth
income goes over the program limit for your family size, • U.S. military record of service or draft record
you must report the change by the 10th day of the next showing U.S. birth
month. • Life or health insurance record showing U.S. birth
• Nursing home admission papers showing U.S. birth
The program income limit for your family size will be on
letters titled “About Your Benefits.” You should always
look at your latest letter for the program income limit for List 3
your family size. • State driver’s license
• ID card issued by federal, state, or local government
Family Planning Only Services • U.S. military dependent ID card
If you are enrolled in Family Planning Only Services, you • U.S. military ID card
only need to report these changes, within 10 days: • School ID card with photo
• For children under age 18, a signed Statement of
• You move to a new address or out of state. Identity form, F-10154, in this application packet
• Your living arrangement changes (example: you go
into a nursing home or other institution). If you have these items available on the day you submit
• You are now in jail or prison or were released from your application (paper or online at access.wi.gov),
jail or prison. include them with your application. You may be
contacted by the agency and be asked to provide proof
HOW TO REPORT CHANGES of missing, conflicting, or vague information if the
information would affect the decision about your
Report changes online at access.wi.gov, by calling your BadgerCare Plus or Family Planning Only Services
agency, or using the Information Change Report, enrollment. If you are applying for benefits, you may
F-10183, in this application packet. have at least 95 days from the date of your application to
provide proof to the agency if it is asked for.
VERIFICATION/PROOF
You may need to provide proof of certain information.
The following are examples of proof documents.

PROOF OF CITIZENSHIP/IDENTITY
People applying for BadgerCare Plus or Family Planning
Only Services may need to give proof of their identity,
citizenship, and/or immigration status. If you have
BADGERCARE PLUS APPLICATION PACKET
F-10182
Page 6 of 35

IMMIGRANTS OTHER PROGRAMS

If you are an immigrant applying for BadgerCare Plus, Medicare Savings Program
you may be asked to send a copy of your USCIS If you or someone in your home is receiving Medicare
documentation showing your immigration status. Parts A and/or B, they may be able to get help paying
their Medicare premiums, copays and deductibles.
Note: Undocumented immigrants can only get coverage
for emergency health care services. Pregnant This is called the Medicare Savings Program. To see if
immigrants may be able to enroll in BadgerCare Plus you can enroll in the program, you will need to complete
Prenatal Services. Attachment 8: Assets and provide proof of these assets.

PROOF OF INCOME FoodShare Wisconsin

Job Income and Wages FoodShare helps people with limited money buy the food
Some applicants who have a job must give proof of their they need for good health.
income. This information can be provided on the
Employer Verification of Earnings form (EVF-E), or you To learn more about FoodShare Wisconsin, visit
can use check stubs you have gotten in the last 30 days. dhs.wisconsin.gov/foodshare/index.htm.
If you want to get a form, call your agency. If enrolled,
you may be asked to provide proof of this information at MINIMUM VALUE STANDARD PLANS
your annual renewal and when you change jobs. Minimum Value Standard means that the plan pays at
least 60 percent of the total benefit costs allowed by that
Self-Employment plan.
You must provide proof of any self-employment income
for any family member who is self-employed. You may Your employer should be able to tell you if they offer a
use copies of your tax forms to provide this proof. minimum value standard plan (MVSP).

Other Income Some employers are required to give their employees a

You may need to provide proof of any other income your letter that says whether their plan meets the minimum
family gets (example, pensions, disability pay, value standard. Or, you can go to
unemployment from another state, etc.). https://marketplace.cms.gov/applications-and-
forms/employer-coverage-tool.pdf to get a form you can
OTHER PROOF give to the employer to help you get more information.
Your worker may ask for other proof. Below are some
examples of other items for which you may need to If your employer does offer a plan that meets the
provide proof. minimum value standard, the questions in the Minimum
Value Standard Plans section on Attachment 5, have to
• Medical expenses to meet a deductible. do with the lowest-cost, employee-only plan that meets
• Documentation for power of attorney and legal the minimum value standard. Employee-only means a
guardianship, or conservator. plan that only covers the person who is employed. This
• Assets. (Only for those applying for the Medicare is not a plan that covers other members of the
Savings Program.) employee’s family.

If you need help getting any required proof, contact your Even if you are enrolled in a plan that costs more than
agency and ask for help. the lowest-cost employee only plan, you should still tell
us about the lowest-cost plan in Attachment 5.
Nondiscrimination Notice: Discrimination is Against the Law – Health Care-Related Programs
The Wisconsin Department of Health Services complies with applicable Federal civil rights laws and does not discriminate on the basis
of race, color, national origin, age, disability, or sex (including pregnancy, gender identity, and sexual orientation). The Department of
Health Services does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.

The Department of Health Services:

• Provides free aids and services to people with disabilities to communicate effectively with us, such as:
o Qualified sign language interpreters.
o Written information in other formats (large print, audio, accessible electronic formats, other formats).
• Provides free language services to people whose primary language is not English, such as:
o Qualified interpreters.
o Information written in other languages.

If you need these services, contact the Department of Health Services civil rights coordinator at 844-201-6870.

If you believe that the Department of Health Services has failed to provide these services or discriminated in another way on the basis
of race, color, national origin, age, disability, or sex, you can file a grievance with: Department of Health Services, Attn: Civil Rights
Coordinator, 1 West Wilson Street, Room 651, PO Box 7850, Madison, WI 53707-7850, 844-201-6870, TTY: 711, fax: 608-267-1434,
or email to dhscrc@dhs.wisconsin.gov. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance,
the Department of Health Services civil rights coordinator is available to help you.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically
through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

U.S. Department of Health and Human Services

200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
800-368-1019, 800-537-7697 (TDD)

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

BADGERCARE PLUS APPLICATION PACKET
F-10182
APP
Page 7 of 35

BADGERCARE PLUS APPLICATION

Instructions For Agency Use Only
• Use blue or black ink Case Number Date Received
• Write all dates in the MM/DD/YY format (example 04/02/58)
• Use an additional sheet of paper or the blank pages at the end of
this application if more room is needed.
• Try to give us as much information as you can. If you don’t give us
some information now, we may have to ask for it before we can
make a decision about your application.
• Keep pages 1–6 and the Information Change Report, F-10183, for
future use.
SECTION 1 – APPLICANT INFORMATION
In this section we will ask about you, the applicant.
Name – Applicant (last, first, MI) Date of Birth (mm/dd/yy)

Name at Birth and/or Previous Names Social Security Number

Address

City State Zip Code

Mailing address, if different from above

City State Zip Code

Are you applying for BadgerCare Plus? Are you applying for Family Planning Only Services?
☐ Yes ☐ No ☐ Yes ☐ No
Do you need help paying for health care in any of the previous three months, for anyone in your home?
☐ Yes ☐ No
If you check yes, complete the Help Paying for Medical Expenses Request (Attachment 7) in this packet.
Sex What language do you want your letters What language is spoken in your home?
☐ Male ☐ Female printed in? ☐ English ☐ Spanish
Ethnicity* (optional)
☐ Hispanic or Latino ☐ Not Hispanic or Latino
Race* (optional, choose one or more)
☐ American Indian/Alaska Native ☐ Asian ☐ Black/African American
☐ Hawaiian/Other Pacific Islander ☐ White
*You don’t have to answer the ethnicity and race questions if you don’t want to. We’re asking these questions to help
improve our programs and make sure they do not discriminate based on ethnicity or race. Your answers will not be used
to make a decision about your benefits.
Is anyone in your home blind, disabled, or unable to work due to illness or injury?
☐ Yes ☐ No
BADGERCARE PLUS APPLICATION PACKET
F-10182
APP
Page 8 of 35

Are you homeless* now or have you been homeless in the last 12 months?
☐ Yes ☐ No
*By homeless, we mean you do not have a long-term place to stay at night. You could be staying at a shelter or with a
friend or relative or may not have a place to stay.
What is your marital status?
☐ Annulled ☐ Divorced ☐ Legally Separated ☐ Married ☐ Never Married ☐ Single ☐ Widowed
Are you a member, child, or grandchild of a member of an American Indian Tribe or an Alaska Native?
☐ Yes ☐ No
If yes, complete Attachment 9.
Are you eligible to get services from Indian Health Services, a tribal clinic, or an urban Indian health program?
☐ Yes ☐ No
Have you received services from Indian Health Services, a tribal clinic, or an urban Indian health program?
☐ Yes ☐ No
Answer the following questions only if you are applying for BadgerCare Plus or Family Planning Only Services.

