A complete renewal is a full review of all eligibility factors that can change. The CAO must use the review to decide on each applicant/recipient group member’s continued eligibility and whether they are in the correct category.
Since an interview is not required, the renewal can be
completed by ex parte review mail, fax, telephone, in-person, or COMPASS.
If necessary, the caseworker can contact the household for information
if information cannot be obtained from an electronic data source or from
the existing case record.
The CAO must always review the following factors for the applicant/recipient group:
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 the applicant/recipient group 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 for MAGI budgets
Resources (when necessary) (See Chapter 340, Resources)
Applications for Social Security numbers that were not already reported to the CAO
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 continued 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 client 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 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) applicant/recipient groups, a complete renewal must be completed every twelve months.
42 CFR 435.916(a)
For Nonmoney Payment (NMP) applicant/recipient groups, 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 an Applicant/Recipient Group. 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.
Reminder: Before taking any action to close an MA budget at renewal with reason code 042 (Failure to Furnish Required Information), the caseworker must complete an MA Closure Checklist (See Appendix C, MA Closure Checklist). The caseworker must submit the completed checklist to their supervisor for review prior to the case closing. The completed MA Closure Checklist must be scanned to the case record after the supervisor has reviewed and signed the checklist.
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.
Social Security Administration (SSA) Renewal and Redetermination Verification (RRV) Interface Service at Enhanced Medical Assistance Renewal (EMAR), OPS180305 (Published March 22, 2018)
The Enhanced Medical Assistance Renewal (EMAR)
process has two functions:
Automated Renewals - Renew MA benefits systematically using electronic date sources.
Automated Scheduling - Create 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.
The system creates each packet based on the categories that are due for renewal and whether the renewal is to be done by mail-in, telephone, or a face-to-face interview. Each packet has certain forms that are required. The caseworker can select other forms that the client may need to fill out. (For more information, see (Appendix B, Automated Renewal Forms.)
Within the EMAR process, renewal packets are either manually generated by a caseworker, or automatically scheduled without caseworker action.
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.
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 information would make the individual ineligible for MA, the case is not renewed automatically. It will move to Automated Scheduling (AS).
376.232 Automated Scheduling (AS)
If a case contains MA-only budgets and 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 case contains MA along with other programs (such as TANF or SNAP), or if the case fails the Automated Scheduling (AS) process, 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 continued eligibility. The renewal process can be completed by:
Ex parte review (See Section 376.22)
Receipt of the renewal form by mail, fax, or walk in.
The COMPASS renewal process.
All MA budgets are renewed at the same time.
NOTE: Eligibility for MAWD (PW00/66), TMA (MG71), and BCCPT (PH20) budgets must not be reviewed prior to renewal date.
If a case contains MA only and a renewal packet has not been automatically scheduled, the CAO must first complete the following steps before generating a renewal packet:
1. Complete an ex parte review of all MA budgets (See Section 376.22, Ex Parte Review).
2. If all information necessary to complete a renewal of MA is available through data sources or the case record, process the renewal without requiring any further information from the individual (s). If all information is not available through data sources or the case record, continue to step 3.
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.
3. Send a renewal packet to the household and allow a minimum of 30 days for the household to return the renewal packet (See Section 376.232, Manually Scheduled Renewals).
Note: The CAO must not close MA budgets prior to the 30 day due date for the renewal packet.
When the manually scheduled renewal packet is received from the household, the CAO must:
1. Review the renewal form to make sure it is complete.
Note: A form must be signed on the Rights and Responsibilities page to be considered complete. If the signature is the only item needed, the CAO will reach out for a signature.
2. Review IEVS information and electronic data sources for all individuals associated with applicant or
recipient.
3. Review and confirm all eligibility factors.
If all necessary information required to process the renewal was requested on the PA 253 that accompanies the renewal form and that information was not provided and is not available through electronic data sources, complete the MA Closure Checklist and close the MA budget for failure to provide information (reason 042) with a 15-day advance notice.
Note: If income not reported on the renewal form 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.
Reminder: The caseworker must submit the completed checklist to their supervisor for review prior to the case closing. The completed MA Closure Checklist must be scanned to the case record after the supervisor has reviewed and signed the checklist.
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 data sources 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.
4. When a delay in providing information is due to a third party and the individual(s) is cooperating, the CAO must continue benefits and review the progress of getting proof and the individual's cooperation every thirty days.
5. For GA-related MA categories, review the client's criminal history inquiry information. (See Chapter 304, Appendix C for procedures.)
6. If there are other possible resources and income, including third-party resources (health insurance coverage), contact the individual and discuss them.
7. Look at the individual's social service needs and plans. Review DHS's services and those of other agencies that eligible clients can get.
8. Make sure the individual(s) gets a copy of the Rights and Responsibilities page from the application.
Note: For COMPASS renewals a copy is not necessary as the client must check a box to indicate that they read and understood the Rights and Responsibilities information prior to submitting the application.
