State of Wisconsin Department of Health Services

HISTORY

The policy on this page is from a previous version of the handbook. 

3.1 Renewals

3.1.1 Renewals Introduction

A renewal is the process during which all eligibility factors subject to change are reexamined and a decision is made if eligibility should continue. 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 Medicaid case is 12 months from the certification month except for cases open with a deductible. A renewal is not scheduled for a case that did not meet its deductible unless someone in the case was open for Medicaid. For cases that did meet the deductible, the renewal date is six months from the start of the deductible period.

 

Note: For manually certified Medicaid cases, send a manual renewal notice 45 days prior to the end of the renewal month.

 

Agency Option

 

The agency may renew any case at any other time when the agency can justify the need. Examples include:

1. Loss of contact, or

2. Member request

 

Note: Shortening certification periods in an attempt to balance agency workload is not permissible.

3.1.2 Choice of Renewal

The member has the choice of the following methods for any Medicaid renewal:

1. Face-to-face Interview,

2. Telephone Interview.

3. Mail in: Mail in renewals can be submitted using the paper application (F-10101) or the pre-printed renewal packet generated through CWW . Cases requesting to complete a Mail-in renewal must be sent the pre-printed renewal packet if the case includes a blind or disabled child, or

4. ACCESS

3.1.3 Renewal Processing

A Medicaid eligibility renewal notice is generated on the first Friday of the 11th month of the certification period. The notice states that "some or all of your benefits will end" if a renewal is not completed by the end of the following month. Do not process a renewal until after adverse action in the month prior to the month of renewal.

 

Example 1: CARES sends out the renewal letter on July 7 for a renewal due in August, do not process the renewal prior to July 18.

 

Do not require a new Authorized Representative form at renewal if the person signing the renewal is the Authorized Representative on file.

 

If the renewal is not completed by the end of the certification period, the case will close. The closure notice is generated through CARES at adverse action in the renewal month.

3.1.4 Signature at Renewal

The member must include a valid signature at the time of renewal. This includes signing:

 

1. The paper application form,
2. The signature page of the Application Summary,
3. The ACCESS or FFM application form with an electronic signature, or
4. Telephonically.

 

The signature requirements for renewals are the same as those for applications. See Section 2.5 Valid Signature.

3.1.5 Administrative Renewals

The following process replaces the administrative renewal process that was in place for SSI -related Medicaid,   HCBW s, MLTC (including Family Care, Family Care Partnership, and PACE ), and MSP cases prior to February 1, 2017.

3.1.5.1 Administrative Renewals Introduction

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 the member’s income as currently recorded in CARES , additional information about income cannot be requested from the member at renewal. This includes earned income information that is found to be reasonably compatible with member-reported information, 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 has not changed.

3.1.5.2 Administrative Renewal Selection Criteria

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.

3.1.5.2.1 Medicaid Cases That Could Be Administratively Renewed

The following are Medicaid cases that could be administratively renewed:

• SSI-related Medicaid. SSI-related Medicaid cases must meet all of the following criteria to be selected for an administrative renewal:

• • Only have income that can be verified through a data exchange (for example, income from Social Security and/or UIB or employment income with a SWICA match or an Equifax match through the FDSH)

  • Have countable assets at or below 50% of the asset limit

  • Not have excess self-employment, child support/maintenance, or IRWE on file

• MAPP . MAPP cases must meet all of the following criteria to be selected for an administrative renewal:

• • Only have income that can be verified through a data exchange

  • Have gross income at or below 150% of the FPL and so would not have a premium

  • Have countable assets at or below 50% of the asset limit

  • Not have excess self-employment, child support/maintenance, IRWEs, special exempt income, or medical/remedial expenses on file

• MSP. MSP cases must meet all of the following criteria to be selected for an administrative renewal:

• • Only have income that can be verified through a data exchange

  • Have countable assets at or below 50% of the asset limit

  • Not have excess self-employment, child support/maintenance, or IRWEs on file

• Group A Community Waivers with eligibility based on SSI. Group A Community Waiver cases must be Group A eligible based on SSI eligibility to be selected for an administrative renewal.

