Health Law Daily CMCS offers reminder of requirements for beneficiaries ineligible due to changed circumstances
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Monday, December 7, 2020

CMCS offers reminder of requirements for beneficiaries ineligible due to changed circumstances

By Sherri M. Schroeder, J.D.

Audits and PERM rates raise questions about state compliance with renewal requirements for Medicaid and CHIP beneficiaries who become ineligible due to changes in circumstances.

A recent informational bulletin sent to states by the Center for Medicaid and CHIP (Children’s Health and Insurance Program) Services (CMCS) serves as a reminder of current federal requirements and expectations for completing redeterminations of eligibility for Medicaid and CHIP beneficiaries. Despite significant effort having been made on the development and implementation of modernized enrollment and renewal systems and processes, states’ failures to conduct timely and accurate redeterminations are a "contributing factor" driving 2019/2020 Payment Error Rate Measurement program improper payment rates in Medicaid and CHIP. Furthermore, the COVID-19 public health emergency (PHE) has heightened the importance of states accurately and efficiently processing the backlog of overdue renewals that is accumulating over the course of the PHE. Further increasing the backlog is the requirement that states continue enrollment for Medicaid beneficiaries enrolled as of or after March 18, 2020, through the end of the month in which the PHE ends to qualify for a temporary 6.2 percentage point increase in the federal medical assistance percentage. In addition to discussing some of the common situations in which such errors are made, the bulletin also include, as appendices, the steps to be taken when acting on changes in circumstances and FAQs on Medicaid and Children’s Health Insurance Program Renewals updated for December 2020 (CMCS Informational Bulletin, December 4, 2020).

Periodic renewal requirements. As required by 42 C.F.R. §§435.916 and 457.343, states must renew eligibility for Medicaid and CHIP beneficiaries whose eligibility is determined using methodologies based on modified adjusted gross income (MAGI) once every 12 months and no more frequently than once every 12 months. For non-MAGI beneficiaries, this must be done at least once every 12 months. States have flexibility to implement periodic data checks of electronic data sources between regular renewals in order to identify beneficiaries who may have experienced a change in circumstances affecting their eligibility.

Ex parte renewals. States must first attempt to conduct an ex parte renewal for all beneficiaries. This is made based on reliable information available to the agency without requiring information from the individual, such as information available in the beneficiary’s account, information accessed through electronic data sources, and information available from other benefit programs or other reliable sources. If the agency is able to renew eligibility based on the available reliable information, the agency must then notify the individual of the eligibility determination, the information relied upon in making the determination, and the beneficiary’s obligation to inform the agency if any information contained in the notice is inaccurate or subsequently changes.

Renewals without sufficient information. If enough information to perform an ex parte renewal is not available, or if the state has information that indicates the beneficiary may be ineligible, the state must provide the beneficiary a renewal form and inform the individual of any additional information or documentation needed to determine eligibility. A prepopulated renewal form must be used for MAGI beneficiaries, but such a form is not required for non-MAGI beneficiaries. Clear instructions and at least 30 days’ time must be given to MAGI beneficiaries to return the form; a reasonable period of time must be allowed for non-MAGI beneficiaries. Renewals, signed under penalty of perjury, may be submitted through any mode of submission available for submitting an application. Once the renewal is received, the state agency must verify any information provided and make a final determination. Beneficiaries must then be notified of any decision affecting their eligibility. At least 10 days advance notice must be given for adverse determinations under Medicaid; CHIP beneficiaries must be given sufficient notice to allow the parent or caretaker to take any appropriate action required to allow coverage to continue without interruption.

Timeliness. States must establish renewal procedures and internal milestones that allow for adequate time to complete the renewal process before the end of a beneficiary’s eligibility period, accounting for both the time given beneficiaries to provide documentation and the time allowed for the agency to process and verify the provided information. CMCS believes 30 days from the date all information provided by or on behalf of the beneficiary is received by the agency should be ample time. CMCS reminds the state agencies that they must continue to furnish Medicaid to beneficiaries who have returned their renewal form and all requested documentation unless and until they are determined to be ineligible.

Consideration of other bases. If a Medicaid beneficiary is found to no longer be eligible for the eligibility group under which he or she is receiving coverage, the agency must consider whether the beneficiary may be eligible under one or more other eligibility groups covered by the state. If a CHIP enrollee is no longer eligible for CHIP, the agency must screen for eligibility in other insurance affordability programs, including Medicaid, on all bases and Exchange coverage. For either type of beneficiary, a reasonable time period must be given to provide any additional information or documentation required. States are expected to make determinations as expeditiously as possible, and terminate eligibility for individuals who either are determined ineligible on all bases or do not provide needed information or documentation in a timely manner.

Termination and reconsideration period. For beneficiaries who are determined ineligible for Medicaid or CHIP, the agency must determine potential eligibility for other insurance affordability programs, transfer the beneficiary’s electronic account, and provide notice of termination and appeal rights. The agency still must provide advance notice of termination to beneficiaries who fail to return the renewal form or other needed documentation in a timely manner, but the state need not determine potential eligibility for other insurance affordability programs. In fact, states should not transfer accounts for individuals that have been terminated for procedural reasons. For MAGI beneficiaries whose eligibility has been terminated, if the renewal form and/or necessary information is returned within 90 days after the date of termination (or a longer period if elected by the state), the agency must reconsider the individual’s eligibility without requiring the individual to fill out a full new application. States may also do this for non-MAGI beneficiaries, but are not required to do so.

Redetermining based on changes in circumstances. States must have procedures designed to ensure that beneficiaries make timely and accurate reports of any change in circumstances that may affect their eligibility. Beneficiaries must be able to report such changes by phone, by mail, or in person. States may also perform periodic data checks to seek information about any changes. When information is received by the state that indicates a change in circumstances that may affect eligibility, the state must act promptly to determine whether the beneficiary continues to meet the eligibility criterion. Information concerning increased income, an out-of-state move, death, and reaching an age milestone (e.g., 19 or 65) are all given as examples of changes that require redetermination of eligibility.

Pregnant women. For many pregnant women, the end of the postpartum period represents a change in circumstances that may impact their eligibility. Because the end of a given woman’s postpartum period may not coincide with the end of her eligibility period and regularly scheduled renewal, the steps states must take to comply with the regulations differ depending on whether the end of the woman’s postpartum period occurs before or after her renewal date.

For women who apply while pregnant and are determined eligible under the group for pregnant women, their postpartum period typically will end before the end of their 12-month eligibility period and first regularly scheduled renewal. Once the birth or other end of her pregnancy is confirmed, the state will need to determine whether or not the woman will remain eligible following the end of her postpartum period under another eligibility group, most likely under the parent or caretaker group or the adult group. Since such a woman would still be within her eligibility period, the state generally would not contact the woman to verify her income. However, the state would need to verify her income when a woman’s postpartum period ends in the middle of her eligibility period if it has received other information indicating her income has changed since her initial determination such that her income may exceed the income standard for coverage under the other eligibility groups under which she might be eligible. If the woman is determined eligible for another group, she would be moved to that new group, and her next regular renewal date would remain the same—12 months after her initial determination.

For women whose postpartum period ends after their regularly scheduled renewal data, the agency must conduct the full renewal at the end of the individual woman’s postpartum period when her continuous eligibility ends. This typically will be the case for women who are enrolled in Medicaid when they become pregnant.

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