Can I Qualify for Medicaid Again After Being Ineligible Due to Changed Cirmcuntance?

The COVID-19 pandemic has resulted in administrative challenges for state Medicaid agencies from staff transitions to telework due to social distancing requirements, increased applications during the economic downturn, and the need to modify policies and procedures to facilitate access to coverage and care in response to the public health crisis. As a result, states have faced increased enrollment while having fewer staff and resources bachelor for routine eligibility and enrollment processing. At the same fourth dimension, Maintenance of Eligibility (MOE) provisions crave states to go along beneficiaries enrolled until the end of the calendar month when the COVID-19 public health emergency (PHE) ends and prohibit states from adopting more stringent eligibility criteria or increasing premiums, as weather of receiving temporary increased federal Medicaid funding under the Families First Coronavirus Response Act. Consequently, states volition need to address a backlog of Medicaid eligibility renewals and redeterminations as well as continue to process new applications afterward the PHE ends.

In add-on, many states have adopted temporary policy changes through various Medicaid emergency authorities to aggrandize eligibility and/or streamline enrollment processes to connect individuals to coverage more rapidly during the pandemic. States too have used emergency regime to prefer other policies such as relaxing cost sharing and prior say-so requirements, increasing provider payments, and adding new benefits. States volition have to decide whether to continue these policy changes after the PHE ends. If states render to pre-PHE eligibility and enrollment rules, they volition demand to redetermine eligibility for impacted enrollees. They also will need to notify beneficiaries and providers well-nigh whatsoever payment or benefit changes.

On December 22, 2020, CMS released a state health official letter outlining how states are expected to unwind emergency authorities and resume normal eligibility and enrollment processing after the end of the PHE. The current PHE declaration expires on Apr 21, 2021, only the Biden Assistants has indicated the PHE volition likely remain in place throughout 2022 and that states will receive 60 days detect before the end of the PHE to ready for the terminate of emergency authorities and the resumption of pre-PHE rules. The change in Presidential administration could take implications for state planning and decisions at the stop of the PHE, equally the Biden Administration could revise the December 2022 guidance every bit well as the Trump Administration'southward acting final dominion (IFR) governing the MOE provisions. Considering the Trump Administration did not finalize the IFR following the finish of the comment period in January, the Biden Assistants will have the opportunity to review comments and could make modifications in response to comments before finalizing the dominion. This brief highlights key issues from the new CMS guidance to states as issued in December 2020.

What actions does CMS expect states to take during the PHE?

CMS expects states to process applications, redeterminations and renewals to the extent possible during the PHE, even though they cannot end coverage for near enrollees due to the MOE. CMS emphasizes prioritizing deportment to ensure that individuals tin enroll in and retain coverage, such as determining eligibility for new applications, during the PHE.¹ Table 1 summarizes the circumstances that may result in state backlogs and the deportment that CMS expects states to take during the PHE to address pending eligibility and enrollment actions. CMS as well encourages states to conduct CHIP and Basic Health Plan (BHP) redeterminations and renewals during the PHE. Because the MOE does not utilize to those programs, CMS notes that states tin process Fleck and BHP actions now, which could allow them more time to focus on clearing Medicaid backlogs after the PHE and MOE conditions end.

Table 1: Country Eligibility and Enrollment Backlogs and Expected State Deportment During the PHE
Type of Activeness	Circumstances That May Contribute to Backlog When PHE Ends	Deportment CMS Expects States to Accept During PHE
Applications	The economic downturn has led to increased applications, and states may non have finished processing all applications received during the PHE past the time the PHE ends. States also need to continue to process new applications received post-PHE.	States should make every try to make timely eligibility determinations for new applicants.
Verifications	States that make up one's mind eligibility based on cocky-attested information must complete post-enrollment verification.	States should begin processing pending post-enrollment verifications to the extent possible and resume checking data sources to verify eligibility criteria for those enrolled based on self-attested data.
Redeterminations	Some individuals may accept gained eligibility due to state-adopted emergency regime that expanded eligibility (such as increased income/asset disregards). States will take to redetermine eligibility for these enrollees if they revert to prior rules after the PHE ends. Enrollees also may have reported changes in circumstances during the PHE, but MOE rules required states to keep coverage.	States should make every effort to procedure changes in circumstances that may expand coverage, and procedure other changes in circumstances to the extent possible.
Renewals	States may accept delayed processing eligibility renewals that were due during the PHE due to the demand to focus on pandemic response.	States should process overdue renewals to the extent possible and initiate renewals based on electronic data/information available to the state.
SOURCE: CMS, SHO #xx-004, Planning for the Resumption of Normal Land Medicaid, Children'southward Wellness Insurance Program (CHIP), and Basic Health Program (BHP) Operations Upon Conclusion of the COVID-19 Public Health Emergency (Dec. 22, 2020).

