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. MemberA recipient of Medicaid; formerly referred to as a "client." 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 CWWCARES Worker Web. 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 either signing telephonically or signing one of the following:

• The paper application form
• The signature page of the Application Summary
• The ACCESS or FFMFederally-Facilitated Marketplace application form with an electronic signature

The signature requirements for renewals are the same as those for applications (see Section 2.5 Valid Signature). The signature requirements do not apply to people whose renewal is completed through the administrative renewal process.

3.1.5 Administrative Renewals

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 an administrative renewal.

If information from electronic data exchanges validated information about the member’s income as currently recorded in CARESThis system supports the income maintenance operations for DHS and DCF. CARES is used to determine eligibility, issue benefits, track premium payments, and manage support for BadgerCare Plus, EBD Medicaid, W-2, Child Care, and Work Programs., 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 SSASocial Security Administration. A federal agency which administers the SSI, OASDI, and Medicare programs. or UIBUnemployment Insurance Benefits 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 and Exclusions

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 EBDElderly, Blind, or Disabled Medicaid assistance groups open, including health care assistance groups open with a suspended status.

The following Medicaid subprograms can be administratively renewed:

• SSI-related Medicaid
• MAPP without premiums (income up to and including 100 percent of the FPL)
• MSP
• Group A Community Waivers with eligibility based on SSI

The following Medicaid subprograms cannot be administratively renewed:

• SSI-related Medically Needy Medicaid with met or unmet deductibles
• MAPP with premiums (income over 100 percent of the FPL)
• 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

SSI-related Medicaid, MAPP, and MSP can be administratively renewed if all members on the case have:

• Only income that can be verified through a data exchange (for example, income with a SWICA match or Equifax match through the FDSH), or only Social Security or Unemployment income
• Countable assets at or below 50% of the asset limit

SSI-related Medicaid, MAPP, and MSP cannot be administratively renewed if any members on the case have or are:

• Income or deductions that cannot be verified through a data exchange (for example, self-employment, in-kind income, child support/maintenance, or IRWEImpairment-Related Work Expensess)
• An unverified or missing SSNSocial Security number
• An unresolved Prisoner, UIB, or SOLQ-IState Online Query Internet discrepancy
• 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
• Persons turning 19 or 65 years old

Note:

Members who receive SSI and SSI MA but are open in CARES for Group A Community Waivers and/or QMB will go through administrative renewal unless the case is in review mode. The criteria listed above do not apply to and will not exclude these types of cases from the Admin Renewal process.

Medicaid also cannot be administratively renewed if anyone on the case is receiving BadgerCare Plus or Family Planning Only Services benefits and is excluded from administrative renewal for a reason listed in BadgerCare Plus Eligibility Handbook 26.1.3.2.

Health care will not be successfully administratively renewed if any of the following occur during the administrative renewal process:

• A new Error Prone Profile (EPP) is generated
• A new discrepancy if found through a data exchange
• A new or increased premium is required
• Health care or FPOS benefits would pend or terminate for any person on the case
• Related unprocessed items are found, such as applications, change reports, renewals, or FoodShare Six Month Report forms

3.1.5.3 Administrative Renewal Process

The administrative renewal process begins in the 11th month of a member’s certification period. CARES determines who qualifies for an administrative renewal, verifies and updates information based on data exchanges, tests employment income and SWICA and FDSH results for reasonable compatibility, and runs through batch eligibility. See Process Help 4.7 Administrative Renewals.

3.1.5.3.1 Successful Administrative Renewals

Cases that have a successful administrative renewal will have health care eligibility redetermined and will be certified for a new 12- month certification period. The member will be sent a letter notifying them that their eligibility has been renewed, along with a case summary (except for cases open only for Group A Community Waivers and/or QMB based on SSI eligibility). 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. The member can make the changes on the summary and mail or fax it to their agency, or they can report their changes through ACCESS or by phone. If all of the information on the case summary is correct, the member does not need to take any other action. Members who have their health care administratively renewed will be sent a Notice of Decision.

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 members 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.

3.1.5.3.2 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, and the member will be sent a 45-day renewal letter and a Pre-Printed Renewal Form (PPRF). The member will have at least 30 days to complete, sign, and return the PPRF or to complete their renewal by phone, in-person, or through ACCESS.

3.1.5.3.3 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.

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 EBDElderly, Blind, or Disabled programs:

• EBD Medicaid
• HCBWHome and Community-Based Waivers
• Institutional Medicaid
• MAPPMedicaid Purchase Plan
• MSPMedicare Savings Programs. Assistance to help pay coinsurance, premiums, and deductibles for Medicare beneficiaries who are also one of these types of Medicaid recipients: QMB, SLMB, SLMB+, or QDWI. This has also been called "Medicare buyin," "buy in," or "Medicare Premium Assistance (MPA)." DHS is using the term "MSP" to refer to this type of assistance. (QMBQualified Medicare Beneficiary/SLMBSpecified Low-Income Medicare Beneficiary/SLMB+Specified Low-Income Medicare Beneficiary Plus/QDWIQualified Disabled and Working Individual).

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 for the current month if there was a gap in coverage.

Note:

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

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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