A complete renewal is a full review of all eligibility factors that can change. The CAO must use the review to decide on each individual's ongoing eligibility and whether they are in the correct category.
The CAO must always review the following factors for the applicant/recipient group:
Ex Parte review (See Section 376.22)
Fax
Telephone
In-Person
Compass
Supporting verification documents can be submitted via:
Fax In-Person
Compass
The CAO must always review the following factors for an individual:
NOTE: If identity and citizenship were proven in the past, proof does not have to be given again at renewal, unless there is a change or information is inconsistent.
Members of the household, including the tax household.
Gross income (earned and unearned) of household members, parents, spouses, and tax household members.
Important: If no income or limited income is reported and the individual's situation is questionable, the CAO may ask for more information to show how the household lives on little or no income (See Chapter 378.311, Past Management).
Income expense deductions, including tax deductions and/or pre tax deductions for MAGI budgets
Resources (when necessary) (See Chapter 340, Resources)
Applications for Social Security numbers that were not already reported to the CAO
NOTE: Social Security numbers are re-validated systematically by the Social Security Administration during the renewal process. See Section 376.27, Social Security Administration (SSA) Renewal and Redetermination Verification (RRV) Interface Service at Renewal
Third-party resources (to update the third-party liability TPL file)
GA-related MA eligibility for PD and TD recipients
Answering a summons or bench warrant to appear as a defendant in a criminal court case for GA-related MA recipients (See Chapter 304, Appendix F for procedures for the criminal history inquiry.)
Medical expenses
The CAO must review all eligibility factors for the categories in which the household is enrolled.
As long as an individual cooperates during the renewal process, benefits can continue while the CAO is waiting for any needed proof. (See Chapter 378, Verification.)
Exception: Proof of an incapacity, if not already established, must be given so that a decision on ongoing MA eligibility can be made within 30 calendar days. Information about third-party resources must also be given within 30 calendar days.
When the CAO needs information to complete a renewal and the information cannot be obtained from an electronic data source, existing case record or the recipient is unable to obtain the information on their own, the CAO can use the optional Authorization for Release of Information (PA 4) form which is a consent form signed by the recipient that lets a third party give information to the CAO. The form is needed only when information or proof is needed from someone else for the individual's eligibility.
A PA 4 requires the signatures of all adults age 18 and over and those under age 18 who are emancipated.
Complete renewals can be done whenever one is needed, but they must be done at least as often as the following times:
For Modified Adjusted Gross Income (MAGI) a complete renewal must be done every twelve months.
42 CFR 435.916(a)
For Nonmoney Payment (NMP) a complete renewal must be done every twelve months.
NOTE: For monthly NMP spend-down, a new application is required if the applicant/recipient group does not get NMP for three months in a row.
For MAWD, a complete renewal must be done every twelve months. The MAWD premium amount is reviewed as part of SAR every six months.
For Healthy Horizons, a complete renewal must be done every twelve months.
For the Breast and Cervical Cancer Prevention and Treatment (BCCPT) program, a complete renewal must be done every twelve months for a woman who continues to need treatment for breast and cervical cancer or for a precancerous condition of the breast or cervix. A partial renewal is required for each woman enrolled in BCCPT whose first treatment was expected to last less than twelve months. The partial renewal must be done at the end of the first eligibility period.
For Medically Needy Only (MNO), a complete renewal must be done every twelve months. All MNO budgets must be enrolled in SAR, except for Long-Term Care (LTC) categories (TAN and TJN) (See Chapter 476 Renewal).
For NMP and MNO, a complete renewal must be done when adding a new individual other than a newborn. (See Section 376.27, Adding a Person to MA. An infant born to an MA or Children's Insurance Program (CHIP) eligible mother is automatically eligible on the date of birth and remains eligible until age one.
When MA is approved, e-CIS sets the renewal due date. The CAO must check the renewal due date and change it if it needs to be a different date. The system creates a renewal work item for the due date.
