Form F-01186 - Wisconsin Chronic Renal Disease Program Application - 2014 Page 3

ADVERTISEMENT

WISCONSIN CHRONIC RENAL DISEASE PROGRAM
Page 3 of 5
APPLICATION
F-01186 (02/14)
23. If you are enrolled in Wisconsin Medicaid, BadgerCare Plus, SeniorCare, or Medicare Part D, you may skip this question and
go to question 24. WCDP is trying to determine if you have insurance that covers drugs that meets Medicare Part D’s definition of
‘creditable coverage’. If you currently have private, group, or other health insurance coverage for medical expenses does it do the
following:
a. Provide coverage for brand and generic prescriptions;
Yes
No
b. Provide reasonable access to retail providers and, optionally for mail order coverage;
Yes
No
c. Pay on average at least 60% of your prescription drug expenses; and
Yes
No
d. Satisfy at least one of the following criteria below:
Yes
No
1. The prescription drug coverage has no annual benefit maximum benefit or a maximum annual benefit payable by the plan of
at least $25,000; or
2. The prescription drug coverage has an actuarial expectation that the amount payable by the plan will be at least $2,000 per
Medicare eligible in 2013; or
3. For plans that have integrated supplemental coverage directly through a specific Part D plan, the integrated health plan has
no more than a $250 deductible per year, has no annual benefit maximum payable by the plan of at least $25,000 and has
not less than a $1,000,000 life time combined benefit maximum.
SECTION 6. FINANCIAL INFORMATION
24. Indicate the number of dependent family members; include yourself if you are a dependent family member.____________________
Average
25. Indicate your current total income by completing items a - m either by
OR
Monthly Totals
Annual Totals
monthly OR annual totals.
________
2 0__ __
2 0 __ __
Month
Year
Year
a. Gross wages, salaries, tips, etc.
$
$
b. Net income from non-farm self-employment.
$
$
c. Net income from farm self employment.
$
$
d. Social Security and/or Supplemental Security benefits.
$
$
e. Dividends and interest income.
$
$
f. Total of estate or trust income, net rental income and royalties.
$
$
g. Cash public benefits (e.g. W-2 payments).
$
$
h. Pensions, annuities and/or veteran’s pension.
$
$
i. Unemployment compensation and/or worker’s compensation.
$
$
j. Maintenance, alimony and/or child support.
$
$
k. Non taxable interest (federal, state or municipal bonds).
$
$
l. Nontaxable deferred compensation.
$
$
m. Total Monthly OR Yearly Income.
26. Do you expect this income to change significantly from month to month or in the next year?
Yes
No
27. If yes, will your income be less or more than the total above?
Less
More
Explain why.
28. On last year’s Wisconsin Income Tax return, what was your total gross family income before taxes?
______________________

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Legal
Go
Page of 5