Are you a U.S. citizen?

☐ Yes ☐ No
If no, complete the following questions:
What is your Alien Registration or USCIS number?

When did you come to the U.S. to live?

Do you have a sponsor?

☐ Yes ☐ No
Are you on active duty in the U.S. military or an honorably discharged veteran, married to someone on active duty or an
honorably discharged veteran, the surviving spouse of a veteran, or the child of someone on active duty or an honorably
discharged veteran?
☐ Yes ☐ No
Tax Filing
Is anyone planning to file taxes jointly with someone outside of your home, or claim any tax dependents who are not living
in your home?
☐ Yes ☐ No
If yes, complete Attachments 1 and 6.
SECTION 2 – CONTACT INFORMATION
Tell us how we can contact you.
Phone Number Type of Phone
☐ Home ☐ Cell ☐ Work
Other Phone Number Who does this number belong to? What is this person’s name?
☐ Self ☐ Friend ☐ Neighbor ☐ Relative
Email Address

What is the best way and time to contact you during weekdays?
BADGERCARE PLUS APPLICATION PACKET
F-10182
APP
Page 9 of 35

SECTION 3 – OTHER FAMILY MEMBERS

Tell us about all other people in the home, even if they are not applying. You don’t have to answer the ethnicity and race
questions if you don’t want to. We’re asking these questions to help improve our programs and make sure they do not
discriminate based on ethnicity or race. Your answers will not be used to make a decision about your benefits. List all
children who live in the home with you at least 40% of the time. Include any child you are responsible for the care of, who
is out of the home for six months or less. Also include any child that has been removed from your home and placed in
foster care or with a relative. Use an additional sheet of paper if more room is needed.
Name – Spouse or Other Adult (last, first, MI) Date of Birth (mm/dd/yy)

Name at Birth Social Security Number

Applying for BadgerCare Plus? Applying for Family Planning Only Services?
☐ Yes ☐ No ☐ Yes ☐ No
Sex Relationship to Applicant
☐ Male ☐ Female

Ethnicity (optional): ☐ Hispanic or Latino ☐ Not Hispanic or Latino

Race (optional, choose one or more)
☐ American Indian/Alaska Native ☐ Asian ☐ Black/African American
☐ Hawaiian/Other Pacific Islander ☐ White
Are you homeless now or have you been homeless in the last 12 months? ☐ Yes ☐ No
What is your marital status?
☐ Annulled ☐ Divorced ☐ Legally Separated ☐ Married ☐ Never Married ☐ Single ☐ Widowed
Are you a member, child or grandchild of a member of an American Indian Tribe or an Alaska Native?
☐ Yes ☐ No
If yes, complete Attachment 9.
Are you eligible to get services from Indian Health Services, a tribal clinic, or an urban Indian health program?
☐ Yes ☐ No
Have you received services from Indian Health Services, a tribal clinic, or an urban Indian health program?
☐ Yes ☐ No
Answer the following questions only if you are applying for BadgerCare Plus or Family Planning Only Services.
Are you a U.S. citizen?
☐ Yes ☐ No
If no, complete the following questions:
What is your Alien Registration or USCIS number?

When did you come to the U.S. to live?

Do you have a sponsor? ☐ Yes ☐ No

Are you on active duty in the U.S. military or an honorably discharged veteran, married to someone on active duty or an
honorably discharged veteran, the surviving spouse of a veteran, or the child of someone on active duty or an honorably
discharged veteran?
☐ Yes ☐ No
BADGERCARE PLUS APPLICATION PACKET
F-10182
APP
Page 10 of 35

Name – Child 1 (last, first, MI) Date of Birth (mm/dd/yy)

Name at Birth Social Security Number

Applying for BadgerCare Plus? Applying for Family Planning Only Services?
☐ Yes ☐ No ☐ Yes ☐ No
Sex Relationship to Applicant
☐ Male ☐ Female
Ethnicity (optional)
☐ Hispanic or Latino ☐ Not Hispanic or Latino
Race (optional, choose one or more)
☐ American Indian/Alaska Native ☐ Asian ☐ Black/African American
☐ Hawaiian/Other Pacific Islander ☐ White
What is your marital status?
☐ Annulled ☐ Divorced ☐ Legally Separated ☐ Married ☐ Never Married ☐ Single ☐ Widowed
Are you a member, child or grandchild of a member of an American Indian Tribe or an Alaska Native?
☐ Yes ☐ No
If yes, complete Attachment 10.
Are you eligible to get services from Indian Health Services, a tribal clinic, or an urban Indian health program?
☐ Yes ☐ No
Have you received services from Indian Health Services, a tribal clinic, or an urban Indian health program?
☐ Yes ☐ No
Is this child in foster care or living with a relative?
☐ Yes ☐ No
Answer the following questions only if you are applying for BadgerCare Plus or Family Planning Only Services.
Are you a U.S. citizen?
☐ Yes ☐ No
If no, complete the following questions:
What is your Alien Registration or USCIS number?

When did you come to the U.S. to live?

Do you have a sponsor? ☐ Yes ☐ No

Are you on active duty in the U.S. military or an honorably discharged veteran, married to someone on active duty or an
honorably discharged veteran, the surviving spouse of a veteran, or the child of someone on active duty or an honorably
discharged veteran?
☐ Yes ☐ No
BADGERCARE PLUS APPLICATION PACKET
F-10182
APP
Page 11 of 35

Name – Child 2 (last, first, MI) Date of Birth (mm/dd/yy)

Name at Birth Social Security Number

Applying for BadgerCare Plus? Applying for Family Planning Only Services?
☐ Yes ☐ No ☐ Yes ☐ No
Sex Relationship to Applicant
☐ Male ☐ Female
Ethnicity (optional)
☐ Hispanic or Latino ☐ Not Hispanic or Latino
Race (optional, choose one or more)
☐ American Indian/Alaska Native ☐ Asian ☐ Black/African American
☐ Hawaiian/Other Pacific Islander ☐ White
What is your marital status?
☐ Annulled ☐ Divorced ☐ Legally Separated ☐ Married ☐ Never Married ☐ Single ☐ Widowed
Are you a member, child or grandchild of a member of an American Indian Tribe or an Alaska Native?
☐ Yes ☐ No
If yes, complete Attachment 9.
Are you eligible to get services from Indian Health Services, a tribal clinic, or an urban Indian health program?
☐ Yes ☐ No
Have you received services from Indian Health Services, a tribal clinic, or an urban Indian health program?
☐ Yes ☐ No
Is this child in foster care or living with a relative?
☐ Yes ☐ No
Answer the following questions only if you are applying for BadgerCare Plus or Family Planning Only Services.
Are you a U.S. citizen?
☐ Yes ☐ No
If no, complete the following questions:
What is your Alien Registration or USCIS number?

