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State of Wisconsin |
HISTORY |
The policy on this page is from a previous version of the handbook.
A renewal is the process during which all eligibility factors subject to change are reexamined and it is determined if eligibility continues. The group’s continued eligibility depends on its timely completion of a renewal. Each renewal results in a determination to continue or discontinue eligibility.
The first required eligibility renewal for a BadgerCare Plus case is 12 months from the certification month, except for the following:
CENs. The renewal date is 12 months from the date of birth.
Pregnant women. The renewal date is two calendar months after the date the pregnancy ends.
Note: Women in the BadgerCare Plus Prenatal Program lose eligibility on the date the pregnancy ends. However, they are automatically eligible for emergency services for two months after eligibility for BadgerCare Plus Prenatal Program ends (see Section 41.6 BadgerCare Plus Prenatal Eligibility End Date).
Deductibles. A renewal is not scheduled for a case that did not meet its deductible, unless someone in the case was open for BadgerCare Plus. For cases that did meet the deductible, the renewal date is six months from the start of the deductible period.
Note: For manually certified BadgerCare Plus cases, make sure the member receives a timely notice of when the renewal is due.
Review Dates for Time-Limited Benefits
BadgerCare Plus members are required to complete a renewal no earlier and no later than 12 months from their certification period. People whose benefits are time-limited (CENs, pregnant women, people who have met a deductible, or people in an extension) are required to complete a renewal at the end of their time-limited benefit unless they are on a case with other open BadgerCare Plus assistance groups. In this situation:
If the regular BadgerCare Plus assistance group has a renewal date after the end of the time-limited benefit certification period, the person enrolled in time-limited benefits will have his or her eligibility redetermined at the end of his or her certification period, but a full renewal is not required at that time.
If the regular BadgerCare Plus assistance group has a renewal date prior to the end of the time-limited benefit certification period, the time-limited benefit will remain open even if there is no renewal completed for the regular BadgerCare Plus assistance group. If a renewal is completed for the BadgerCare Plus assistance group, the length of the time-limited benefit certification period does not change.
Workers can complete an early renewal only if the member requests an early renewal. Once the member requests an early renewal, the renewal must be completed.
Note: Shortening certification periods in an attempt to balance agency workload is not permissible.
Most health care renewals received within three months of the renewal month can be processed as a late renewal instead of requiring a new application. This policy applies to the following subprograms:
BadgerCare Plus
EBD Medicaid
Institutional Medicaid
The policy applies to members receiving health care benefits based on a met deductible, but not to members with an unmet deductible.
Late renewals are only permitted for people whose eligibility has ended because of lack of renewal, and not for other reasons. Members whose health care benefits are closed for more than three months because of lack of renewal must reapply.
Agencies should consider late submission of an online or paper renewal form or a late renewal request by phone or in person to be a valid request for health care. The new certification period should be set based on the receipt date of the signed renewal. If verification is required during the completion of a late renewal, the member has 10 days to provide it.
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Example 1: Jenny’s renewal is due on January 31, 2016. She submits an online renewal via ACCESS on March 15, 2016. If the renewal is processed on the same day and verification is requested, the verification would be due on March 25, 2016. If she provides verification on or before this due date and meets all other eligibility criteria for BadgerCare Plus, her eligibility and certification period would start on March 1, 2016. Her next renewal would be due February 28, 2017. |
Note: The three-month period starts after the month the renewal was due. It does not restart when a late renewal has been submitted. If Jenny submits her renewal on March 15 but does not provide verification until May, she will need to reapply after the three-month period that started with her January renewal date.
If the BadgerCare Plus renewal was completed timely, but requested verifications were not provided as part of the renewal, BadgerCare Plus can reopen without a new application if these verifications are submitted within three months of the renewal month. The submission of the renewal-related verifications is considered a request for health care. Only the missing verifications must be provided. However, the verifications must include information for the current month of eligibility. If verification is submitted for a past month, a new Verification Checklist must be generated to request the current verification, allowing 10 days to submit the verification.
