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What is Medicaid Renewal and How Often Does it Occur?
Medicaid renewal, also called Medicaid redetermination or recertification, is a necessary part of being a Medicaid beneficiary, regardless of if you receive benefits through the regular state plan, get long-term home and community based services (HCBS) via a Medicaid waiver, or are on nursing home Medicaid. The Medicaid redetermination process ensures one is still eligible to receive Medicaid benefits, and in the case of many seniors and disabled persons, continue to receive Medicaid-funded long-term services and supports. Medicaid has income and asset (resource) limits for elderly recipients and the Medicaid agency wants to ensure that the individual continues to fall under those financial limits.
Medicaid beneficiaries must report any change in income or assets, even if it is not time for renewal of Medicaid benefits. This is because circumstances, such as an increase in income or an inheritance, can result in one being ineligible for Medicaid. Most states allow between 10 and 30 days to report any such changes. Failure to do so can result in the loss of Medicaid benefits, repayment of services / benefits for which Medicaid paid, fines, and even jail time.
Medicaid renewal for seniors and disabled individuals must occur at least every 12 months, but a state may choose do redeterminations more frequently. However, generally speaking, Medicaid redetermination is limited to once every 12 months. To be clear, adults aged 65 and over, persons eligible for Home and Community Based Services, those eligible for SSI, and institutionalized individuals in nursing homes all fall must renew their Medicaid.
What Does the Medicaid Agency Do During Renewal?
During Medicaid renewal, the Medicaid agency checks to ensure eligibility criteria that are subject to change are still within the eligibility thresholds. Specifically, monthly income and countable assets are checked to make sure they are still under the income and asset limits. Furthermore, Medicaid will check to ensure assets did not exceed the asset limit at any point during the year.
In practical terms, this means the Medicaid agency will review bank accounts, taxes, income, pension statements, the equity value of one’s home and any other financial documents that were reviewed during the initial Medicaid application.
There is some information that was provided at initial application that does not have to reverified. This includes one’s age, Social Security number, and citizenship.
What is Required of the Medicaid Beneficiary During Renewal?
In some cases, a Medicaid beneficiary may not have to do anything during the renewal process. This is because in some states and situations, the Medicaid agency may be able to process the entire Medicaid renewal electronically without requesting any documentation from the Medicaid recipient. (Learn more below under What is the Renewal Process). In other cases, the senior receiving Medicaid benefits may have to complete a redetermination form, either via paper, online, or in person, and may be asked to provide proof of income or resources.
Proof of income may include alimony check copies, award letters of benefits from SSI or the VA, tax forms, pension statements, or a letter of self-declaration of income when there is not another way to provide proof of income. Requested documentation related to proof of resources might include checking / savings accounts, certificates of deposit, money market accounts, stocks, bonds, retirement accounts, and cash surrender value of life insurance policies (copies of life insurance policy). If equity value in one’s home or car has changed, documentation may also be required.
How Does the Medicaid Renewal Process Work?
Medicaid renewal process is not consistent across all states and Medicaid groups. Below are the federal regulations that govern Medicaid renewals. Keep in mind, states do not have to comply to this redetermination process in its entirety when determining continued eligibility for persons who are elderly. Instead, this is a rough guideline as to how the renewal process might work.
For redetermination of benefits, states are required to utilize available electronic data sources to determine if the Medicaid beneficiary still meets the eligibility criteria. If it is determined that the individual is still eligible for benefits, the state must “automatically renew” that individual’s coverage without requesting any information from him / her. This process is also called an ex parte renewal, administrative renewal, or automated renewal. Please note; only if redetermination cannot be determined electronically by a state Medicaid agency, can paper documentation be requested.
A state may not always be able to complete an automated renewal. For example, in some situations, the Medicaid recipient’s income and / or assets may not be able to be verified electronically. As an example, rental income and self-employment are two types of income that cannot be verified via electronic databases. In the case where electronic sources indicate that a recipient’s income is over the income limit, Medicaid renewal cannot be automatically extended. Furthermore, if a recipient does not have a Social Security number, electronic databases will be of no use for verification of eligibility information.
Pre-Populated Renewal Form
If a Medicaid recipient’s continuing eligibility cannot be determined via automatic renewal, the state may send out a pre-populated form. This means that the state will fill in the information in which it already knows about the recipient, such as his / her name and the names of the other persons living in the household, and he / she will only need to complete the information that is unknown to the Medicaid agency. If any of the pre-populated information is incorrect, the individual must correct it.
To be clear, states are only required to send a prepopulated form to specific eligibility groups, those within the MAGI group, such as adults between the ages of 19 and 64 without children, pregnant women, and parents / caretaker relatives. For seniors who are aged 65 years and over, persons receiving long-term home and community based services, SSI recipients, and persons in Medicaid-funded nursing homes, sending a pre-populated renewal form is optional. However, the important thing to bear in mind is if a state cannot renew a beneficiary’s Medicaid eligibility automatically, a renewal form, pre-populated or not, will be sent to the Medicaid recipient.
The completed renewal form must be signed, dated, and returned to the Medicaid agency. The recipient is also instructed to provide any required documentation, such as proof of income and assets, along with the redetermination form. The beneficiary must be given a minimum of 30 days to do so. Alternatively, persons may be able to do their Medicaid redetermination online, via phone, or in person at one’s local Medicaid agency.
Does the Renewal Process Differ By State or Specific Medicaid Program?
Yes, the redetermination process varies based on the state and the Medicaid program in which one is enrolled. For instance, there are many different Medicaid eligibility groups, such as children, adults under age 65, parents and caretaker relatives, pregnant women, SSI-eligible persons, seniors aged 65+, aged and disabled that require long-term services and supports, and individuals that require nursing home care. Essentially, these groups are broken down into two categories: MAGI (Modified Adjusted Gross Income) and non-MAGI.
The MAGI group consists of children who are under the age of 19, pregnant women, parents and caregiver relatives, and adults without children who are between the ages of 19 and 64. The non-MAGI group, which is relevant for elderly individuals, includes SSI recipients, aged, blind and disabled individuals, persons receiving home and community based waiver services, and those receiving long term care services, such as nursing home care.
The Affordable Care Act (ACA) streamlined the redetermination process for the MAGI group throughout the states. However, these federal regulations are not necessarily required for elderly and physically disabled individuals.
What Happens When You Don’t Renew in Time?
If a Medicaid beneficiary does not complete the redetermination process in time, Medicaid benefits will cease and there will be a lack of coverage. However, under federal law, the individual has 90 days from the date in which the case was closed to provide the Medicaid agency with all of the required information. In this case, Medicaid benefits can be reinstated without the individual going through the application process again if he / she continues to meet the eligibility criteria. When this happens, Medicaid coverage in some states is retroactive. This means any accrued medical bills during the lapse in coverage that are generally covered by Medicaid will be covered. If one does not submit the necessary documentation and complete the redetermination process within the 90 day period, he / she has to reapply for Medicaid benefits and a gap in benefits is very likely to occur.
Medicaid Renewal Services
A public benefits counselor or a case manager, can be a great help during the redetermination process. These professionals commonly work at state Medicaid agencies, Aging and Disability Resource Centers, and Area Agencies on Aging and provide free assistance with filling out a renewal form and gathering and submitting required documentation. However, if a Medicaid recipient no longer meets the eligibility criteria, a public benefits counselor cannot assist. For example, if the beneficiary receives an inheritance and now have assets valued above the Medicaid limit, they will not receive assistance from a public benefits counselor.
If the individual enrolled in Medicaid using the help of a private Medicaid planner, that professional may provide assistance with the renewal process for free or for a minor annual fee.