3.1.5.2.2 Medicaid Cases That Cannot Be Administratively Renewed

The following are Medicaid cases that cannot be administratively renewed:

• SSI-related Medically Needy Medicaid with met or unmet deductibles
• MAPP with premiums
• Institutional Medicaid
• Group B and B+ Community Waivers
• Group A Community Waivers with eligibility based on 1619(b), BadgerCare Plus, EBD Medicaid, or Adoption Assistance

3.1.5.2.3 Exclusions From the Administrative Renewal Process

Cases can be excluded from the administrative renewal process for a number of reasons.

Exclusions During the Administrative Renewal Process

Cases are excluded from being administrative 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
  • Turning 19 or 65 years old
• The case has or is any of the following:
• • Income that cannot be verified or is not found reasonable compatible through a data exchange (such as self-employment or room and meals income)
  • A BadgerCare Plus assistance group with tax deductions on file
  • A BadgerCare Plus assistance group with a calendar year tax dependent(s)
  • A BadgerCare Plus Extension
  • A pending health care assistance group (i.e., health care eligibility has not been confirmed for all people in the case)
  • Related unprocessed ACCESS items, including applications, program adds, renewals, change reports, and SMRF s
  • Related unprocessed PPRF or SMRF documents
  • An unresolved EPP
  • A met deductible
  • A reason for exclusion from batch eligibility processes (for example, due to an eligibility override)
  • In review mode

Exclusions When CARES Runs Eligibility

Cases are excluded from being administrative 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.

3.1.5.3 Administrative Renewal Process

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 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.

3.1.5.3.1 Administrative Renewal Data Exchange Results

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.

 

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.

3.1.5.3.2 Successful Administrative Renewals

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 health care and/or FPOS can be successfully recertified through an administrative renewal (except for cases open only for Group A Community Waivers and/or QMB based on SSI eligibility), 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 from 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 the 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 does not need to take any other action.

 

If a successfully administratively renewed case is open only for Group A Community Waivers and/or QMB based on SSI eligibility, the member will be sent a different administrative renewal letter that does not include a case summary. Because these people are categorically eligible based on their SSI eligibility, the letter informs them that their benefits have been renewed because they continue to receive SSI. These members will not need to review a case summary and do 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).

3.1.5.3.3 Unsuccessful Administrative Renewals

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.

3.1.5.3.4 Change Reporting After Administrative Renewal

Cases that have a successful administrative renewal remain subject to their applicable 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 would be 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.

3.1.6 Late Renewals

Late renewals are only permitted for individuals whose eligibility ended because of lack of renewal and not for any other reasons for the following EBD programs:

 

• EBD Medicaid
• HCBW s
• Institutional Medicaid
• MAPP
• MSP ( QMB / SLMB / SLMB+ / QDWI ).

 

Late renewals and related-renewal verifications should be accepted for up to three calendar months after the renewal date. Members whose health care benefits are closed more than three months due to lack of renewal must reapply.

 

Consider late submissions of an online or paper renewal form or a late renewal request by phone or in person as a valid request for health care. The new health care certification date should be set based on receipt of the signed renewal. If verification is required to complete the renewal, the member will have 10 days to provide it.

 

If the health care renewal was completed timely but the requested verifications were not provided as part of the renewal, the health care program can be reopened without a new application if these verifications are submitted within three months of the renewal month. The verifications must include information for the current month of eligibility. If verification was submitted for a past month, a new Verification Checklist must be generated to request current verification. The member will have 10 days to provide it.

 

If a gap in coverage occurs because of a late renewal, the member may request coverage of the past month in which the gap occurred.  The member must provide all necessary information and verification for those months and must pay any required premiums to be covered for those months. For EBD Medicaid renewals, the member must provide the missing verification and verify assets or the current month if there was a gap in coverage.

 

Note: QMB coverage is not retroactive. Members cannot request backdated eligibility for this program.

 

 

 

This page last updated in Release Number: 17-01

Release Date: 05/05/2017

Effective Date: 05/05/2017

 

---

The information concerning the Medicaid program provided in this handbook release is published in accordance with: Titles XI and XIX of the Social Security Act; Parts 430 through 481 of Title 42 of the Code of Federal Regulations; Chapters 46 and 49 of the Wisconsin Statutes; and Chapters HA 3, DHS 2, 10 and 101 through 109 of the Wisconsin Administrative Code.

Notice: The content within this manual is the sole responsibility of the State of Wisconsin's Department of Health Services (DHS). This site will link to sites outside of DHS where appropriate. DHS is in no way responsible for the content of sites outside of DHS.

Publication Number: P-10030