To help ensure that futurity workloads are manageable, states can take action to evenly distribute renewals throughout the year. When completing renewals that were delayed during the PHE on an ex parte basis (using information bachelor to the state and non requiring information from the individual), states have the option to retain the individual'south original eligibility period (effective when the renewal was due) instead of get-go a new eligibility menstruation on the date the renewal actually is completed. This may help states distribute workloads in time to come years past staggering renewal dates but may too result in renewal periods for enrollees that are shorter than 12 months.

How quickly does CMS wait states to articulate eligibility and enrollment backlogs after the PHE ends?

CMS expects states to complete all pending eligibility and enrollment deportment and clear any backlogs within half dozen months afterward the PHE ends. The guidance sets timelines for states to render to normal operations for eligibility determinations on new applications as well as eligibility verifications, redeterminations based on changes in circumstances, and renewals that are awaiting when the PHE ends (Figure 1). Initial milestones focus on processing applications, followed by completing pending verifications, redeterminations, and renewals.

Figure 1: CMS Timeline for States to Address Medicaid Eligibility and Enrollment Actions Pending When COVID PHE Ends

States need to adopt a methodology for prioritizing which pending eligibility and enrollment actions to complete first, focused on individuals "virtually probable" to no longer exist eligible (Table two).ⁱⁱ States have discretion well-nigh whether to adopt ane of CMS'south methodologies or to develop their own approach. The land's methodology will be part of the operational plan that information technology must develop to set out how it will process pending actions within CMS-required timeframes later on the PHE ends. CMS will not approve state operational plans but may request them from states that are not meeting the required timeframes. States must submit baseline data about pending eligibility and enrollment actions at the end of the PHE and submit updates quarterly thereafter to testify progress toward the timeframes. If states meet these timeframes, CMS will not consider eligibility and enrollment actions delayed due to the PHE as untimely for Programme Error Rate Measurement (PERM) purposes.³

Tabular array two: State Options for Methodology to Prioritize Pending Eligibility and Enrollment Actions
Methodology	Description
Population-based arroyo	Prioritizes eligibility and enrollment deportment for individuals in groups who are nearly likely to be no longer eligible (due east.chiliad., those who aged out of grouping, expansion adults who became Medicare-eligible).
Time-based approach	Prioritizes actions based on the length of time the action has been awaiting (state completes oldest awaiting actions first).
Hybrid approach	Combines the population and time-based approaches (e.g. utilize time-based approach to prioritize post-enrollment verifications and changes in circumstances and use population-based approach to prioritize renewals; or use population-based approach for outset moving ridge of pending actions and then switch to time-based arroyo).
State-adult approach	Develop some other approach that prioritizes actions for individuals who are most likely to be no longer eligible or that pose a greater risk for ineligible individuals remaining enrolled longer.
SOURCE: CMS, SHO #twenty-004, Planning for the Resumption of Normal State Medicaid, Children's Wellness Insurance Program (CHIP), and Basic Health Program (BHP) Operations Upon Conclusion of the COVID-19 Public Wellness Emergency (Dec. 22, 2020).

The guidance reiterates existing policies states can adopt to streamline eligibility and enrollment processes and reduce administrative workload. For MAGI populations (whose eligibility is based solely on low income), these options include renewing coverage for 12 months when processing changes in circumstances and a information cheque shows continued eligibility, relying on income determinations made by SNAP or TANF, equally well as Express Lane Eligibility and 12-month continuous enrollment for children. States can besides streamline eligibility and renewal processes for non-MAGI enrollees (whose eligibility is based on old age or disability) by adopting 12 calendar month renewal periods, using prepopulated renewal forms, offering renewal afterthought periods, and modifying verification policies to accept self-attestation, among other policies.⁴

After the PHE ends, what exercise states need to do before terminating coverage?

