PM 19-02-04: Medical Redeterminations

WAG 19-02-04

Medical Redeterminations

The redetermination process is used to complete a periodic review to determine if a customer is eligible to continue receiving benefits or whether the benefit level has changed. Medical redeterminations must be completed at least once every 12 months for each active medical EDG.

If a customer is found eligible during redetermination to continue receiving the same medical benefits they are currently receiving, the customer will be assigned a new 12-month certification period. If a customer is determined eligible for a different medical program than what they are currently receiving, the new benefits will begin the first month of their new 12- month certification period. If a customer is found ineligible at redetermination, their benefits will end the next effective month unless they are eligible for continuous eligibility.

The first medical redetermination is due 12 months from the calendar month in which the EDG is initially approved. Each redetermination thereafter is due the last month of the 12-month certification period. See PM 19-02-7 for when certification periods/redetermination due dates may change.

Federal regulations require each customer due for medical redetermination to be evaluated for ex parte eligibility.  Customers determined ex parte eligible are automatically renewed with no action required. Customers who do not qualify for ex parte redetermination will receive a manual redetermination form that must be returned in order to be evaluated for ongoing benefits. 

Ex Parte Eligible= Customer's medical benefits automatically renewed for new 12-month period.

Ex Parte Ineligible= Customer's ongoing medical benefits must be determined through the manual redetermination process.