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9.1.5 Assignment Process At application or a new request for health care on an existing case, the IM agency must give a Notice of Assignment: Child Support, Family Support, Maintenance, and Medical Support (DCF-F-DWSP2477, available in English and Spanish) to each applicant. Applicants and members are not required to sign this form in order to be eligible for health care programs. Exception: The agency does not need to provide the Notice of Assignment to health care applicants who apply via ACCESS since this information is included in the ACCESS application This page last updated in Release Number: 26-03 Release Date: 08/12/2026 Effective Date: 06/01/2026 9.2 Nursing Home, Hospital, and Long-Term Care Insurance 9.2.1 Nursing Home, Hospital, and Long-term Care Insurance Introduction All members must cooperate in providing TPL coverage information for nursing home, hospital, and long-term care insurance policies. All members must do the following: 1. Assign to the state of Wisconsin their rights to payments from a nursing home, hospital, or long- term care insurance policy (see SECTION 9.2.2 ASSIGNMENT). 2. Send any payments to the state of Wisconsin that they received from a nursing home, hospital, or long-term care insurance carrier while receiving Medicaid (see SECTION 9.2.3 RECOVERY OF PAYMENTS). Any nursing home, hospital, or long-term care insurance payments that exceed the amount that Medicaid has paid in benefits for that member will be refunded to that member. Terminate Medicaid eligibility for the individual who is not cooperating in providing TPL insurance information (see SECTION 9.1.2 TPL COOPERATION), unless they have good cause (see SECTION 9.1.4 TPL GOOD CAUSE CLAIM). 9.2.2 Assignment To assign hospital or long-term care insurance payments, the member must complete the Long-Term Care Insurance Policy – Assignment of Benefits form (F-01567) that requests all current or future payments be made payable to the state of Wisconsin. The member must send the completed Long-Term Care Policy-Assignment of Benefits form to his or her long-term care carrier and mail a copy to the following address: Wisconsin DHS TPL Unit PO Box 6220 Madison, WI 53784-6220 The long-term care carrier must mail payments to the following address: