PM 19-02-04-g: Medical Redetermination Forms

WAG 19-02-04-g

The following table provides a brief description of Medical Redetermination Forms.

Form # Form Name Form Description
643A 19 Year Old Aging Out of All Kids Medical Benefits A manual redetermination form sent to individuals aging out (turning 19) from All Kids.
643M MAGI Medical only redetermination A manual redetermination form sent to customers due for medical redetermination only.
643N Non-MAGI Medical only redetermination A manual redetermination form sent to customers due for medical redetermination only.
643X LTC Medical only redetermination A manual redetermination form sent to customers due for an LTC medical redetermination only.
643RNW Courtesy Renewal Follow Up Letter A reminder letter sent to the customers who were sent a manual redetermination and no response has been received.
1893 Medical, SNAP and Cash Redetermination Notice A manual redetermination form sent to customers due for medical and/or SNAP and or/TANF redetermination
2381C Medical Redetermination Notice A notice sent to every customer due for medical redetermination approximately 60 days prior to their redetermination due date. Notice will inform each customer in the household due for redetermination of their ex parte eligibility.
2381* Medical Benefits: Time to Renew (Medical Only) This form is sent to the customer when they are due for a redetermination. Provides information on completing Form 643 Medical Redetermination.
2381A* Medical Redetermination Notice (Auto-renew medical; REDE due for Cash/SNAP) This form notifies customer that an auto redetermination was completed for their medical benefits. Sent separately from Form 1893.
2381B* Medical Benefits: Time to Renew (Cash/SNAP and Medical renewal) Mailed with 1893 REDE form. This form is sent with Form 1893 and notifies customer additional information is needed for the medical redetermination.
3771A Reinstatement (all medical programs) This form is sent to customer when a medical case is reinstated and certified in IES.

* Forms 2381, 2381A and 2381B have been discontinued and replaced by Form 2381C.

NOTE: The Form 1893 description above is under the context of a medical redetermination due. If medical is due for redetermination at the same time as CASH/SNAP/TANF the customer will receive Form 1893.

2381C

Effective 8/6/2024, Forms 2381, 2381A and 2381B will be discontinued and incorporated into the highly dynamic 2381C Notice. This notice will be provided to the head of household approximately 60 days prior to the redetermination due date via postal mail and electronically via ABE. The notice will state each individual due for medical redetermination and whether they were eligible for ex parte redetermination or must submit a manual redetermination to be evaluated for continuing eligibility. If an individual is not eligible for ex parte redetermination, the appropriate 643 form will be included.