When did you come to the U.S. to live?

Do you have a sponsor? ☐ Yes ☐ No

Are you on active duty in the U.S. military or an honorably discharged veteran, married to someone on active duty or an
honorably discharged veteran, the surviving spouse of a veteran, or the child of someone on active duty or an honorably
discharged veteran?
☐ Yes ☐ No
BADGERCARE PLUS APPLICATION PACKET
F-10182
APP
Page 12 of 35

Name – Child 3 (last, first, MI) Date of Birth (mm/dd/yy)

Name at Birth Social Security Number

Applying for BadgerCare Plus? Applying for Family Planning Only Services?
☐ Yes ☐ No ☐ Yes ☐ No
Sex Relationship to Applicant
☐ Male ☐ Female
Ethnicity (optional)
☐ Hispanic or Latino ☐ Not Hispanic or Latino
Race (optional, choose one or more)
☐ American Indian/Alaska Native ☐ Asian ☐ Black/African American
☐ Hawaiian/Other Pacific Islander ☐ White
What is your marital status?
☐ Annulled ☐ Divorced ☐ Legally Separated ☐ Married ☐ Never Married ☐ Single ☐ Widowed
Are you a member, child or grandchild of a member of an American Indian Tribe or an Alaska Native?
☐ Yes ☐ No
If yes, complete Attachment 9.
Are you eligible to get services from Indian Health Services, a tribal clinic, or an urban Indian health program?
☐ Yes ☐ No
Have you received services from Indian Health Services, a tribal clinic, or an urban Indian health program?
☐ Yes ☐ No
Is this child in foster care or living with a relative?
☐ Yes ☐ No
Answer the following questions only if you are applying for BadgerCare Plus or Family Planning Only Services.
Are you a U.S. citizen?
☐ Yes ☐ No
If no, complete the following questions:
What is your Alien Registration or USCIS number?

When did you come to the U.S. to live?

Do you have a sponsor? ☐ Yes ☐ No

Are you on active duty in the U.S. military or an honorably discharged veteran, married to someone on active duty or an
honorably discharged veteran, the surviving spouse of a veteran, or the child of someone on active duty or an honorably
discharged veteran?
☐ Yes ☐ No
BADGERCARE PLUS APPLICATION PACKET
F-10182
APP
Page 13 of 35

Name – Child 4 (last, first, MI) Date of Birth (mm/dd/yy)

Name at Birth Social Security Number

Applying for BadgerCare Plus? Applying for Family Planning Only Services?
☐ Yes ☐ No ☐ Yes ☐ No
Sex Relationship to Applicant
☐ Male ☐ Female
Ethnicity (optional)
☐ Hispanic or Latino ☐ Not Hispanic or Latino
Race (optional, choose one or more)
☐ American Indian/Alaska Native ☐ Asian ☐ Black/African American
☐ Hawaiian/Other Pacific Islander ☐ White
What is your marital status?
☐ Annulled ☐ Divorced ☐ Legally Separated ☐ Married ☐ Never Married ☐ Single ☐ Widowed
Are you a member, child or grandchild of a member of an American Indian Tribe or an Alaska Native?
☐ Yes ☐ No
If yes, complete Attachment 9.
Are you eligible to get services from Indian Health Services, a tribal clinic, or an urban Indian health program?
☐ Yes ☐ No
Have you received services from Indian Health Services, a tribal clinic, or an urban Indian health program?
☐ Yes ☐ No
Is this child in foster care or living with a relative?
☐ Yes ☐ No
Answer the following questions only if you are applying for BadgerCare Plus or Family Planning Only Services.
Are you a U.S. citizen?
☐ Yes ☐ No
If no, complete the following questions:
What is your Alien Registration or USCIS number?

When did you come to the U.S. to live?

Do you have a sponsor? ☐ Yes ☐ No

Are you on active duty in the U.S. military or an honorably discharged veteran, married to someone on active duty or an
honorably discharged veteran, the surviving spouse of a veteran, or the child of someone on active duty or an honorably
discharged veteran?
☐ Yes ☐ No
BADGERCARE PLUS APPLICATION PACKET
F-10182
APP
Page 14 of 35

SECTION 4 – OTHER INFORMATION

You must answer yes or no for each question listed below. If you answer yes, you must go to the following Attachments
and complete the section indicated.
A. Is anyone in your home planning to file a tax return for income received this year?
☐ Yes ☐ No
If yes, complete Attachment 6, Tax Information. If you are applying only for Family Planning Only Services, you do not
need to complete Attachment 6, Tax Information.
B. Does anyone pay alimony, higher education expenses, deductible self-employment tax, student loan interest, etc.?
☐ Yes ☐ No
If yes, complete Attachment 1, Tax Deductions
C. Was anyone in your home in foster care, court-ordered Kinship Care, or a subsidized guardianship on his or her 18th
birthday?
☐ Yes ☐ No
If yes, name of person(s)
D. Is anyone in your home pregnant?
☐ Yes ☐ No
If yes, complete Attachment 2, Pregnant Women.
E. Do any children under age 18, (including unborn children) have a natural or adoptive mother or father who is not living
in the home?
☐ Yes ☐ No
If yes, is there a reason you do not want to provide information about an absent parent?
☐ Yes ☐ No
F. Will anyone in your home get income from a job this month or in the next month?
☐ Yes ☐ No
If yes, complete Attachment 3, Employment.
G. If your child is found to be over the income limit or has access to employer-sponsored health insurance where the
employer pays at least 80% of the premium, do you want to enroll your child in a BadgerCare Plus Deductible? (For
more information on BadgerCare Plus Deductible, see page 2.)
☐ Yes ☐ No
If yes, what is the child’s name(s)?
H. Is anyone in your home self-employed?
☐ Yes ☐ No
If yes, complete Attachment 4a, Self-Employment.
I. Does anyone in your home get income from a source other than a job? Examples of this income include Social
Security, maintenance/alimony, Unemployment Insurance, disability or sick pay, etc. If yes, complete Attachment 4b,
Other Income.
☐ Yes ☐ No
J. Does anyone have medical or health insurance now, or in the previous three months?
☐ Yes ☐ No
If yes, complete Attachment 5, Health Insurance.
K. Does anyone in your home get Medicare Part A and/or Part B?
☐ Yes ☐ No
If yes and this person would like to apply for the Medicare Savings Program, complete Attachment 8, Assets.
BADGERCARE PLUS APPLICATION PACKET
F-10182
APP
Page 15 of 35

L. Does anyone expect their income to change from month to month?

☐ Yes ☐ No
If yes, complete Attachment 10, Yearly Income.
SECTION 5 – SIGNATURE
Please read the following statements before signing. If you don’t understand any part of this application, contact your
agency.
Under penalties of law and/or perjury, I declare I have read and understand this application and any attachments and to
the best of my knowledge, the information I have given is true, correct and complete. I understand the penalties for giving
false information or breaking the rules. I understand I will have to provide proof that what I have said is true. I understand I
will have to repay any benefits paid on my behalf that are issued incorrectly due to my failure to report changes or provide
complete and correct information.

I understand my rights as well as my responsibilities and agree to abide by them.

I know that federal rules state any information I have given must be reviewed and verified by state staff. Also, I understand
that I must cooperate fully with state and federal workers if my case is reviewed. No additional permission by me is
needed to get any proof or other information.

