Medicaid Recertifications
Provider Guidance

After nearly 3 years of automatic Medicaid recertifications due to COVID flexibilities, recipients will again be required to recertify their Medicaid in the near future.  With the ending of the Public Health Emergency (PHE), Medicaid cases expiring in June 2023 will have to be recertified.  Failure to recertify will result in cases being closed and a person will need to reapply. 

To assist with preparing for this upcoming and significant change, the following guidance is being provided.  We hope it is helpful in clarifying actions that should be taken to ensure minimal disruption to individuals’ coverage.

Importance of Medicaid Coverage

Medicaid coverage is critical to ensuring access to services, whether OPWDD services, healthcare services, medications, or durable medical equipment and supplies.  For this reason, it is incumbent upon all providers to work together to ensure we are collectively supporting the people who rely on us all.

Care Managers

Care Managers are responsible for assisting individuals who reside in non-certified settings to ensure their Medicaid coverage remains active and all necessary recertification activities/requests for information and documentation by DSS/HRA are attended to and provided timely.  The level of assistance provided will vary based on the person’s preferences; in some cases, the person/family may require a great deal of assistance with the process, while in others, they may not need or want as much involvement from the Care Manager.  The most important thing is to make sure that the people Care Managers support are aware of the upcoming need to recertify and the assistance that is available to them.

Residential Providers

Residential provider agencies retain primary responsibility for maintaining Medicaid coverage and other benefits for people that reside in their certified residences; however, this should be seen as a team effort with the Care Managers monitoring to ensure that coverage remains active.  Care Managers in these situations should ensure that the residential provider takes the appropriate steps to secure ongoing Medicaid coverage, including submitting recertification packets and responding timely to inquiries or requests for documentation by DSS/HRA.  While the residential provider is ultimately responsible, it is in the individuals’ best interest for all providers to work together for the benefit of the person.

Tips to Help Prepare for Recertifications

  • Check individuals’ mailing addresses on file with Medicaid to ensure that they are accurate and up-to-date. If someone has moved during the pandemic, their address must be updated with DSS/HRA so that their recertification packets and other notices get to them successfully.  Please be aware that Medicaid mail is NOT forwarded by the Post Office; if mail is returned to them, the associated Medicaid case will be closed.
  • Notify individuals and advocates as appropriate about upcoming recertification requirements so that everyone within a person’s circle of support understands the changes and everyone’s responsibilities.
  • Be prepared to provide income and resource information as part of the recertification process – remember that there are significant changes to Medicaid income and resource limits, effective January 1, 2023, that should positively impact Medicaid eligibility for many, effectively lowering or eliminating spenddown amounts.
  • Know what is happening when:
    • March 2023 – HRA is mailing notices to Medicaid recipients with information and instructions as to what they need to do. This is a precursor to recertification packets being mailed to ensure that addresses are correct and the appropriate person/entity receives the packet.
    • April 2023 – DSS begins mailing recertification packets for cases expiring in June.
    • First case closings if not actively recertified will occur in June.
  • Know what to do if a case is closed inappropriately:
    • File promptly for a Fair Hearing with Aid to Continue (AC) within 10 days of the notice date. Requesting AC will allow Medicaid coverage to continue until the Fair Hearing is held and a decision is made.  After the 10-day window, a Fair Hearing can still be requested within 60 days of the notice date, but AC is not an option.  We recommend that AC be requested, regardless, in case they do honor the request (never hurts to ask!).

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