NOTE: There is no provision that extends the renewal due date longer than twelve months to allow the determination of other potential benefits, such as Title IV-E eligibility for children in Children and Youth Agency (CYA) or juvenile probation office (JPO) placement.
The renewal due date cannot be longer than one year.
A renewal is timely if it is completed within the calendar month in which it is due.
Ex Parte is defined as "an action by one party without the involvement of the other party in obtaining verification or information."
At renewal, all MA budgets must have an ex parte review completed and must be processed without requiring additional information from the individual, if the CAO is able to obtain necessary verification through available data sources or from the existing case record.
NOTE: Income information from a data source must be considered "reasonably compatible" in order to be used as verification (See Chapter 378.12, Reasonable Compatibility). If no income is known to the record and data exchanges return income which will not result in ineligibility or reduction in benefits, this information is reasonably compatible. The income should be adjusted to the record and a new 12-month certification period given.
Information from the case and/or electronic data sources must meet the following criteria to be used to process a renewal based on the ex parte review:
Case information is defined as previously verified eligibility factors that must be reviewed and re-verified at renewal to determine eligibility.
Reliable case information is defined as information verified within the last 6 months. If reliable case information is available to use for processing, other sources including EDX, imaging, etc. do not need to be reviewed.
Case information is not considred reliable if:
If there is a pending change reported, the CAO must attempt to use electronic data sources to verify the change before sending a renewal packet to the household.
Example: Case is parent (MG 91) and child (MG 00 C) open with an October 31 renewal date. Parent’s income was updated on July 5. Parent’s income is considered reliable.
NOTE: The Asset Verification System (AVS) is a data source that must be reviewed for all non-MAGI MA budgets that have a resource test. See the AVS Reasonable Compatibility Desk Guide, for more information about the use of AVS at renewal.
Employer information (name of employer and number of employers) from electronic data sources does NOT need to match employer information in the case record. If information from the electronic data sources is reasonably compatible, it must be used in the renewal determination. Any previous employer(s) not returned from electronic data sources should be finalized, and the new employer information added to the case record.
EXCEPTION: If employer is not known to any data source (Example: employer does not participate with TALX and is out-of-state and not available through Department of Labor and Industry), do not finalize. Verification must be provided if case information is not considered reliable.
Example: Case is parent (MG 91) and children (MG 00 C, MG 19 Y) open with a September 30 renewal date. Case record shows parent working at Wal-Mart. Electronic data sources only return information showing parent working at Target and Amazon with income that is reasonably compatible with case income. Employment record for Wal-Mart should be end dated and income from Target and Amazon entered and used to process the renewal in September.
The Enhanced Medical Assistance Renewal (EMAR) process has two functions:
Automated Renewals - Renew MA benefits systematically using electronic date sources.
Automated Scheduling - Generate and send out renewal packets if benefits cannot be renewed systematically.
NOTE: If a case has MA in addition to other benefits (SNAP and/or TANF), the case does not complete the EMAR process and the renewal is scheduled by the worker. See Section 376.243, Manually Scheduled Renewal - Combination Case.
In addition, cases that are not processed through AR or AS must be manually scheduled by a caseworker.
Each renewal packet is based on the categories that are due for renewal. Each packet has certain forms that are required. When manually scheduling a renewal packet, the caseworker can select other forms that the recipient may need to fill out. (For more information, see (Appendix B, Automated Renewal Forms.)
The Automated Renewal (AR) process within EMAR begins 90 days prior to the MA budget’s renewal date. A Change Reporting Flyer (CM 537) is mailed to the household. The flyer reminds the recipient to report any changes that may impact eligibility.
Approximately sixty days before the renewal date, the AR process begins by identifying cases with MA-only budgets due for renewal.
Example: An MG budget has a renewal date of 7/31. The Change Reporting Flyer is generated around 5/1. The Automated Renewal process begins the first full weekend in June.