9. Review the case record to determine if all budgets are aligned with a common renewal date. The renewal due date for all budgets in a case record must be aligned. If MA budgets are the only budgets open in a case, align all MA budgets to the same renewal date when processing the renewal.
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:
MA-TMA budgets (MG71)
MA-MAWD budgets (PW/PI)
MA-BCCPT budgets (PH20)
Other MA budgets that have a specific time period that the budget must be open (examples: pregnant women, newborns, continuous eligibility for children under age 4 and certain MA spend-down budgets).
NOTE: Renewal dates for budgets not listed above can be shortened to align with exempted budgets.
10. Process the renewal in the system and determine ongoing MA eligibility. Make sure eligibility, renewal due date, and case record information is updated.
11. Ensure that the correct notice is sent to the individual.
12. Enter a case comment in the system.
When the renewal form is not received from the individual the CAO must:
1. Confirm that the renewal form and verification information have not been received in the CAO by the renewal packet due date. Review Imaging in eCIS to determine if the packet was received.
2. Confirm that the renewal form was generated and mailed to the recipient.
3. If more than one individual has active MA, review record for any individuals whose budget could be renewed through ex parte.
Note: If an individual is subject to a resource test, an ex parte review should be completed prior to closure regardless of number of active MA budgets on the record as AVS information is not available for review prior to scheduling the renewal packet.
4. If there has been no contact from the individual to demonstrate that the individual is cooperating in providing the renewal information, complete the MA Closure Checklist for any individuals who cannot be renewed through ex parte and close these individuals for failure to provide information (reason 042) with a 15-day advance notice.
NOTE: The CAO must ensure that the 30-day due date has passed prior to closing any MA budgets.
Reminder: The caseworker must submit the completed checklist to their supervisor for review prior to the case closing. The completed MA Closure Checklist must be scanned to the case record after the supervisor has reviewed and signed the checklist.
5. Process an MA renewal for any identified individuals whose budget is able to be renewed through ex parte. Make sure that the case record is updated, send a notice, and narrate.
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.
When an automatically scheduled renewal packet is received from the household, the CAO must:
1. Review the renewal form to make sure it is complete.
NOTE: A form must be signed on Rights and Responsibilities page to be considered complete. If the signature is the only item needed, the CAO will reach out for a signature.
2. Review and confirm all eligibility factors.
If all information required to process the renewal was requested on the PA 253 that accompanies the renewal form and that information was not provided, complete the MA Closure Checklist and close the MA budget for failure to provide information (reason 042) with a 15-day advance notice.
Reminder: If self-attested income is under limits but verification is not provided and data source income information will result in a reduction in benefits or budget closure, the budget recertification cannot be completed and must be closed 042.
Note: If income not reported on the renewal form 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.
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 data sources 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 individuals who know the individual(s). 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.
3. When a delay in providing information is due to a third party and the individual(s) is cooperating, the CAO must continue benefits and review the progress of getting proof and the individual's cooperation every thirty days.
4. For GA-related MA categories, review the client's criminal history inquiry information. (See Chapter 304, Appendix C for procedures.)
5. If there are other possible resources and income, including third-party resources (health insurance coverage), contact the individual and discuss them.
6. Look at the individual's social service needs and plans. Review DHS's services and those of other agencies that eligible clients can get.
7. Make sure the individual(s) gets a copy of the Rights and Responsibilities page from the application.
Note: For COMPASS renewals, the client must show that he or she read the Rights and Responsibilities information.
8. Review the case record to determine if all budgets are aligned with a common renewal date. The renewal due date for all budgets in a case record must be aligned. If MA budgets are the only budgets open in a case, align all MA budgets to the same renewal date when processing the renewal.
The requirement to align MA budget renewal dates does not apply to the following MA budget exceptions:
MA-TMA budgets (MG71)
MA-MAWD budgets (PW/PI)
MA-BCCPT budgets (PH20)
Other MA budgets that have a specific time period that the budget must be open (examples: pregnant women, newborns, continuous eligibility for children under age 4, and certain MA spend-down budgets).
NOTE: Renewal dates for budgets not listed above can be shortened to align with exempted budgets.
9. Process the renewal in the system and determine ongoing MA eligibility. Make sure eligibility, renewal due date, and case record information is updated.
10. Ensure that the correct notice is sent to the individual.
11. Enter a case comment in the system.
When an automatically scheduled renewal is not received from the individual, the CAO must:
1.Confirm that the renewal form and verification information have not been received in the CAO by the renewal packet due date. Review Imaging in eCIS to determine if the packet was received.
2. Confirm that the renewal form was generated and mailed to the recipient.
3. If more than one individual has active MA, review record for any individuals whose budget could be renewed through ex parte.
Note: If an individual is subject to a resource test, an ex parte review should be completed prior to closure regardless of number of active MA budgets on the record as AVS information is not available for review prior to scheduling the renewal packet.
