Health insurance

Publication of guidance on Medicaid and the Children’s Health Insurance Program

During the COVID-19 Public Health Emergency (PHE), insurers, health technologies, and some FDA-regulated products have been granted various flexibilities in their care offerings. Now, the Biden administration is beginning a “return to normal operations” with the release of state guidelines that provide up to 12 months to ensure eligibility and renewal reviews for people who remained covered by Medicaid during the pandemic. Without proper planning, this could lead to a lapse in coverage as states begin to verify and renew those covered by Medicaid and the Children’s Health Insurance Program (CHIP).

During the pandemic, states received incentive payments to maintain continued enrollment for all Medicaid enrollees. It is estimated that more than 40 million children were enrolled in Medicaid or CHIP during the pandemic. It is also estimated that up to 15 million people, including 6 million children, are at risk of losing this coverage when eligibility determinations are back in place.

This new guidance sets out some specific criteria for states to plan and implement a smooth transition to ensure those enrolled in Medicaid are indeed eligible. Here are the key issues set out in this guidance for states – which could affect individuals, providers and plans:

  1. States received a temporary 6.2% increase in federal medical assistance – and a major condition for receiving this increase was the requirement to maintain continuous enrollment.

  2. When this condition ends, States will have up to 12 months to restart the normal registration process.

  3. This will include Medicaid, CHIP, and the Basic Health Program (BHP).

The Centers for Medicare & Medicaid Services (CMS) has introduced a tool for states to plan a return to the standard process for new and existing enrollees. States will be required to submit data showing completion of pending applications and review of renewals for those currently enrolled. The CMS will monitor errors, delays and data submission by States and may require States to provide additional reports more frequently.

Key Questions for States in the Compliance Toolkit

  1. At the end of the PHE, States will again renew the eligibility requirements every 12 months for those enrolled in Medicaid and CHIP based on eligibility criteria. For people who are no longer eligible for the program they are enrolled in, states should consider other insurance affordability programs before terminating Medicaid and CHIP coverage.

  2. Applications must be processed quickly and cannot exceed 90 days for a disability-based Medicaid applicant, or 45 days for everyone else.

  3. States are encouraged to plan to comply with these requirements by considering personnel and organizational needs, prioritizing work, and determining mitigation strategies.

  4. The first step is to assess the processing of renewals to perform post-registration verification and re-determination of eligibility due to changes in the registrant’s circumstances. Although states are required to initiate renewals for all enrollees within 12 months, the start month may vary by state. States will have to assess the number of renewals, the waiting period, which populations can be stable (children, people who are doubly eligible); vulnerable populations and other populations.

  5. Processing of requests should be done in a timely manner – CMS expects States to process requests quickly beginning immediately. States can use a phased approach to completing applications, such as two months after the month in which the PHE ends. States should complete eligibility determinations for people age 65 and older; three months after the end of the PHE, states must complete eligibility determinations for all pending disability-related applications; four months after the end of the PHE, states should resume the timely processing of all applications.

  6. CMS expects States to begin processing Fair Hearing requests in a timely manner after PHE ends. The approach should be customized by each state based on volume, types of requests and personnel.

  7. States should develop an outreach and communications plan and, in doing so, should consider key audiences and key messages.

  8. States should have a monthly plan for completing eligibility determinations; timely processing of requests; initiate renewals 12 months after the start of the state liquidation period; and complete all pending actions. This will require a detailed effort to communicate with existing populations of eligible people as well as those previously covered.

CMS has identified additional guidance and resources for states in this transition to ensure Medicaid and CHIP enrollees are screened and supported through the 12-month cycle with planning tools. Plans, providers, and other health care entities should carefully monitor each state’s efforts and help provide accurate information about potential coverage changes that may occur during this transition.

©2022 Greenberg Traurig, LLP. All rights reserved. National Law Review, Volume XII, Number 67