During the AR process, the system uses information available on the case and through electronic data sources to review for ongoing MA eligibility. If the system can make a determination, MA is renewed, and a new eligibility notice is issued. No further action is needed by the CAO or the recipient.
If there is not enough information available in the case or through electronic data sources OR the information would make the individual move to a lower level of coverage OR information would make the individual ineligible for MA, the case is not renewed automatically. It will move to Automated Scheduling (AS) or Manual Scheduling (MS).
376.232 Automated Scheduling (AS)
If a case cannot be renewed automatically during the Automated Renewal (AR) process, the system will automatically generate a pre-populated renewal form. The pre-populated information is pulled from the existing case in eCIS. Information that is pre-populated includes:
Demographic information (not including SSN)
Income information
Resource information
All automatically scheduled forms are generated with a 30-day due date.
NOTE: The CAO must not close MA budgets prior to the 30-day due date for the renewal packet.
If the system encounters an issue and cannot automatically schedule the packet, the worker will be assigned the work item to manually schedule the packet.
If a renewal packet cannot be sent via Automated Scheduling (AS), the renewal form must be manually scheduled through Case Management by the CAO.
The CAO must give 30 days for the individual to return the packet and all necessary verification.
NOTE: The CAO must not close MA budgets prior to the 30-day due date for the renewal packet.
Case Management provides two types of processes for manually scheduled forms:
Quick Process
The Quick Process lets the CAO schedule renewals for several cases at the same time. The CAO enters the packet due date. The CAO can select any optional forms that may be needed.
Detail Process
The Detail Process lets the CAO view each case in detail. The Detail Process gives the CAO the chance to include future budgets in the current renewal process. The CAO may also change the packet mailing address or the mailing date.
After the CAO processes using the Quick Process or the Detail Process, the AR system pulls, prints, packages, mails the renewal packets and automatically enters a case narrative including the due date.
The CAO must review the household’s situation for ongoing eligibility by following the steps outlined in the below subsections.
These steps are also outlined in the Ex Parte Review Desk Guide.
All MA budgets are renewed at the same time.
Exception: Eligibility for MAWD (PW00/66), TMA (MG71), and BCCPT (PH20) budgets must not be reviewed prior to renewal date.
For Manually Scheduled (MS) renewal packets, begin with Section 376.241, Step 1- Ex Parte Review Before Generating MA Renewal Packet (Pre-Packet Review).
For Automatically Scheduled (AS) renewal packets, begin with:
Section 376.243, Step 3A - Renewal Packet Returned Complete
OR
Section 376.244, Step 3B - Renewal Packet Not Returned or Returned Incomplete (Post-Packet Review)
If a renewal packet has not been sent via Automated Scheduling (AS), the CAO must first complete an ex parte review of all MA budgets (See Section 376.22, Ex Parte Review) before generating a renewal packet.
A renewal can only be processed for MA based on the ex parte review in this step if the eligibility result of processing the renewal would show:
REMINDER: As part of the ex parte review, it is very important to review for disability-related MA, including MA for Workers with Disabilities and Children with Special Needs (PH 95). The CAO must review the case to see if initial disability verification or documentation needed for the Medical Review Team has been provided, and review data exchanges to see if the Social Security Administration has made a disability determination.
The CAO’s next action will depend on the case composition and the outcome of the ex parte review:
All MA Recipients Eligible Based on Ex Parte Review
If all MA recipients in the household remain eligible for MA at the same or higher benefit/coverage level based on the ex parte review, the CAO must:
REMINDER: If data source income information will result in a reduction in benefits or budget closure, an ex parte recertification cannot be completed, and a renewal packet must be mailed.
If no income is known to the record and data exchanges return income which will not result in ineligibility or reduction in benefits, this information is reasonably compatible. The income should be adjusted to the record and a new 12-month certification period given.