States cannot cease coverage until the end of the month in which the PHE ends, due to the MOE requirements. Afterwards the MOE and any temporary emergency authorities finish, states must follow regular plan rules that require sending ten day advance detect and providing the opportunity for a fair hearing prior to terminating coverage. If states are catastrophe emergency regime and redetermining eligibility under more than restrictive pre-PHE rules, states must provide enrollees with a reasonable timeframe, at least 30 days, to provide information to establish their continued eligibility.⁵ States likewise must ensure a smooth transition to other insurance affordability programs for those who lose Medicaid eligibility but may be eligible for Marketplace or other coverage.

After the PHE and MOE requirements end, states do not have to repeat redeterminations or renewals before terminating coverage for individuals who accept been determined ineligible within six months of the date the state sends an accelerate observe of coverage termination. To adopt this option, states must inform the enrollee at the fourth dimension of the ineligibility decision that coverage will stop after the month in which PHE ends, and the state volition redetermine their eligibility based on whatever changes in circumstances that they report prior to termination. The state and then must send a second detect in accelerate of the termination date. In cases where the state requests information to establish continued eligibility, states must allow individuals to respond through the end of the PHE, regardless of when the request was sent. If an private has not responded to a request that was sent within half-dozen months of the date on which the land intends to stop coverage after the PHE ends, the state may send accelerate discover of termination without attempting a repeated verification or redetermination.

What do states demand to practice if they desire to continue or end policies adopted through emergency government?

The diverse Medicaid emergency authorities adopted during the PHE will cease automatically (when the PHE ends or on a specified end appointment), unless a state takes action to extend them. States are not subject to public notice requirements for returning to pre-PHE rules. However, CMS strongly encourages states to communicate almost changes with providers, enrollees, and managed care plans. And, states must provide advance notice to enrollees of any actions that result in a loss of eligibility, a reduction in benefits, or an increase in cost-sharing; this includes changes due to ending an emergency authority that temporarily expanded eligibility or benefits. Although some states already have sent notices during the PHE informing enrollees of changes that volition have effect after the PHE or MOE ends (such as increased cost-sharing), states must send a second advance notice at the stop of the PHE prior to implementing these changes.^vi

CMS encourages states to consider whether some emergency authorities should end earlier the PHE ends. For example, many states paused Preadmission Screening and Resident Review (PASRR) assessments, which preclude unnecessary nursing facility stays and facilitate community transitions, for people with intellectual or developmental disabilities or mental illness entering nursing homes during the pandemic. Given PASRR'south role in preventing unnecessary institutionalization, CMS encourages states to re-start PASRR before the PHE ends.^seven

States may want to go along some policies adopted under emergency authorities after the PHE ends, though not all policies can exist continued. For case, states can ameliorate their land plans or HCBS waivers to continue service delivery via telehealth. States also tin can update their verification plans to continue streamlined eligibility and enrollment options. CMS specifically encourages states to identify any temporary authorities that increased access to HCBS and make these changes permanent. However, states that used Section 1135 waiver authority to relax provider screening requirements and/or temporarily enroll providers who participate in other state Medicaid programs or Medicare must return to regular program rules. States accept six months from the end of the PHE to complete screenings of these conditional providers and to stop payments to any providers not fully enrolled.

CMS is also now assuasive states to extend HCBS waiver emergency authorities adopted under Appendix K upwards to half-dozen months afterward the PHE ends. Appendix K allows states to brand temporary changes to HCBS waivers in response to emergencies, such as modifying or expanding eligibility or benefits, modifying or suspending service planning and delivery requirements, and adopting policies to support providers. Appendix Thousand approvals to date were scheduled to elapse afterwards one year, with the outset expirations to occur in late January 2021. Given the pandemic's longevity and uncertainty almost how long the PHE ultimately will terminal, CMS is now allowing states to submit requests to extend existing Appendix Yard approvals up to half-dozen months after the PHE ends and will employ this end date to new Appendix Grand requests going forrad.^viii Afterwards half dozen months post-PHE, states can continue many Appendix One thousand policies by alteration their HCBS waivers.^ix

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Source: https://www.kff.org/medicaid/issue-brief/key-issues-for-state-medicaid-programs-when-the-covid-19-public-health-emergency-ends/