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Example 2: Jenny’s renewal is due on January 31, 2016. She completes her renewal on January 20, 2016, and a Verification Checklist is generated requesting income verification for the 30 days prior to January 20. Jenny does not submit the requested verification, and her BadgerCare Plus eligibility is terminated as of January 31, 2016. On April 27, 2016, she submits her paystubs for April 10 and April 24. If she meets the eligibility criteria for BadgerCare Plus, her certification period will start on April 1, 2016, and her next renewal will be due March 31, 2017. If she had submitted the verification of her income for January, a new Verification Checklist should be generated asking for verification of her current income for April. |
If a member has a gap in coverage because of his or her late renewal, he or she may request coverage of the past months in which the gap occurred. Backdated coverage under the late renewal policy is available to all BadgerCare Plus members who meet program rules, including children who would not otherwise qualify for backdated coverage because their income is too high (see Section 25.8.1 Backdated Eligibility). However, this does not change the rules for backdating at application.
If a member requests coverage for past months during a late renewal, he or she must provide all necessary information and verifications for those months (including verification of income for all months requested) and must pay any required premiums to be covered for those months.
The following process replaces the administrative renewal process that was in place for BadgerCare Plus and FPOS cases prior to January 1, 2014.
Based on federal requirements, health care eligibility must be redetermined once every 12 months based on information available to an agency. Agencies cannot require information from health care members during an annual renewal unless the information cannot be obtained through an electronic data exchange or the information from the electronic data exchange is not reasonably compatible with the information on file. The process of using electronic data exchanges for renewals is referred to as the administrative renewal process.
If information from electronic data exchanges validated information about a member’s income as currently recorded in CARES, additional information about income cannot be requested from the member at renewal. This includes member-reported information about earned income that is found to be reasonably compatible with earned income information obtained from SWICA and FDSH data exchanges, as well as any information about unearned income verified through SSA or UIB data exchanges. Unless reported otherwise, it is assumed during the administrative renewal process that household composition and tax filing status have not changed.
To be considered for an administrative renewal, a case must be due for renewal in the following month and have one or more qualifying BadgerCare Plus, FPOS, or EBD Medicaid assistance groups open.
Cases may be excluded from the administrative renewal process for a number of reasons.
A BadgerCare Plus or FPOS case is excluded from being administratively renewed if:
Any person on the case has or is any of the following:
An unverified or missing SSN
An unresolved Prisoner, UIB, or SOLQ-I discrepancy
A new discrepancy found through a data exchange during the administrative renewal process
An expired immigration status
An expired disability diary date
MAPP benefits with a work requirement waiver or Health and Employment Counseling enrollment
A presumptive disability
A Former Foster Care Youth turning 26 (this is because the person's income information has not been previously collected)
A pregnant woman whose due date is in or before the renewal month (this is because there is an anticipated change in household composition)
A CEN turning 13 months old (this is because the child is aging out of his or her current assistance group and may either lose eligibility or become eligible under a new assistance group)
Turning 19 or 65 years old
The case has or is any of the following:
Income that cannot be verified or is not found reasonably compatible through a data exchange (such as self-employment or room and meals income)
Tax deductions on file
A calendar year tax dependent for a past year
A pending health care assistance group (i.e., health care eligibility has not been confirmed for all people on the case)
Related unprocessed ACCESS items, including applications, program adds, renewals, change reports, and SMRFs
Related unprocessed PPRF or SMRF documents
An unresolved EPP
A met deductible
A BadgerCare Plus extension
A reason for exclusion from batch eligibility processes (for example, an eligibility override)
In review mode
A BadgerCare Plus or FPOS case is excluded from being administratively renewed if any of the following occur when CARES is running eligibility for the renewal:
A new EPP is generated as a result of a data exchange.
Health care or FPOS benefits pend.
Health care or FPOS benefits would be terminated for any person on the case.
A premium is now required, or the premium amount increased.
During the administrative renewal process, CWW will automatically do the following:
Select cases subject to administrative renewal
Verify and update information using data exchanges
Determine the new 12-month certification period for health care
Notify the member of the administrative renewal
Notify the member of his or her eligibility determination
The administrative renewal process will occur in the 11th month of a member’s certification period, prior to a 45-day renewal letter being sent. On the first Saturday of the 11th month, CARES will determine who qualifies for an administrative renewal and initiate a batch request through the RRV service through the FDSH to request Equifax data.
On the second Saturday of the 11th month, the following will occur:
CARES will determine who qualifies for an administrative renewal.
Data exchange updates will occur for SWICA, New Hire, and EVHI.
The existing batch process will update SSA and UIB data.
The RRV response with Equifax data will be processed.
Reasonable compatibility will be tested as applicable.
The administrative renewal process will run through a batch eligibility cycle to determine if the administrative renewal is successful or unsuccessful.
