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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.
Medicaid redetermination is also known as eligibility redetermination, renewal, case review, and recertification. All of these terms mean the same thing, and refer to the process by which the state rechecks each year to see if an enrollee is still eligible for Medicaid.
If a state can determine an enrollee’s continued eligibility using available electronic resources (ex-parte renewal), 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 the normal 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. But states can have continuous coverage rules that allow people to maintain coverage for a certain amount of time, even if they report a change that would otherwise make them lose their coverage. Oregon is an example of this. And 12 months of continuous coverage is common for children (required as of 2024, as described below) and postpartum mothers.
During the COVID public health emergency, Medicaid disenrollments 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.
This was initially slated to continue through the end of the public health emergency, but the Consolidated Appropriations Act, 2023 (omnibus spending bill enacted in late 2022) calls for the continuous coverage requirement (also known as maintenance of eligibility) to end on March 31, 2023. So states will be able to resume Medicaid disenrollments starting April 1, 2023.
(Many states have continued their regular Medicaid eligibility redetermination processes throughout the pandemic, but they have not been able to disenroll people who are determined ineligible or who didn’t respond to renewal information requests. That will change as of April 2023.)
HHS projects that about 15 million people could lose their Medicaid eligibility once disenrollments resume starting in April 2023. States have a year to initiate the redetermination process for people who are enrolled as of April 2023, so the disenrollments will not occur all at once, as the process will be spread out across most of 2023 and the first part of 2024.
What guardrails and reporting requirements are in place for the resumption of Medicaid redeterminations?
The Consolidated Appropriations Act, 2023 includes some rules to protect Medicaid enrollees and ensure transparency and accountability during the unwinding of the continuous coverage requirements. Specifically:
- States must use the U.S. Post Office’s change of address database and/or state department of health and human services data to ensure that enrollees’ current contact information is on file with the state Medicaid office.
- States cannot disenroll someone simply due to mail being returned as undeliverable. The state has to make a good-faith effort to find the person.
- From April 2023 through June 2024, states must provide monthly reporting that shows how many Medicaid enrollees’ coverage has been renewed or terminated, how many enrollees’ coverage was terminated for procedural reasons (ie, not because they were actually found to be ineligible for the program; HHS projects that nearly 7 million people could lose coverage for procedural reasons), data regarding the number of people who transition to coverage through the exchange, and customer service data for the state Medicaid program, including call center volume, wait times, and the number of people who abandon the call without receiving assistance. And there’s a penalty for failure to comply with the reporting requirements: For each quarter that a state doesn’t comply, they lose 0.25 of a percentage point of federal Medicaid funding, up to a maximum of 1 percentage point.
- States will continue to receive additional COVID-related federal Medicaid funding through the end of 2023, although it will start to taper off in the second quarter of the year and will be gradually reduced in each subsequent quarter. Previously, this additional federal Medicaid funding was set to expire all at once at the end of the quarter when the COVID public health emergency ended. That could have incentivized states to disenroll people from Medicaid as quickly as possible, whereas the promise of a slow reduction in this funding (instead of a sudden end) may help states to take a more measured approach to eligibility redeterminations and disenrollments.
In addition, HealthCare.gov is offering an “unwinding” special enrollment period for anyone who loses Medicaid between March 31, 2023 and July 31, 2024, in a state that uses HealthCare.gov (states that run their own exchanges are free to implement a similar special enrollment period, or can opt to use their normal loff-of-coverage special enrollment period rules). This special enrollment period gives anyone who loses Medicaid in that 16-month period an opportunity to enroll in a plan through HealthCare.gov during that same window. In other words, the normal time limit for loss-of-coverage special enrollment periods (60 days after the loss of coverage) does not apply during the “unwinding” window.
How will 12 months of continuous coverage work for children?
Under the Consolidated Appropriations Act, 2023, all states will have to provide 12 months of continuous coverage for children deemed eligible for Medicaid or CHIP, even if the family has a change in circumstances before that 12-month period is up. Many states already provide this, but some do not. As of 2024, they will have to do so. This means that once a child is enrolled in Medicaid or CHIP, their coverage will continue, uninterrupted, for at least 12 months, unless the child moves out of the state, requests a disenrollment, or (when applicable) premiums are not paid for the coverage.
Does postpartum Medicaid always continue for 12 months?
The American Rescue Plan gave states the option to offer 12 months of postpartum Medicaid coverage, instead of having the mother’s coverage end two months after the baby is born, but this provision was only valid for five years. As of early 2023, Washington DC and 28 states had already implemented this provision, and six more planned to do so.
The Consolidated Appropriations Act, 2023 makes this option permanent for states, instead of just a five-year program. It’s not a requirement that states offer 12 months of postpartum coverage, but it’s likely that more states will offer this now that the program has been made permanent. Several states have legislation to this effect under consideration in the 2023 legislative session.
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