B-8200, Redetermining Eligibility

Revision 24-3; Effective Sept. 1, 2024

Redetermine eligibility:

• when a change is anticipated;
• within 10 business days after a reported change that may affect eligibility or co-payment, including program transfers;
• within 30 business days after a reported change that does not affect eligibility or co-payment;
• at least once every 12 months; or
• at least every six months when income is averaged or an incurred medical expense is budgeted.

*Note: Children under 19 receive 12 months of continuous eligibility. Refer to continuous Medicaid coverage policy for exceptions.

For couple cases, including cases with spouses who may be certified under different types of programs, align the annual redeterminations to simplify the renewal process. A full redetermination of each spouse's eligibility must be completed at least once every 12 months.

The following information must be included in the case record documentation:

• If a special review is needed
• Date special review will be conducted
• Method of monitoring for special review

Clearly document:

• specific information about the reason for setting a special review;
• which person is affected; and
• the eligibility criteria subject to the review.

Example: If the person has a private pension and the pension amount is anticipated to increase in the future, set a special review for the anticipated change. The case documentation must specify pension information that needs to be verified at the special review, including:

• date that the anticipated change will occur;
• type of pension;
• source of pension; and
• payment frequency of the pension.

Use Form H1020, Request for Information or Action, and Form H1020-A, Sources of Proof, to request information from the person or their authorized representative (AR). When requesting more information during a change or redetermination, allow the person at least 10 calendar days from the date of the notice to provide the information. Deny the case for failure to provide information after the due date listed on Form H1020.

Note: Monitor special reviews for resource or income elements through entry of the special review due date in the eligibility determination system.

Data Broker request is not required on redeterminations, including streamlined renewals.

Related Policy

Continuous Medicaid Coverage, B-6600
Procedures for Redetermining Eligibility, B-8400
Special Reviews, B-8430
Streamlined Redetermination (Passive Redetermination), B-8440
How to Budget Variable Income at Applications, E-5400
Ongoing IME Budget, H-2400