Please return the completed survey by January 31, 2008
E-mail the completed survey to: Robyn Bockweg at:
RESPONDING STATE: Wisconsin
SECTION I
Contact Information for AAICAMAState Page
Compact Administrator: Dale Langer
E-mail: / Telephone:608 - 266 - 3595 (ext )
Compact Administrator: (if more than one is designated)
E-mail: / Telephone: - - (ext )
DeputyCompact Administrator: June Paul
E-mail: / Telephone:608 - 267 - 2079 (ext )
DeputyCompact Administrator: (if more than one is designated)
E-mail: / Telephone: - - (ext )
ICAMA Contact: Dale Langer
E-mail: / Telephone:608 - 266 - 3595 (ext )
Alternate ICAMA Contact: Jennifer Broberg
E-mail: / Telephone:608 - 266 - 255 (ext )
Office Information
Telephone: 608 - 266 - 3036 (ext )
Toll Free Telephone: 866 - 666 - 5532
Fax: 607 - 264 - 6750
First Class Mailing Address
1 W. Wilson Street, Room 527
P.O. Box 8916
City: Madison / State: WI / Zip 53708 - 8916
Over night Mailing Address (if different)
City: / State: / Zip -
AAICAMA SURVEY
SECTION II
Survey Questions
Question 1.
To what age can children eligible for Title IV-E adoption assistance receive Medicaid in your state?
MAXIMUM AGE / 21
To what age can children eligible for state-funded adoption assistance receive Medicaid in your state?
MAXIMUM AGE / 21
Question 2.
Does your state provide Medicaid to children living in your state who have state-funded adoption assistance agreements with other states, i.e. has your state instituted COBRA-reciprocity?
YES / If yes, go to question 3
NO / If no, go to question 4
Question 3.
To which states does your state offer COBRA-reciprocity?
(Please choose only one)
My state offers COBRA-reciprocity to ICAMA member states only regardless of whether they reciprocate with my state
My state offers COBRA-reciprocity to ICAMA member states who offer COBRA-reciprocity to my state
My state offers COBRA-reciprocity only to states who offer COBRA-reciprocity to my state
My state offers COBRA-reciprocity to all states regardless of whether they reciprocate with my state
Question 4.
If your state does NOT extend COBRA-reciprocity to a state-funded AA eligible child coming to reside in your state, do you provide referrals to other state programs, community resources, etc. which may enable families to obtain Medicaid or medical benefits ?
NO / If no, go to question 5
YES / If yes, please check all those below that apply
Refer to providers in your state who are licensed by the AA state as Medicaid providers
Refer to other state or local agencies or programs (i.e., TANF) in your state
Refer to independent or private community resources or organizations
Other (please specify)
Question 5.
After receipt of the ICAMA 6.01,how long does it generally take your state to issue a Medicaid card for an incoming adoption assistance eligible child?
Choose the most common timeframe
Within 2 business days
Within 5 business days
Within 10 business days
Within 20 business days
Within 45 business days
Other (specify number of days ) days
Question 6.
Does your state offer an Emergency (or temporary) Medicaid card for an incoming adoption assistance eligible child?
NO / If no, go to question 8
YES / If yes, go to question 7
Question 7.
After receipt of the ICAMA 6.01,how long does it take your state to issue an Emergency (or Temporary) Medicaid card if one is needed?
Choose the most common timeframe
Less than1 business day
Less than 2 business days
Less than 5 business days
Other (specify number of days) days
Question 8.
Does your state offer any other ways for these children to access medical services before the issuance of a Medicaid card?
NO / If no, go to question 10
YES / If yes, go to question 9
Question 9.
How does your state assist families to access medical services prior to the issuance of a Medicaid card?
Choose all that apply
Call or Fax provider or pharmacy to provide Medicaidnumber
Provide a letter verifying that the child is eligible for Medicaid in your state
Provide direct payment to the provider for the needed services
Provide reimbursement to adoptive parents upon submission of receipts
Other (please specify) Issue a temporary card to be used until the permanent card is received.
