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• Routine transactions such as notification of an address change, notification of death or divorce of a remainder beneficiary, and other similar circumstances. • Changes that occur based on terms of the annuities that existed prior to January 1, 2009, and which do not require a decision, election, or action to take effect. • Changes beyond the control of the individual, such as a change in law, a change in the policy of the issuer, or a change in the terms based on other factors, such as the issuer’s economic status. 16.12.3.1 Annuity Disclosure For annuities purchased or substantively changed after January 1, 2009, an annuity disclosure form (Annuity Information - Disclosure, F-10192) must be completed for each annuity owned by the LTC applicant/member or their community spouse. If the LTC applicant/member or their community spouse does not complete the annuity disclosure form, they are ineligible for Medicaid coverage of long-term care services for failure to provide requested information. 16.12.3.2 Remainder Beneficiary Designation For annuities purchased or substantively changed after January 1, 2009, the annuity contract must name the State of Wisconsin Estate Recovery program as the remainder beneficiary in the first position, or in second position if a community spouse or minor or disabled child is named in the first position, unless it is verified that the annuity has no death benefit. To fulfill this requirement, the annuity owner must complete and submit the Medicaid Annuity Beneficiary Designation form (F-10191) to the IM agency. The form must be completed when the annuity is disclosed even if the State of Wisconsin Estate Recovery program is already named as the appropriate remainder beneficiary on the annuity contract. If the completed F-10191 is received by the due date, the eligibility determination must be completed and the completed F-10191 along with the Medicaid Issuer of Annuity - Notice of Obligation form (F- 10190) must be sent to both the annuity issuer and the Wisconsin Medicaid Estate Recovery program. If the LTC applicant/member or spouse fails to cooperate with naming the state as remainder beneficiary when required, a divestment penalty period will be imposed. The divested amount is the full purchase price of the annuity. 16.12.3.3 Notice of Obligation to Annuity Issuer Once the state has been designated as the remainder beneficiary, the annuity issuer must notify the agency about any changes made to that annuity to ensure the annuitant does not change the terms of the annuity beneficiary designation at a later date. The issuer acknowledges this obligation by completing and returning the Medicaid Issuer of Annuity - Notice of Obligation form (F-10190). When the IM agency receives a completed F-10190, or any other subsequent annuity information from the annuity issuer, it must be sent to the Estate Recovery program.

This page last updated in Release Number: 25-03 Release Date: 08/13/2025 Effective Date: 08/13/2025