I know that BadgerCare Plus does not pay medical costs that a third party, such as a private health insurance company or
someone who injures me, is supposed to pay. I therefore assign and give my rights to any payments from a liable third
party to the Wisconsin Department of Health Services up to the payment amount that BadgerCare Plus has made for my
medical care. This assignment applies to any of my minor children. These payments may include payments from hospital
and health insurance policies or payments received as a settlement from an accident.

I understand that my signature authorizes the local agency and the Wisconsin Department of Health Services to request
any information that is appropriate and necessary for the proper administration of BadgerCare Plus as authorized under
Wisconsin law.

I understand that if I do not meet the rules to enroll in BadgerCare Plus and/or Medicaid, the agency may send my
information to the federal Health Insurance Marketplace. The Marketplace will use this information to see if I can get help
with paying for private health insurance.

SIGNATURE – Applicant or Authorized Representative, Legal Guardian, Power of Date Signed

Attorney, or Conservator
BADGERCARE PLUS APPLICATION PACKET
F-10182
APP
Page 16 of 35

ATTACHMENT 1 – TAX DEDUCTIONS

Check the boxes to tell us which tax deductions you expect to take on your tax return for this year. You can check “Yes”
for anyone who has the expense (for example, student loan interest), even if they are not planning to file taxes. You can
see some descriptions of the less common Tax Deductions in the Descriptions of Less Common Tax Deductions table.
Type of Tax Deduction Who gets this deduction? How much? How often?
Alimony Paid
☐ Yes ☐ No
Higher Education Expenses
☐ Yes ☐ No
Deductible Self-Employment Tax
☐ Yes ☐ No
Student Loan Interest
☐ Yes ☐ No
These are less common Tax Deductions:
Type of Tax Deduction Who gets this deduction? How much? How often?
Domestic Production Activities Deduction
☐ Yes ☐ No
Fee-based Officials’ Tax-deductible Expenses
☐ Yes ☐ No
Individual Retirement Account Contribution
☐ Yes ☐ No
Loss from Sale of Business Property
☐ Yes ☐ No
Military Reserve Tax-deductible Expenses
☐ Yes ☐ No
Net Operating Loss (NOL)
☐ Yes ☐ No
Out-of-pocket Costs for a Job-related Move
☐ Yes ☐ No
Penalties for Early Withdrawal of Savings
☐ Yes ☐ No
Performance Artists’ Tax-deductible Expenses
☐ Yes ☐ No
Self-Employed Health Insurance Plan
Contribution
☐ Yes ☐ No
Self-Employed Retirement Plan Contribution
☐ Yes ☐ No
Teachers’ Tax-Deductible Expenses
☐ Yes ☐ No
Other Allowable Write-In Deductions
☐ Yes ☐ No
Describe deduction:
BADGERCARE PLUS APPLICATION PACKET
F-10182
APP
Page 17 of 35

DESCRIPTIONS OF LESS COMMON TAX DEDUCTIONS

Type of Tax Deduction Description
Domestic Production Activities Deduction A deduction for self-employed people who produced or invented items in
the U.S. Examples of production are:
• Property
• Natural gas
• Potable water

Examples of inventions are:

• Creating software
• Recording
• Film
Fee-based Officials’ Tax-Deductible Expenses A deduction for fee-based officials that have out-of-pocket business
expenses. This does not include expenses paid for by their employer.
Examples of fee-based officials include:
• Chaplains
• County commissioners
• Judges
• Justices of the peace
• Sheriffs
• Constables.
• Registrars of deeds
• Building inspectors
If you are not sure if you qualify, check IRS Form 2106.
Loss from Sale of Business Property A deduction for self-employed people with a loss from the sale or
exchange of property that they owned for their business.
Net Operating Loss (NOL) If the person has more deductions than income for the year, they may
have a net operating loss (NOL). An NOL can be deducted from income
from another year or years. If the person has an NOL carryover from a
previous year, check this box.
The IRS has a number of rules for having an NOL. Generally, an NOL is
caused by a loss from operating a sole proprietorship business or rental
property. The IRS also has rules that limit what can be deducted when
calculating an NOL. For example, you cannot deduct capital losses in
excess of capital gains. In addition, the NOL deduction cannot exceed
80% of taxable income for losses in tax years after 2017.
For more information about NOL, please see the instructions for
completing IRS Form 1040 and IRS Publication 536.
Out-of-Pocket Costs for a Job-Related Move A deduction for people who paid out-of-pocket to move for a job. The
move must be for a job-related reason, such as starting a new job. In
addition, the new job must be at least 50 miles farther than their old
home was from their old job. It also counts, if they didn't have a job
before, and their new job is at least 50 miles from their old home
This deduction is not used if their employer paid their moving expenses.
Penalties for Early Withdrawal of Savings A deduction for penalties paid to a bank for withdrawing funds early from
an account where money must stay for a fixed period of time. This
includes:
• A time savings account
• A certificate of deposit
• An annuity
BADGERCARE PLUS APPLICATION PACKET
F-10182
APP
Page 18 of 35

Performance Artists’ Tax-Deductible Expenses A deduction for performing artists who have out-of-pocket business
expenses for their art. This does not include expenses that paid by their
employer. This can only be used if all these are true:
• They worked for at least two employers who each paid at least
$200.
• They did not earn more than $16,000 for their work.
• Their out-of-pocket expenses were more than 10% of their
earnings.
If you are not sure if you qualify, check IRS Form 2106.
Self-Employed Health Insurance Plan A deduction for self-employed people who contribute to a retirement or
Contribution savings plan for self-employed people. This includes:
• Simplified Employee Pension (SEP) plan
• Savings Incentive Match Plan for Employees (SIMPLE)
• Qualified plan contributions
Teachers’ Tax-Deductible Expenses A deduction for K-12 teachers who have up to $250 in out-of-pocket
work expenses. This does not include expenses paid for by their
employer.
Other Allowable Write-In Deductions Other write-in deductions can include:
• Contributions to Archer Medical Savings Accounts
• Deductions for rents and royalties
• Certain deductions of life tenants or income beneficiaries of
property
• Jury duty pay given to the employer because the juror was
paid a salary during duty
• Reforestation expenses
• Costs for discrimination suits
• Attorney fees for awards to whistleblowers
• Contributions to section 501(c)(18)(D) pension plans
• Contributions by certain chaplains to section 403(b) plans
If you are not sure if you qualify for any of these, check IRS Form 1040.
BADGERCARE PLUS APPLICATION PACKET
F-10182
APP
Page 19 of 35

ATTACHMENT 2 – PREGNANT WOMEN

If more room is needed for any section, use an extra sheet of paper.
PREGNANT WOMAN
Name of pregnant woman Due date (mm/dd/yy) If multiple births, number of babies expected.

Name of pregnant woman Due date (mm/dd/yy) If multiple births, number of babies expected.

Name of pregnant woman Due date (mm/dd/yy) If multiple births, number of babies expected.
BADGERCARE PLUS APPLICATION PACKET
F-10182
APP
Page 20 of 35

ATTACHMENT 3 – EMPLOYMENT
EMPLOYMENT
Complete this section for anyone in your home that will get income or in-kind income from a job this month or in the next
month. By in-kind income we mean a job that pays only in goods or services instead of money. For example, someone
who gets free housing in exchange for work. Use an additional sheet of paper if more room is needed.
Job 1 – Name of employed person (last, first, MI) Date employment started

Employer name

Employer Address

City State Zip Code

Is this person on strike? How many hours does this person work each week?
☐ Yes ☐ No
Is this person paid hourly or salary? If hourly, how much If salary, how much each pay period?
☐ Hourly ☐ Salary each hour? $
$
Does this person get cash and/or tips? If yes, how much per pay period?
☐ Yes ☐ No $
Does this person get bonuses and/or commissions? If yes, how much per pay period?
☐ Yes ☐ No $
How often is this person paid?
☐ Weekly ☐ Every 2 weeks ☐ Twice each month ☐ Once a month
☐ Other, explain:
Job Type Job Title
☐ Permanent ☐ Temporary ☐ Manager ☐ Staff
If employment ended, date ended (mm/dd/yy) Date of last paycheck Amount of last paycheck
$
Is this person a migrant worker?
☐ Yes ☐ No
List all pre-tax deductions this employed person has taken out of his or her paychecks for this job.
Type of Pre-tax Deduction How much? How often?
Child Care Savings Account $
☐ Yes ☐ No
Group Life Insurance $
☐ Yes ☐ No
Health Insurance Premiums $
☐ Yes ☐ No
Health Savings Account $
☐ Yes ☐ No
Parking and Transit Costs $
☐ Yes ☐ No
BADGERCARE PLUS APPLICATION PACKET
F-10182
APP
Page 21 of 35

Retirement Contributions $
☐ Yes ☐ No
Job 2 – Name of employed person (last, first, MI) Date employment started (mm/dd/yy)

Employer name

Employer Address

City State Zip Code

Is this person on strike? How many hours does this person work each week?
☐ Yes ☐ No
Is this person paid hourly or salary? If hourly, how much If salary, how much each pay period?
☐ Hourly ☐ Salary each hour? $
$
Does this person get cash and/or tips? If yes, how much per pay period?
☐ Yes ☐ No $
Does this person get bonuses and/or commissions? If yes, how much per pay period?
☐ Yes ☐ No $
How often is this person paid?
☐ Weekly ☐ Every 2 weeks ☐ Twice each month ☐ Once a month
☐ Other, explain:
Job Type Job Title
☐ Permanent ☐ Temporary ☐ Manager ☐ Staff
If employment ended, date ended (mm/dd/yy) Date of last paycheck Amount of last paycheck
$
Is this person a migrant worker?
☐ Yes ☐ No
List all pre-tax deductions this employed person has taken out of his or her paychecks for this job.
Type of Pre-tax Deduction How much? How often?
Child Care Savings Account $
☐ Yes ☐ No
Group Life Insurance $
☐ Yes ☐ No
Health Insurance Premiums $
☐ Yes ☐ No
Health Savings Account $
☐ Yes ☐ No
Parking and Transit Costs $
☐ Yes ☐ No
Retirement Contributions $
☐ Yes ☐ No
BADGERCARE PLUS APPLICATION PACKET
F-10182
APP
Page 22 of 35

Job 3 – Name of employed person (last, first, MI) Date employment started (mm/dd/yy)

Employer name

Employer Address

City State Zip Code

Is this person on strike? How many hours does this person work each week?
☐ Yes ☐ No
Is this person paid hourly or salary? If hourly, how much If salary, how much each pay period?
☐ Hourly ☐ Salary each hour? $
$
Does this person get cash and/or tips? If yes, how much per pay period?
☐ Yes ☐ No $
Does this person get bonuses and/or commissions? If yes, how much per pay period?
☐ Yes ☐ No $
How often is this person paid?
☐ Weekly ☐ Every 2 weeks ☐ Twice each month ☐ Once a month
☐ Other, explain:
Job Type Job Title
☐ Permanent ☐ Temporary ☐ Manager ☐ Staff
If employment ended, date ended (mm/dd/yy) Date of last paycheck Amount of last paycheck
$
Is this person a migrant worker?
☐ Yes ☐ No
List all pre-tax deductions this employed person has taken out of his or her paychecks for this job.
Type of Pre-tax Deduction How much? How often?
Child Care Savings Account $
☐ Yes ☐ No
Group Life Insurance $
☐ Yes ☐ No
Health Insurance Premiums $
☐ Yes ☐ No
Health Savings Account $
☐ Yes ☐ No
Parking and Transit Costs $
☐ Yes ☐ No
Retirement Contributions $
☐ Yes ☐ No
BADGERCARE PLUS APPLICATION PACKET
F-10182
APP
Page 23 of 35

ATTACHMENT 4A – SELF-EMPLOYMENT
SELF-EMPLOYMENT
Please tell us about any self-employment income you and/or anyone in your home gets. If more room is needed or you
have more than two self-employment businesses, use a separate sheet of paper.
Self-Employment 1
Name of Self-Employed Person Business Name

Business Address

Business Ownership Type: ☐ Partnership ☐ S corporation ☐ Sole proprietorship ☐ I don’t know

Business Type (for example, a farm, home day care) Date Business Started

Has this business filed taxes? ☐ Yes ☐ No

If yes, for what tax year did the business last file taxes?
Has the business had a significant change in income or expenses? ☐ Yes ☐ No ☐ I don’t know

On average, how much does this business make each month? Please give us the income received before expenses are
taken out. $

On average, what are the total expenses this business has each month? $

On average, how many hours per month does this person work for this business?

Self-Employment 2
Name of Self-Employed Person Business Name

Business Address

Business Ownership Type: ☐ Partnership ☐ S corporation ☐ Sole proprietorship ☐ I don’t know

Business Type (for example, farm, home day care) Date Business Started

Has this business filed taxes? ☐ Yes ☐ No

If yes, for what tax year did the business last file taxes?
Has the business had a significant change in income or expenses? ☐ Yes ☐ No ☐ I don’t know

On average, how much does this business make each month? Please give us the income received before expenses are
taken out. $

On average, what are the total expenses this business has each month? $

On average, how many hours per month does this person work for this business?
BADGERCARE PLUS APPLICATION PACKET
F-10182
APP
Page 24 of 35

ATTACHMENT 4B – OTHER INCOME

OTHER INCOME
Please list below all other income you and/or your family members get each month (except for Child Support,
Supplemental Security Income, Workers Compensation, Veterans Benefits and gifts/money from another person).
Type of income Name of person who gets this income (first, last, MI) Gross monthly amount
$
$
$
$
$
$
$
$
$
$
$
$
$
BADGERCARE PLUS APPLICATION PACKET
F-10182
APP
Page 25 of 35

ATTACHMENT 5 – HEALTH INSURANCE

HEALTH INSURANCE
Complete the following if anyone has medical or health insurance now, or in the previous three months.
Name – Policy holder Policy number Begin Date

Name of Plan (for example “Silver Plan”)

Name of Insurance Company

Insurance Company Address

City State Zip Code

Who is or was covered under this policy (family member’s names)?

Has this coverage ended in the last three months?

☐ Yes ☐ No
If yes, what is the date the coverage ended? Why did the coverage end?

Does this insurance cover services from a doctor?

☐ Yes ☐ No
Is/was this insurance provided by a current employer?
☐ Yes ☐ No
If no, tell us the source of the insurance:
☐ COBRA Continuation Coverage ☐ Retiree Health Plan
☐ Private Insurance Plan ☐ TRICARE
☐ Past Employment ☐ Veterans Health Administration Programs
☐ Peace Corps
If yes, answer all of the remaining questions on this page.
If the insurance is through a current or past employer, what is the employer’s name?

What is the employer’s address?

What is the employer’s Federal Employer Identification Number (FEIN), if known?