If new income information is identified from SSA or UIB during the administrative renewal process, the case will be updated with the new information. Income information obtained from SWICA or FDSH will be tested for reasonable compatibility (see Section 9.12 Reasonable Compatibility for Health Care).
For health care- and/or FPOS-only cases where a person in the household has current employment, the Begin Month on the Employment page will be updated to the current month. In addition, the wage verification code on the Employment page will be set to “Q?” if the existing verification code is not "?," "QV," "NV," "Q?," "?O," "WN," or "SP." These verification codes will allow CARES to test wages for reasonable compatibility. The income types and amounts will not be systematically updated. For cases that include programs other than health care and/or FPOS or for cases for which the administrative renewal is unsuccessful, the original wage verification code will be retained. Keeping the original verification code will ensure that other programs only have to verify wages when appropriate for their program rules.
Cases that pass the administrative renewal criteria after the eligibility batch run will go through the administrative renewal confirmation process. During the confirmation process the following will occur:
Case level review dates will be set.
A case comment will be added by CARES that states "Administrative Renewal completed."
The Interview Details page will display "Admin Renewal" as the interview type for health care and/or FPOS.
The Generate Summary Page will display "Admin Renewal" as the signature type.
The appropriate administrative renewal letter, with or without a case summary, will be generated and mailed. The letter will be stored in the ECF.
The Enrollment and Benefits Handbook will be sent to the member.
Most categories of health care will be renewed during the administrative renewal. For example, if a case is open for both BadgerCare Plus and MAPP without a premium and the programs have different renewal dates, both programs would be renewed and their renewal dates would be synced to the later of the two renewal dates. This does not apply to time-limited health care benefits (such as pregnancy-related BadgerCare Plus) because these benefits are not renewed for additional months. In addition, FPOS benefits will be renewed separately from other categories of health care, and the renewal date will not be synced, unless it is due for renewal at the same time as the other health care program(s).
If BadgerCare Plus and/or FPOS is successfully recertified through an administrative renewal, the member will be sent an administrative renewal letter with an attached case summary. The member must review the information on the case summary and report if any of the information is incorrect within 30 days of the mailing date on the letter. The member has the option to make changes on the summary and mail or fax it to his or her agency or to call his or her agency to report changes. When changes are applied to the case, a Notice of Decision will be sent and will include the message "Your health care renewal has been completed." If all of the information on the case summary is correct, the member will not need to take any other action.
Cases will go through a batch run on the second Saturday of the 12th month of the certification period, approximately 30 days after the administrative renewal. This batch run will generate a Notice of Decision, unless one has already been sent following the processing of a change or a renewal for another program(s).
Benefits may not be terminated or reduced (for example, being charged a greater premium amount) during the administrative renewal process based solely on information obtained from a data exchange. This includes information obtained from SSA, UIB, FDSH, or SWICA data exchanges. If benefits cannot be continued through the administrative renewal process, the case will be excluded from the administrative renewal process.
If the administrative renewal process was initiated, but not completed, any updates made to the case, with the exclusion of data exchange updates, will be undone, and the case will be returned to its original status. The member will be sent a 45-day renewal letter and a PPRF. The PPRF will include any SSA or UIB updates.
Members have at least 30 days to complete, sign, and return the PPRF or to complete their renewal by phone, in-person, or through ACCESS. Failure to complete a renewal by the end of the certification period will result in the termination of benefits.
Cases that have a successful administrative renewal remain subject to change reporting requirements. The administrative renewal letter instructs a member to review and report any changes to the attached case summary and informs him or her of the potential consequences for not reporting those changes. If a member does not correct information that is wrong and gets benefits that he or she should not get, the member is liable for any resulting overpayments. In addition, administrative renewal cases will receive a Notice of Decision that identifies program-specific change reporting requirements, as well as the potential consequences for not reporting changes timely. Changes reported for a case that has undergone an administrative renewal should be processed under existing policy.
Changes reported as part of a renewal for another program should also be applied to health care. The other program may require the person to verify his or her information. Once verification is received for the other program, the information should also be used for ongoing health care eligibility.
This page last updated in Release Number: 17-04
Release Date: 12/13/2017
Effective Date: 12/13/2017
The information concerning the BadgerCare Plus program provided in this handbook release is published in accordance with: Titles XI, XIX and XXI of the Social Security Act; Parts 430 through 481 of Title 42 of the Code of Federal Regulations; Chapter 49 of the Wisconsin Statutes; and Chapters HA 3, DHS 2 and 101 through 109 of the Wisconsin Administrative Code.
Publication Number: P-10171