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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 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:
| Note: | Shortening certification periods in an attempt to balance agency workload is not permissible. |
The member has the choice of the following methods for any Medicaid renewal:
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.
The member must include a valid signature at the time of renewal. This includes either signing telephonically, electronically or providing a handwritten signature on one of the following:
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.
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 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.
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, including health care assistance groups open with a suspended status.
The following Medicaid subprograms can be administratively renewed:
The following Medicaid subprograms cannot be administratively renewed:
SSI-related Medicaid, MAPP, and MSP can be administratively renewed if all members on the case have:
SSI-related Medicaid, MAPP, and MSP cannot be administratively renewed if any members on the case have or are:
| 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:
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.
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.
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.
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.
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 for the following health care programs:
This 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 due to lack of renewal and not for other reasons. Late renewals and renewal-related verifications must be accepted for up to three calendar months after the renewal month. Members whose health care benefits are closed more than three months due to lack of renewal must reapply.
Agencies must consider late submissions 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 health care certification date should be set based on receipt date of the signed renewal. If verification is required to complete the renewal, the member has 20 days to provide it.
| Example 1 | Jenny's renewal is due on January 31. She submits an online renewal via ACCESS on March 10. If the renewal is processed on the same day and verification is requested, the verification would be due on March 30. If she provides verification on or before this due date and meets all other eligibility criteria for Medicaid, her eligibility and certification period would start on March 1. Her next renewal would be due February 28 of the following year. |
| Note | The late renewal 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 20, she will need to reapply since she submitted her verification after the three-month period that started with her January renewal date and ended April 30. |
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 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 any month(s) of the eligibility determination. For example, if verification was submitted for a past month, the agency must request current verification, allowing the member 20 days to submit the verification.
| Example 2 |
Jenny's renewal is due on January 31. She completes her renewal on January 5, and a Verification Checklist is generated requesting income verification for the previous 30 days. Jenny does not submit the requested verification, and her Medicaid eligibility is terminated as of January 31. On April 27, she submits paystubs for April 10 and April 24. If she meets the eligibility criteria for Medicaid, her certification period will start on April 1, and her next renewal will be due March 31 of the following year. 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 she is requesting a backdate, verification must be requested for all backdated months. |
If a member has a gap in coverage because of a late renewal, they may request coverage of the past months in which the gap occurred. Backdated coverage under the late renewal policy is available to all health care members who meet program rules (see Section 2.8.2 Backdated Eligibility).
If a member requests coverage for past months during a late renewal, they must provide all necessary information and verification for those months (including verification of income and assets for all months requested) and must pay any required premiums to be covered for those months.
| Note: | QMB coverage is not retroactive. Members cannot receive backdated eligibility for this program. |
This page last updated in Release Number: 23-03
Release Date: 08/14/2023
Effective Date: 08/14/2023
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