Is this insurance through a state employee benefit plan? Does this insurance cover services from a doctor?
☐ Yes ☐ No ☐ Yes ☐ No
Minimum Value Standard Plans (For more information about Minimum Value Standard Plans, see page 6.)
Does this employer offer a plan that meets the minimum value standard?
☐ Yes ☐ No ☐ Do not know
BADGERCARE PLUS APPLICATION PACKET
F-10182
APP
Page 26 of 35

What is the name of the lowest-cost employee-only plan offered by this employer?

How much are the monthly premiums? How often do these premiums need to be paid?
$ ☐ Weekly ☐ Every Two Weeks ☐ Monthly
Plan Changes (Tell us more about changes that this employer may make to the health insurance if offers next year.)
Will this employer continue to offer health insurance next year?
☐ Yes ☐ No ☐ Do not know
Will there be any change in premiums for the lowest-cost employee-only plan that meets the minimum value standard?
☐ Yes ☐ No ☐ Do not know
How much will this plan’s new premiums be? How often do these premiums need to be paid?
$ ☐ Do not know ☐ Weekly ☐ Every Two Weeks ☐ Monthly
Name – Policy holder Policy number Begin Date

Name of Plan (for example “Silver Plan”)

Name of Insurance Company

Insurance Company Address

City State Zip Code

Who is or was covered under this policy (family member’s names)?

Has this coverage ended in the last three months?

☐ Yes ☐ No
If yes, what is the date the coverage ended? Why did the coverage end?

Does this insurance cover services from a doctor?

☐ Yes ☐ No
Is/was this insurance provided by a current employer?
☐ Yes ☐ No
If no, tell us the source of the insurance:
☐ COBRA Continuation Coverage ☐ Retiree Health Plan
☐ Private Insurance Plan ☐ TRICARE
☐ Past Employment ☐ Veterans Health Administration Programs
☐ Peace Corps
If yes, answer all of the remaining questions on this page.
If the insurance is through a current or past employer, what is the employer’s name?

What is the employer’s address?

BADGERCARE PLUS APPLICATION PACKET
F-10182
APP
Page 27 of 35

What is the employer’s Federal Employer Identification Number (FEIN), if known?

Is this insurance through a state employee benefit plan? Does this insurance cover services from a doctor?
☐ Yes ☐ No ☐ Yes ☐ No
Minimum Value Standard Plans (For more information about Minimum Value Standard Plans, see page 5.)
Does this employer offer a plan that meets the minimum value standard?
☐ Yes ☐ No ☐ Do not know
What is the name of the lowest-cost employee-only plan offered by this employer?

How much are the monthly premiums? How often do these premiums need to be paid?
$ ☐ Weekly ☐ Every Two Weeks ☐ Monthly
Plan Changes (Tell us more about changes that this employer may make to the health insurance if offers next year.)
Will this employer continue to offer health insurance next year?
☐ Yes ☐ No ☐ Do not know
Will there be any change in premiums for the lowest-cost employee-only plan that meets the minimum value standard?
☐ Yes ☐ No ☐ Do not know
How much will this plan’s new premiums be? How often do these premiums need to be paid?
$ ☐ Do not know ☐ Weekly ☐ Every Two Weeks ☐ Monthly
BADGERCARE PLUS APPLICATION PACKET
F-10182
APP
Page 28 of 35

ATTACHMENT 6 – TAX INFORMATION

TAX FILER
List information for each person in your household who expects to file taxes for income they will get this year. If you are
married and file jointly, you only need to complete one section for both filers.
Name Tax Filer 1 Name of Spouse (if married and filing jointly)

Tax Filing Status

☐ Singe or Head of Household ☐ Married Filing Jointly ☐ Married Filing Separately
Will this tax filer be claimed as a dependent by someone outside of the home?
☐ Yes ☐ No
Tax Dependents: List the dependents this tax filer will be claiming on his or her taxes. Use an additional sheet of paper if
more room is needed.
Name of Tax Dependent Date of Birth

Social Security Number Sex

☐ Male ☐ Female
Is this dependent expected to have more than $12,400 in earned income this year?
☐ Yes ☐ No
Is this dependent expected to have more than $1,100 in unearned income this year? (Do not include Child Support, Social
Security, Supplemental Security Income, Worker’s Compensation, Veterans Benefits or gifts/money from another person.)
☐ Yes ☐ No
Is this tax dependent living outside of the home? Is this tax dependent deceased?
☐ Yes ☐ No ☐ Yes ☐ No
Name of Tax Dependent Date of Birth

Social Security Number Sex

☐ Male ☐ Female
Is this dependent expected to have more than $12,400 in earned income this year?
☐ Yes ☐ No
Is this dependent expected to have more than $1,100 in unearned income this year? (Do not include Child Support, Social
Security, Supplemental Security Income, Worker’s Compensation, Veterans Benefits or gifts/money from another person.)
☐ Yes ☐ No
Is this tax dependent living outside of the home? Is this tax dependent deceased?
☐ Yes ☐ No ☐ Yes ☐ No
Name of Tax Dependent Date of Birth

Social Security Number Sex

☐ Male ☐ Female
Is this dependent expected to have more than $12,400 in earned income this year?
☐ Yes ☐ No
BADGERCARE PLUS APPLICATION PACKET
F-10182
APP
Page 29 of 35

Is this dependent expected to have more than $1,100 in unearned income this year? (Do not include Child Support, Social
Security, Supplemental Security Income, Worker’s Compensation, Veterans Benefits or gifts/money from another person.)
☐ Yes ☐ No
Is this tax dependent living outside of the home? Is this tax dependent deceased?
☐ Yes ☐ No ☐ Yes ☐ No
Name of Tax Dependent Date of Birth

Social Security Number Sex

☐ Male ☐ Female
Is this dependent expected to have more than $12,400 in earned income this year?
☐ Yes ☐ No
Is this dependent expected to have more than $1,100 in unearned income this year? (Do not include Child Support, Social
Security, Supplemental Security Income, Worker’s Compensation, Veterans Benefits or gifts/money from another person.)
☐ Yes ☐ No
Is this tax dependent living outside of the home? Is this tax dependent deceased?
☐ Yes ☐ No ☐ Yes ☐ No
Name Tax Filer 2 Name of Spouse (if married and filing jointly)

Tax Filing Status

☐ Singe or Head of Household ☐ Married Filing Jointly ☐ Married Filing Separately
Will this tax filer be claimed as a dependent by someone outside of the home?
☐ Yes ☐ No
Tax Dependents: List the dependents this tax filer will be claiming on his or her taxes. Use an additional sheet of paper if
more room is needed.
Name of Tax Dependent Date of Birth

Social Security Number Sex

☐ Male ☐ Female
Is this dependent expected to have more than $12,400 in earned income this year?
☐ Yes ☐ No
Is this dependent expected to have more than $1,100 in unearned income this year? (Do not include Child Support, Social
Security, Supplemental Security Income, Worker’s Compensation, Veterans Benefits or gifts / money from another
person.)
☐ Yes ☐ No
Is this tax dependent living outside of the home? Is this tax dependent deceased?
☐ Yes ☐ No ☐ Yes ☐ No
Name of Tax Dependent Date of Birth

Social Security Number Sex

☐ Male ☐ Female
Is this dependent expected to have more than $12,400 in earned income this year?
☐ Yes ☐ No
BADGERCARE PLUS APPLICATION PACKET
F-10182
APP
Page 30 of 35

Is this dependent expected to have more than $1,100 in unearned income this year? (Do not include Child Support, Social
Security, Supplemental Security Income, Worker’s Compensation, Veterans Benefits or gifts / money from another
person.)
☐ Yes ☐ No
Is this tax dependent living outside of the home? Is this tax dependent deceased?
☐ Yes ☐ No ☐ Yes ☐ No
Name of Tax Dependent Date of Birth

