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CMS Guidance on Medicaid Eligibility Determinations, Renewal Strategies

Julie Kozminski
May 13, 2024

The Centers for Medicare and Medicaid Services (CMS) on May 9 released two informational bulletins on Medicaid eligibility determinations and Medicaid unwinding flexibility.

Ensuring Timely and Accurate Medicaid and CHIP Eligibility Determinations at Application

CMS released guidance to ensure state compliance with federal requirements and support timely coverage and care. At the end of 2023, states processed 7 percent of Modified Adjusted Gross Income applications in more than 45 days, exceeding federal timeliness requirements.

CMS outlines three immediate strategies to mitigate the impact of backlogged applications:

  • Implement flexibilities to increase real-time determination and ex parte renewal rates.
  • Invest in workforce improvements and other strategies to expand staff capacity.
  • Take steps available under existing regulations and temporary waivers and flexibility to expediate access to care for individuals, pending a final determination of eligibility.

CMS also proposed four longer-term strategies for continued compliance:

  • Invest in modernized eligibility systems.
  • Conduct ongoing and regular eligibility worker and vendor training.
  • Increase availability of and reliance on electronic data sources for verification at application and renewal.
  • Ensure effective communication and sufficient assistance for consumers.

CMS provided an updated slide deck for more information.

Extension of Temporary Unwinding-Related Flexibility

CMS will further extend unwinding-related Section 1902(e)(14)(A) waivers, originally scheduled to end Dec. 31, 2024, through June 30, 2025. States do not need to file a new waiver request; all waivers authorized under this section from April 2022 through May 9, 2024, are considered unwinding-related for the purpose of this informational bulletin. This includes waivers to:

  • Increase ex parte renewal rates.
  • Support enrollees with renewal form submissions or completion, such as permitting managed care plans to provide assistance with completing and submitting renewal forms.
  • Update beneficiary contact information.
  • Facilitate reinstatement of eligible individuals disenrolled for procedural reasons.
  • Address other issues, such as:
    • Delaying the resumption of premiums until a beneficiary’s eligibility has been redetermined.
    • Temporarily simplifying the eligibility determination process for the former foster care children group.
    • Extending the timeframe to take final administrative action on certain fair hearing.

CMS is also extending through other authorities through June 30, 2025:

  • Temporary verification policies and procedures submitted through a Verification Plan Addendum.
  • The timeliness exception to delay procedural disenrollments for renewals if conditions continue to be met; this is permitted during an administrative or other emergency beyond the agency’s control, such as when a state begins to work through a large volume of renewals.

Contact Director of Policy Rob Nelb, MPH, at rnelb@essentialhospitals.org or 202.585.0127 with questions.

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