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Medicaid redetermination

What is Medicaid redetermination?

What is Medicaid redetermination?

Medicaid redetermination is the process that states use to ensure that Medicaid enrollees continue to be eligible for Medicaid coverage. To be eligible for Medicaid, a person’s income has to be fairly low, and some populations are also subject to asset tests. So states are required to periodically redetermine enrollees’ eligibility, and disenroll those who no longer meet the eligibility guidelines.

If a state can determine an enrollee’s continued eligibility using available electronic resources, the enrollee may not have to provide any additional information for the redetermination. But if not, the state will send the enrollee a request for more information. It’s important to respond to these notices, as coverage will be terminated if requested documentation is not provided.

What are typical guidelines for Medicaid redetermination?

Medicaid is jointly run by the federal and state governments, so states have some leeway to set their own Medicaid rules. But the federal government maintains various minimum standards for the program, including rules for Medicaid redeterminations:

  • For people whose eligibility is based solely on MAGI (ie, adults aged 19 to 64, children, parents/caretakers of minor children, and people who are pregnant), Medicaid redeterminations must be conducted once every 12 months.
  • For people whose eligibility is based on income as well as assets (ie, enrollees who are 65 or older, blind, disabled, or receiving HCBS or long-term care services), eligibility redeterminations must be completed at least once every 12 months.
  • If the state Medicaid agency receives updated information about an enrollee’s circumstances, they must promptly conduct an eligibility redetermination, even if it’s not time for the person’s regular redetermination. States generally require Medicaid beneficiaries to report a change in circumstances within 10 to 30 days.
During the COVID public health emergency, Medicaid redeterminations have been paused in every state. This is due to the Families First Coronavirus Response Act, and the additional federal Medicaid funding that states are receiving during the public health emergency. Once the public health emergency period ends, Medicaid redeterminations will resume.  

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