Question 10.
Does your state require any forms or applications, in addition to the ICAMA 6.01, to provide Medicaid to an adoption assistance eligible child?
YES / If yes, go to question 11
NO / If no, go to question 12
Question 11.
What forms or applications does your state require, in addition to the ICAMA 6.01, to provide Medicaid to an adoption assistance eligible child? (Please list)
Question 12.
Under Federal law, Medicaid eligibility must be redetermined at least once every 12 months. States must determine annually that a child remains eligible for AA and therefore is eligible for Medicaid. States primarily use either the Ex-parte* or Passive* method of redetermination.
How are your state Medicaid redeterminations made for children receiving Adoption Assistance?
Please check the boxes in the chart below that reflect your state practice for each group.
* These terms are defined below.
Medicaid
Re-determination Review Process / Medicaid redeterminations for
adoption assistance eligible children:
Receiving AA from your state and living
in your state / Receiving AA from your state and living out-of--state / Receiving AA from another state and living in your state
Ex-parte
Passive
Other (specify)
* Ex-parte redetermination
State relies on information available in its own records or,in interstate cases, requests information from the AA state to determine that the child remains adoption assistance-eligible before ever contacting the family.
For example: the state can look at its own paperwork to verify that the child’s AA agreement is still in effect. In interstate cases, the resident state can contact the AA state directly for information regarding the child’s continuing eligibility.
*Passive redetermination
Resident state contacts adoptive parent or AA state indicating that the state agency will assume that child remains adoption assistance-eligible unless information is provided to the contrary.
For example: the resident state can send a letter to the adoptive parents stating that the agency will assume the child continues to be receive adoption assistance unless it receives information to the contrary by a specified date.
No action by the adoptive parent(s) is required unless there is a change.
AAICAMA SURVEY
SECTION III
ICAMA staff provide information to inquiring agencies or families on:
Choose all that apply
Agency and/or agency contact for admission to public education
Agency and/or agency contact for access to special educational services
Agency and/or agency contact for access to EPSDT (Early Periodic Screening, Diagnosis and Testing)
Agency and/or agency contact for application to SCHIP
Other agencies and/or contacts not listed above that provide important information to families and out of state agencies. (please specify)
(See page 7 to provide additional agency information)
Service(s) provided by agency noted below:
Agency:
Staff contact:
E-mail: / Telephone: - - (ext )
NOTE: IFICAMA staff DO NOT provide agency and contact information for any of the above categories please provide agency and/or contact information below
A.
Public education Special Education EPSDT SCHIP
Agency:
Staff contact:
E-mail: / Telephone: - - (ext )
B.
Public education Special Education EPSDT SCHIP
Staff contact:
E-mail: / Telephone: - - (ext )
C.
Public education Special Education EPSDT SCHIP
Agency:
Staff contact:
E-mail: / Telephone: - - (ext )
D.
Public education Special Education EPSDT SCHIP
Agency:
Staff contact:
E-mail: / Telephone: - - (ext )
AAICAMA SURVEY
SECTION IV
About You
Your Name: Dale Langer
E-mail: / Telephone:608 - 266 - 3595 (ext )
Date: 01/16/2008
NOTE: If you have questions about the information requested, contact
Warren Lewis, AAICAMA Staff
or telephone 717-215-4129
Please e-mail the completed survey to:
Robyn Bockweg,
AAICAMA SURVEYSECTION III (addendum)
Service(s) provided by agency noted below:
Agency:
Staff contact:
E-mail: / Telephone: - - (ext )
Service(s) provided by agency noted below:
Agency:
Staff contact:
E-mail: / Telephone: - - (ext )
Service(s) provided by agency noted below:
Agency:
Staff contact:
E-mail: / Telephone: - - (ext )
AAICAMAState Page Survey 2008 Page 1 of 7