4. If there has been no contact from the individual to demonstrate that the individual is cooperating in providing the renewal information, complete the MA Closure Checklist for any individuals who cannot be reviewed through ex parte and close these individuals for failure to provide information (reason 042) with a 15-day advance notice.
NOTE: The CAO must ensure that the 30-day due date has passed prior to closing any MA budgets.
Reminder: The caseworker must submit the completed checklist to their supervisor for review prior to the case closing. The completed MA Closure Checklist must be scanned to the case record after the supervisor has reviewed and signed the checklist.
5. Process an MA renewal for any identified individuals whose budget is able to be renewed through ex parte. Make sure that the case record is updated, send a notice, and narrate.
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.
If a case contains MA along with other benefits (SNAP and/or TANF), the CAO must send a renewal form to the household (See Section 376.231, Manually Scheduled Renewals).
When the signed renewal packet is received from the household, the CAO must:
1. Complete an ex parte review for MA only (See Section 376.22, Ex Parte Review). If all information necessary for a renewal determination is available through data sources or the case record, continue to step 8.
Note: If income not reported on the renewal form 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.
If all information necessary for a renewal determination is not available through data sources or the case record, continue to step 2.
2. For GA-related MA categories, review the client's criminal history inquiry information. (See Chapter 304, Appendix C for procedures.)
3. Review and confirm all eligibility factors. If information is reported and verification of that information was not requested on the PA 253 that accompanies the renewal form and is not available through data sources or the case record, contact the household for verification and allow a minimum of 10 days to provide the needed information.
Reminder: If self-attested income is under limits but verification is not provided and data source income information will result in a reduction in benefits or budget closure, the budget recertification cannot be completed and must be closed 042
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 individuals who know the individual(s). 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.
4. When a delay in providing information is due to a third party and the individual(s) is cooperating, the CAO must continue benefits and review the progress of getting proof and the individual's cooperation every thirty days.
5. If there are other possible resources and income, including third-party resources (health insurance coverage), contact the individual and discuss them.
6. Look at the individual's social service needs and plans. Review DHS's services and those of other agencies that eligible clients can get.
7. Make sure the individual(s) gets a copy of the Rights and Responsibilities page from the application.
Note: For COMPASS renewals, the client must show that he or she read the Rights and Responsibilities information.
8. Review the case record to determine if all budgets are aligned with a common renewal date. The renewal due date for all budgets in a case record must be aligned. If MA budgets are the only budgets open in a case, align all MA budgets to the same renewal date when processing the renewal.
The requirement to align MA budget renewal dates does not apply to the following MA budget exceptions:
MA-TMA budgets (MG71)
MA-MAWD budgets (PW/PI)
MA-BCCPT budgets (PH20)
Other MA budgets that have a specific time period that the budget must be open (examples: pregnant women, newborns, continuous eligibility for children under age 4 and certain MA spend-down budgets).
NOTE: Renewal dates for budgets not listed above can be shortened to align with exempted budgets.
9. Process the renewal in the system and determine ongoing MA eligibility. Make sure eligibility, renewal due date, and case record information is updated.
10. Ensure that the correct notice is sent to the individual.
11. Enter a case comment in the system.
When a combination renewal form is not received from the individual, the CAO must:
1. Complete an ex parte review for all individuals. If all information for renewal is available through data sources, process renewal for eligible individuals, make sure the case record is updated, send a notice, and narrate.
Note: 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.
If all information is not available through data exchanges, or data exchange information is not reasonably compatible, continue to step 2.
2. Confirm that the renewal form and verification information have not been received in the CAO by the renewal packet due date. Review Imaging in eCIS to determine if the packet was received.
3. Confirm that the renewal form was generated and mailed to the recipient.
4. If there has been no contact from the individual to demonstrate that the individual is cooperating in providing the renewal information, complete the MA Closure Checklist and close the MA budget for failure to provide information (reason 042) with a 15-day advance notice.
NOTE: The CAO must ensure that the 30-day due date has passed prior to closing any MA budgets.
Reminder: The caseworker must submit the completed checklist to their supervisor for review prior to the case closing. The completed MA Closure Checklist must be scanned to the case record after the supervisor has reviewed and signed the checklist.
A new application is not required for individuals who completed the required renewal form and ask for MA to be reopened, request reconsideration, as for a new application, and/or submit required verification within 90days of the date of benefits closure. See Section 379.3 Reopening Benefits that we Closed at Renewal.
To continue to be eligible, the individual representative must take the following actions:
1. Complete all forms to the best of their ability, and sign the PA 600R or other renewal form.
2. Provide the information needed to complete the renewal.
3. Provide the information needed to complete the third-party liability form. The client must provide information about third-party resources 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 continued eligibility.
A new application form, a renewal form, or a COMPASS application can be used to add a individual (other than a newborn) who was not previously known or in the record to an existing applicant/recipient group. 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 applicant/recipient group.
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 a individual is added.
Updated September 19, 2023, Replacing January 23, 2020