Social Security Number Sex

☐ Male ☐ Female
Is this dependent expected to have more than $12,400 in earned income this year?
☐ Yes ☐ No
Is this dependent expected to have more than $1,100 in unearned income this year? (Do not include Child Support, Social
Security, Supplemental Security Income, Worker’s Compensation, Veterans Benefits or gifts/money from another person.)
☐ Yes ☐ No
Is this tax dependent living outside of the home? Is this tax dependent deceased?
☐ Yes ☐ No ☐ Yes ☐ No
Name of Tax Dependent Date of Birth

Social Security Number Sex

☐ Male ☐ Female
Is this dependent expected to have more than $12,400 in earned income this year?
☐ Yes ☐ No
Is this dependent expected to have more than $1,100 in unearned income this year? (Do not include Child Support, Social
Security, Supplemental Security Income, Worker’s Compensation, Veterans Benefits or gifts/money from another person.)
☐ Yes ☐ No
Is this tax dependent living outside of the home? Is this tax dependent deceased?
☐ Yes ☐ No ☐ Yes ☐ No
BADGERCARE PLUS APPLICATION PACKET
F-10182
APP
Page 31 of 35

ATTACHMENT 7 – HELP PAYING FOR MEDICAL EXPENSES REQUEST

If insurance has not paid for your medical expenses or family planning services from the last three months, you can apply
for Badger Care Plus or Family Planning Only Services coverage to pay those expenses. If you meet all program rules in
those months, you can get BadgerCare Plus and Family Planning Only Services starting up to three months before your
application month. The application month is the month in which you agency gets your application. Please Note:
Requesting this BadgerCare Plus or Family Planning Only Services coverage does not guarantee you will be enrolled for
the months requested.
If there are any changes in the three months before your application month, list the changes below for each month. These
changes may include: your address, who lives in the household, income, health insurance. You must provide proof of
income for any of the three months you are requesting BadgerCare Plus or Family Planning Only Services coverage.
Check the type(s) of coverage you are requesting.
☐ BadgerCare Plus ☐ Family Planning Only Services
What is the date you want coverage to begin? Note: This date cannot be more than three months ago.

1. Are you asking for help paying medical and/or family planning only services expenses from the month prior
to the month you are applying?
☐ Yes ☐ No
If yes, is the information you provided in your application the same in that month? ☐ Yes ☐ No
If no, describe the changes.

If your income was different, what was your total gross family income for this month?

2. Are you asking for help paying medical and/or family planning only services expenses from two months
prior to the month you are applying?
☐ Yes ☐ No
If yes, is the information you provided in your application the same in that month? ☐ Yes ☐ No
If no, describe the changes.

If your income was different, what was your total gross family income for this month?

3. Are you asking for help paying medical and/or family planning only services expenses from three months
prior to the month you are applying?
☐ Yes ☐ No
If yes, is the information you provided in your application the same in that month? ☐ Yes ☐ No
If no, describe the changes.

If your income was different, what was your total gross family income for this month?

SIGNATURE – Applicant / Authorized Representative Date Signed

BADGERCARE PLUS APPLICATION PACKET
F-10182
APP
Page 32 of 35

ATTACHMENT 8 – ASSETS (FOR MEDICARE SAVINGS PROGRAMS ONLY)

This form should be completed only if someone in your home gets Medicare Part A and/or Part B and you want to apply
for the Medicare Savings Program (also called Medicare Premium Assistance or Buy-In program). You must list all your
family’s assets. Include assets owned jointly with any other person. Do not include the value of personal household
belongings (televisions, furniture, appliances). Do not list motor vehicle information in this section. Assets include items
such as cash, checking or savings accounts, certificates of deposit, prepaid debit cards, trust funds, stocks, bonds,
retirement accounts, interest in annuities, U.S. savings bonds, property agreements, contracts for deeds, timeshares,
rental property, life estates, livestock, tools, farm machinery, Keogh plans or other tax shelters, personal property being
held for investment purposes, etc.
NOTE: You will be required to provide proof of all your assets. Examples of proof include a copy of your bank statement
showing the value of your bank account on the date the application is completed, or something that shows the face value
and cash value of your life insurance policy. Use an additional sheet of paper if more room is needed.
Type of Asset Current Dollar Bank / Financial
(See Above) Name of Owner(s) Amount Institution Name Account Number
$
$
$
BURIAL ASSETS
List all burial assets.
Type of Burial Asset Name of Owner(s) Value
Burial Insurance:
$
☐ Yes ☐ No
Irrevocable Burial Trust
(which means it can’t be
returned or changed): $
☐ Yes ☐ No
Other:*
☐ Yes ☐ No
*Other examples could be $
a headstone, casket,
marker, or opening and
closing costs.
VEHICLE INFORMATION
List all motor vehicles. Include vehicles owned jointly with another person.
Vehicle 1 Vehicle 2
Type of Vehicle Year Make Model Type of Vehicle Year Make Model

Amount Owed on Vehicle Fair Market Value* Amount Owed on Vehicle Fair Market Value*
$ $ $ $
*By fair market value, we mean the price you could sell the vehicle for right now. Looking up the vehicle's Blue Book value
online (www.kbb.com/whats-my-car-worth) is a good way to find this out.
LIFE INSURANCE
Tell us about any life insurance you and/or your family has.
Do you or any family member have any life insurance policies? ☐ Yes ☐ No
If yes, complete the section below.
BADGERCARE PLUS APPLICATION PACKET
F-10182
APP
Page 33 of 35

Name of Owner(s) Cash Surrender Value* Face Value**

$ $
$ $
$ $
*By cash surrender value, we mean the amount you will get if you cancel the policy.
**By face value, we mean the minimum benefit paid out upon death. In most cases, this is the amount written on the
policy.
BADGERCARE PLUS APPLICATION PACKET
F-10182
APP
Page 34 of 35

ATTACHMENT 9 – AMERICAN INDIAN OR ALASKA NATIVE FAMILY MEMBER

FEDERALLY RECOGNIZED TRIBE
Is anyone a member of a federal recognized tribe?
☐ Yes ☐ No
If yes, list them below.
Person’s Name Name of Tribe

NON-GAMING TRIBAL INCOME

Some tribal income types may not be counted for BadgerCare Plus. List any income (amount and how often) reported on
your application that includes money from these sources:
• Per capita payments from a tribe that come from natural resources, usage rights, leases, or royalties
• Payments from natural resources, farming, ranching, fishing, leases, or royalties from land designated as Indian trust
land by the Department of Interior (including reservations and former reservations)
• Money from selling things that have cultural significance
Tribal per capita payments from gaming activities are counted for BadgerCare Plus, so you should not list them here.
Name of Person Who Gets Income Amount Type of Income How Often Paid
$
$
$
$
$
BADGERCARE PLUS APPLICATION PACKET
F-10182
APP
Page 35 of 35

ATTACHMENT 10 – YEARLY INCOME

Complete only if someone’s income changes from month to month. If you do not know the exact amount, use your best
guess, or write “I don’t know.”
What is the expected What is the expected
Name of Person income for this year? income for next year?
$ $
$ $
$ $
$ $
STATE OF WISCONSIN
DEPARTMENT OF HEALTH SERVICES
Division of Health Care Access and Accountability
ID
F-10154 (07/08)

STATEMENT OF IDENTITY FOR CHILDREN UNDER 18 YEARS OF AGE

This Statement may be used only to meet the new Medicaid/BadgerCare Plus/Family Planning Only Services proof of
identity rule for children under 18 years of age. This statement may not be used to meet the Medicaid, BadgerCare Plus/
Family Planning Only Services proof of citizenship rule.