All or Some MA Recipients NOT Eligible Based on Ex Parte Review
If any MA recipients in the household would not remain eligible for MA at the same or higher benefit/coverage level based on the ex parte review, the CAO must:
376.242 Step 2 - Generate Renewal Packet
If MA could not be renewed for the entire household via ex parte review prior to generating a renewal packet (See Section 376.241, Step 1- Ex Parte Review Before Generating MA Renewal Packet (Pre-Packet Review) the CAO must:
NOTE: The CAO must not close MA budgets prior to the 30-day due date for the renewal packet.
REMINDER: Renewal dates for open programs on a case should be aligned whenever possible. See Budget Alignment and Certification Period Desk Guide for guidance when scheduling renewals.
NOTE: The renewal form must be signed on the Rights and Responsibilities page to be considered signed.
376.243 Step 3A - Renewal Packet Returned Complete
A renewal packet is considered complete at this step if all verification needed to make an eligibility determination for all MA recipients in the household is returned with the renewal packet and/or it is available through electronic data sources.
How to proceed at this step will be determined by whether the renewal form is signed or unsigned.
NOTE: The renewal form must be signed on the Rights and Responsibilities page to be considered signed.
Renewal Form Signed
If the renewal packet is returned complete and signed, the CAO must t process the renewal as indicated in Section 376.246, Processing a Renewal Packet.
Renewal Form Unsigned
If the renewal packet is unsigned the CAO will take action based on whether all verification is available:
376.244 Step 3B - Renewal Packet Not Returned or Returned Incomplete (Post-Packet Review)
If the renewal packet is not returned or is returned incomplete, an ex parte review MUST be completed for ALL MA budgets before taking action to close for failing to provide a renewal packet or required verification. (See Section 376.22, Ex Parte Review)
This ex parte review is in addition to the first ex parte review (if applicable) discussed in Section 376.241, Step 1- Ex Parte Review Before Generating MA Renewal Packet (Pre-Packet Review).
During this ex parte review, if the information obtained during the review would cause any of the outcomes listed below for the individual, a renewal can be processed:
The CAO’s next actions depend on the outcome of the ex parte review:
All MA recipients in the household would be eligible as described by the criteria above for MA.
The CAO must process the renewal as indicated in Section 376.246, Processing a Renewal Packet.
All MA recipients in the household would not remain eligible as described by the criteria above.
The CAO must process according to Section 376.247, Closing MA at Renewal.
Some MA/CHIP recipients in the household would remain eligible as described by the criteria above for MA/CHIP, but some recipients would be ineligible.
Example: Household is parent (MG 91) and child aged three (MG 00 C). A renewal packet is generated, but not returned. Based on an ex parte review, income is available on data sources and shows income at 145 percent of the Federal Poverty Income Guidelines (FPIG).
This income is over the limit for MG 91 (133 percent FPIG) but is under for the child (157 percent FPIG).
When processing in eCIS, the CAO must:
NOTE: For individuals who remain eligible for MA, ensure renewal is processed per Section 376.246, Processing a Renewal Packet.
For individuals who are being closed for MA, ensure closure is processed per Section 376.247, Closing MA at Renewal.
376.245 Step 3B – Allowable Program Changes When Conducting an Ex Parte Review Before Case Closure (Post-Packet Review)
The following movements CAN be made via an ex parte review only if a renewal packet is not returned or is returned incomplete:
NOTE: If an ex parte review before closure cannot be completed, terminate MA based for failure to complete the renewal process. Instead, complete the MA Closure Checklist (PA 1961) and MA should be closed with reason code 042 (Failure to Furnish Required Information).
Movement Within MA
If a renewal packet is not returned or is returned incomplete and the ex parte review before closure indicates either of the following, the renewal can be processed based on information found via data sources during the ex parte review:
Example: Individual receiving MA in a PH 80 D category. A renewal packet is generated but not returned by the due date. The CAO completes an ex parte review before closure and data sources show household income at 115 percent FPIG. Review also shows resources totaling $1,300.
CAO Action: The CAO will complete a “Reapplication” workflow using the data source income and resources. The individual will transition from PH 80 D to TJ 65.