Instructions: In the space provided below, list all the children under age 18 in your household for whom you are a parent,
guardian or caretaker relative. For each child you list, include the child’s date of birth and place of birth (city, state and
country). Complete, sign and return this statement to your agency.

Child’s Full Name (First, MI, Last) Date of Birth Place of Birth (City, State, Country)

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

13.

14.

Personally identifiable information will be used only for the direct administration of Family Planning Only Services,
Medicaid and BadgerCare Plus programs.

By signing this statement, I certify, under penalty of perjury and false swearing, that the information I have given
is correct and complete to the best of my knowledge. I understand that the local agency may contact other
persons or organizations, to confirm the accuracy of my statement.

SIGNATURE Date Signed

(Parent, Guardian or Caretaker Relative)

Print Name Case Number

(Parent, Guardian or Caretaker Relative)
STATE OF WISCONSIN
DEPARTMENT OF HEALTH SERVICES
Division of Medicaid Services
F-10183 (10/2023)

INFORMATION CHANGE REPORT

BadgerCare Plus
If you are enrolled in BadgerCare Plus, you must report the following types of changes no later than 10 days after the
change has occurred:

• You move to a new address or out of state.

• Someone moves in or out of your home, becomes pregnant, or gives birth.
• Your living arrangement changes (for example, you are incarcerated or you go into a nursing home or other
institution).
• You get married or divorced.
• Someone in your home has a change in health insurance.
• Someone in your home has a change in expected tax filing status or tax dependents or no longer has a tax deduction
that he or she previously reported.

If you have a change in income that makes your gross monthly income go over the BadgerCare Plus program limit, you
must report that change by the 10th day of the next month.

When you enroll in BadgerCare Plus or if you have a change in benefits, you will get a notice in the mail with the
program limits for your family size. You should always look at your latest notice for the most current information.

Family Planning Only Services

If you are enrolled in Family Planning Only Services, you must report only the following types of changes no later than
10 days after the change has occurred:

• You move to a new address or out of state.

• Your living arrangement changes (for example, you are incarcerated or you go into a nursing home or other
institution).

You can report the changes noted above using this form, by calling your agency, or online at ACCESS.wi.gov. If you use
this form to report your changes, once you have completed and signed the form, you should mail or fax it to:

If you live in Milwaukee County: If you do not live in Milwaukee County

MDPU CDPU
6055 N 64th St. PO Box 5234
Milwaukee WI 53218 Janesville, WI 53547-5234
Fax: 1-888-409-1979 Fax: 1-855-293-1822
If this form does not provide enough room to describe a change, attach a sheet of paper with the additional information.
INFORMATION CHANGE REPORT
F-10183
CHG
Page 2 of 5

Name – Member (Last, First MI) Case Number or Social Security Number

CHANGE IN ADDRESS
Use this section to report a new address if you moved.
New Street Address

City State Zip Code

New Phone Number Date of Change (mm/dd/yy)

CHANGE IN HOUSEHOLD
Use this section to report if someone moved in or out of your home, got married, became pregnant, or gave birth. If
someone became pregnant, tell us who it is, the due date, and the number of expected babies.
Name (Last, First MI) Social Security Number

Date of Birth (mm/dd/yy) Relationship to You Date of Change (mm/dd/yy)

Describe the Change

CHANGE IN INCOME
Use section A to report changes in income from a job or self-employment or from sources other than a job, such as Social
Security or unemployment insurance. Fill out section B if someone in your home lost a job or section C if someone in your
home got a new job.
A. Changes in Income From Any Source
Name (Last First MI) Source of Income

What changed?

Date of Change (mm/dd/yy) New Income Amount How often is it paid?

$
B. Loss of Job
Name (Last, First MI)

Name – Employer

Date Job Ended (mm/dd/yy) Date of Final Paycheck (mm/dd/yy) Amount of Final Paycheck
$
INFORMATION CHANGE REPORT
F-10183
CHG
Page 3 of 5

C. New Job
Name (Last, First MI) Date Job Started (mm/dd/yy)

Name – Employer Phone Number

Street Address – Employer

City State Zip Code

Is this person on strike? Hours Worked Each Week

Yes No
Amount Per Hour Amount Per Pay Period
Paid by the hour $ Paid a salary $
Does this person get cash and/or tips? If Yes – Amount Per Pay Period
Yes No $
Does this person get bonuses and/or commissions? If Yes – Amount Per Pay Period
Yes No $
How often is this person paid?
Weekly Every 2 weeks Twice each month Once a month Other – Explain Below

Job Type Job Title Is this person a migrant worker?

Permanent Temporary Manager Staff Yes No

List all pre-tax deductions this person has taken out of his or her paychecks for this job.
Type of Pretax Deduction How much? How often?

Child care savings account $

Group life insurance $

Health insurance premiums $

Health savings accounts $

Parking and transit costs $

Retirement contributions $

CHANGE IN TAX INFORMATION

Use this section to report if someone in your home had a change in expected tax filing status or tax dependents. If the
person is married and filing jointly, you only need to complete the information for one of the spouses. If you need more
room, attach a sheet of paper with the additional information.
Name (Last, First MI) Name – Spouse if Filing Jointly (Last, First MI)

Is this person expecting to file taxes for income he or she will get this year?
Yes No
INFORMATION CHANGE REPORT
F-10183
CHG
Page 4 of 5

If yes, what is his or her tax filing status?

Single Married filing jointly Married filing separately
Will this tax filer be claimed as a dependent by someone outside of the home?
Yes No

List the dependents this person will be claiming on his or her taxes.
Name – Tax Dependent (Last, First MI)

Date of Birth (mm/dd/yy) Social Security Number Sex

Male Female
Is this tax dependent expected to have more than $6,300 in earned income this year?
Yes No
Is this tax dependent expected to have more than $1,050 in unearned income this year? (Do not include child support,
Social Security, Supplemental Security Income, workers compensation, or veterans benefits.)
Yes No
Is this tax dependent living outside of the home? Is this tax dependent deceased?
Yes No Yes No
Name – Tax Dependent (Last, First MI)

Date of Birth (mm/dd/yy) Social Security Number Sex

Male Female
Is this tax dependent expected to have more than $6,300 in earned income this year?
Yes No
Is this tax dependent expected to have more than $1,050 in unearned income this year? (Do not include child support,
Social Security, Supplemental Security Income, workers compensation, or veterans benefits.)
Yes No
Is this tax dependent living outside of the home? Is this tax dependent deceased?
Yes No Yes No
Name – Tax Dependent (Last, First MI)

Date of Birth (mm/dd/yy) Social Security Number Sex

Male Female
Is this tax dependent expected to have more than $6,300 in earned income this year?
Yes No
Is this tax dependent expected to have more than $1,050 in unearned income this year? (Do not include child support,
Social Security, Supplemental Security Income, workers compensation, or veterans benefits.)
Yes No
Is this tax dependent living outside of the home? Is this tax dependent deceased?
Yes No Yes No
INFORMATION CHANGE REPORT
F-10183
CHG
Page 5 of 5

OTHER CHANGES
Use this space to report other changes.

I understand that there are penalties for hiding information or giving false information. I also understand that I may have to
pay back any benefits I get because I do not fully report changes in my circumstances. I agree to provide proof of any
changes if asked to do so. My answers on this form are correct and complete to the best of my knowledge.

SIGNATURE – Member Date Signed (mm/dd/yy)