MA to CHIP
If a renewal packet is not returned and the ex parte review before closure indicates either of the following for a child under age 19, the renewal can be processed using the data source income:
Example One: A child is receiving MA in an MG 00 C category. A renewal packet is generated but not returned by the due date. The CAO completes an ex parte review before closure and data sources show household income at 175 percent FPIG.
CAO Action: The CAO will complete a “Reapplication” workflow using the data source income. The child will transition from MG 00 C to CHP 00.
Example Two: A child is open for MA in an MG 00 Y category. A renewal packet is generated but submitted incomplete. The CAO completes an ex parte review before closure and data sources show household income at 275 percent FPIG.
CAO Action: The CAO will complete a “Reapplication” workflow using the data source income. The child will transition from MG 00 Y to CHP 02.
Example Three: A child (age eight) is receiving MA in an MG 00 Y category. A renewal packet is generated, but not returned by the due date. The CAO completes an ex parte review before closure and the data sources show household income at 350 percent FPIG.
CAO Action: The CAO will complete a “Reapplication” workflow using the data source income. The child will transition from MG 00 Y to CHP 04.
376.246 Processing a Renewal Packet
If all verification necessary for an eligibility decision is provided with the renewal packet or is available through electronic data sources/EDX, the CAO must process the renewal, the CAO will take the following steps to process the renewal:
NOTE: If some, but not all, household members can be renewed see system processing information under heading “Some but Not All MA/CHIP Recipients Eligible Based on Ex Parte Review” in Section 376.244 Step 3B - Renewal Packet Not Returned or Returned Incomplete (Post-Packet Review).
NOTE: If income is not reported on the renewal form and is found on data exchanges, the unreported income is considered reasonably compatible if it does not result in total record income that closes or reduces benefits.
NOTE: If information is reported on the renewal form and verification of that information was not requested on the PA 253 that accompanies the renewal form and is not available through electronic data sources/EDX or the case record, contact the household for verification and allow a minimum of 10 days to provide the needed information.
If necessary, the CAO must help the individual(s) get proof, or set up a plan for the individual(s) to get proof. Except when the caseworker suspects fraud, they must try to let the individual(s) know before contacting any third parties. The CAO does not need to get proof of eligibility factors that have already been proven and are not likely to change (such as SSN, birth date, identity, or citizenship) unless the caseworker has an indication that the current information may have changed or is incorrect.
NOTE: For COMPASS renewals a copy is not necessary as the recipient must check a box to indicate that they read and understood the Rights and Responsibilities information prior to submitting the application.
NOTE: The renewal date for MA can be shortened for alignment but cannot be extended past the 12-month period.
The requirement to align MA budget renewal dates does not apply to the following MA budget exceptions:
NOTE: Renewal dates for budgets not listed above can be shortened to align with exempted budgets.
If the renewal packet is not returned or is returned incomplete and all necessary verification is not provided by the household or available through electronic data sources/EDX, the CAO must follow the steps below to close MA.
NOTE: If some, but not all, household members can be renewed see system processing information under heading “Some but Not All MA/CHIP Recipients Eligible Based on Ex Parte Review” in Section 376.244 Step 3B - Renewal Packet Not Returned or Returned Incomplete (Post-Packet Review).
REMINDER: MA budgets that are not due for renewal cannot be closed for failing to provide a renewal form.
Any MA budget(s) not due for renewal which were scheduled for purposes of alignment should not be closed for failure to return the renewal packet.
In order to close individual MA budgets but allow others to remain open, workers should instead navigate to the “Individual Program Request” screen, deselect the appropriate individuals, and then use the dropdowns on the notice screen to select the appropriate reason, option, and type codes.
REMINDER: The caseworker must submit the completed checklist to their supervisor for review prior to taking action to close MA. The MA Closure Checklist (PA 1961) must be scanned to the case record after the supervisor has reviewed and signed the checklist.
NOTE: The CAO must ensure that the 30-day due date has passed prior to closing any MA budgets.
A new application is not required for individuals who completed the required renewal form and ask for MA to be reopened, request reconsideration, ask for a new application, and/or submit required verification within 90 days of the date of benefits closure. See Section 379.3 Reopening Benefits that were Closed at Renewal.
To continue to be eligible, the individual or their representative must take the following actions:
1. Complete all forms to the best of their ability, and sign renewal form on the Rights and Responsibilities page.
2. Provide the information needed to complete the renewal.
3. Provide the information needed to complete the third-party liability form. Information about third-party resources must be provided within 30 days after each renewal review.
4. If sent, sign a PA 4 to let the CAO get information from third parties if more information or proof is needed to decide on ongoing eligibility.
A new application form, a renewal form, or a COMPASS application can be used to add an individual (other than a newborn) who was not previously known or in the existing household record. The payment name or that individual’s representative must complete the application and turn in all necessary papers of proof with the application. The CAO must update the case record. The completed form serves as an application for the individual who is being added and as a renewal for the rest of the individuals in the record.
NOTE: A change of status for a household member who is in the record but is not getting benefits requires a complete review of all eligibility factors for all household members. A new application form is not required.
EXCEPTION: A newborn is automatically eligible for one year as long as the mother was eligible for MA or CHIP on the day the child was born. The CAO must set a renewal due date for twelve months from the date of birth. A renewal is not needed until the newborn reaches their first birthday. When the child reaches age one, the CAO must process a renewal to determine whether the child remains eligible for MA. This redetermination occurs no later than the first work day of the week after the child’s birthday. (See Section 338.41, Medical Assistance for Newborns, for complete information on approving medical benefits for newborns.)
55 Pa. Code § 141.81(a)(8)(ii)
For MNO, the CAO must begin a new six-month eligibility period when an individual is added.
376.27 Social Security Administration (SSA) Renewal and Redetermination Verification (RRV) Interface Service at Renewal
DHS sends a monthly bulk request file with demographic information and SSNs of MA recipients to the Social Security Administration (SSA) through the Renewal and Redetermination Verification (RRV) service as part of the EMAR process.
SSA provides a response file that contains codes based on whether the information provided through the DHS file is successfully matched to SSA information. Based on the code returned, the SSN verification field will be automatically updated in the Master Client Index (MCI).
The chart below lists the SSA response codes, SSA response descriptions and the SSN verification that will be updated based on the code:
|
SSA Reason Code |
SSA Response Description |
SSN Verification Code |
|
A |
Verified: SSN, Name, and DOB verified |
7 - Validation (system entered) |
|
B |
Not verified: Input SSN does not exist on Numident, marked for deletion, or inaccessible |
2 - Unverified/Pending Verification |
|
C |
Not verified: SSN exists; no match on Name or DOB |
2 - Unverified/Pending Verification |
|
D |
Not verified: SSN exists; match on Name but not on DOB |
2 - Unverified/Pending Verification |
|
E |
Not verified. SSN exists; match on DOB but not on Name |
2 - Unverified/Pending Verification |
If the code is updated to “7 - Validation (system entered),” the match was successful and no further information is needed.
If the code is updated to “2 - Unverified/Pending Verification,” a workload dashboard alert will be created to prompt review of the individual’s demographic/SSN information.
When the RRV returns a response from SSA that updates the SSN verification to “2 - Unverified/Pending Verification,” an SSN 020 alert will be created.
The “Notes” section of the SSN 020 alert will contain the SSA reason code and the current demographic information available in MCI for the individual.
The County Assistance Office (CAO) must address the discrepancy based on current policy in Chapter 950 (Enumeration) of the Supplemental Handbook.
The alert will be worker cleared and will provide the caseworker 45 days to contact the recipient to resolve the SSN discrepancy and update the Demographic Screen in eCIS Case Processing. More time can be allowed if the individual is cooperating in obtaining information.
Updated April 24, 2025, Replacing September 19, 2023