Streamlining Eligibility & Enrollment Notice of Propose Rulemaking (NPRM)
The Centers for Medicare & Medicaid Services’ (CMS’) new proposed rule would make it easier for millions of eligible people to enroll in and retain their Medicaid coverage. The rule would reduce red tape and simplify applications, verifications, enrollment, and renewals for health care coverage through Medicaid and the Children’s Health Insurance Program (CHIP). The proposed rule responds to President Biden’s January 2021 and April 2022 Executive Orders to strengthen Medicaid and access to affordable, quality health coverage.
Certain current Medicaid and CHIP enrollment policies can contribute to coverage disruptions and create churning as people lose their Medicaid or CHIP coverage and then re-enroll within a short period of time. When people lose access to coverage, they lose access to vital health services. CMS has identified opportunities to ease administrative burden for states and reduce barriers to enrollment and retention of coverage for eligible individuals. For example:
- Children in some CHIP programs remain subject to potentially harmful policies that delay access to care. Barriers to coverage that are not permitted under any other insurance affordability program – including lock-outs for children terminated due to non-payment of premiums, required periods of uninsurance prior to enrollment, and annual or lifetime caps on benefits – remain state options under separate CHIPs.
- Individuals whose eligibility is based on being age 65 or older, having blindness, or a disability are excluded from many of the enrollment simplifications established under the Affordable Care Act (ACA), leaving such individuals at greater risk than other Medicaid enrollees of being denied or losing coverage due to procedural reasons, even if they continue to meet eligibility requirements.
- There are no regulations that ensure consumers have access to an efficient and streamlined enrollment process for the Medicare Savings Programs (MSPs), through which Medicaid covers the cost of Medicare premiums and/or cost sharing for Medicare enrollees highly likely or certain to be eligible for the MSPs based on receipt of other program benefits (e.g., Extra Help for Medicare Part D). As a result, millions of eligible individuals are not enrolled.
- There is currently no guidance providing clear and consistent timeframes for applicants and beneficiaries to return information needed to determine eligibility, or for states to process and act upon information received. This leads to unnecessary delays in processing applications and renewals, some individuals being denied services for which they are eligible, and some ineligible individuals retaining coverage.
- Recordkeeping regulations, which are critical to enabling appropriate oversight and identifying errors in state policies and operations, were last updated over three decades ago, resulting in inconsistent practices across states and contributing to eligibility error rates.
In this rulemaking, CMS seeks to close these and other gaps, further streamlining Medicaid and CHIP eligibility and enrollment processes, reducing administrative burden on states and applicants/enrollees, and increasing enrollment and retention of eligible individuals.
- This proposed rule includes several provisions aimed at simplifying the enrollment process and maintaining continuity of coverage for eligible beneficiaries, including children and individuals dually enrolled in Medicare and Medicaid, many of whom are over 65 and/or have a disability.
- CMS estimates that this proposed rule would remove barriers to enrollment and increase the number of eligible individuals who obtain coverage and are continuously enrolled in Medicaid and CHIP.
There will be a 60-day comment period, and comments on the notice of proposed rulemaking must be submitted to the Federal Register no later than November 7, 2022. For more information on how to submit comments or to review the rule in its entirety, visit the Federal Register.
Below are some of the proposed requirements to streamline Medicaid and CHIP application, enrollment, and renewal processes, as well as improve program integrity.
Streamlining Application and Enrollment
Sometimes eligible people who apply for Medicaid and CHIP never enroll in coverage because the administrative process can be burdensome and include unnecessary delays. The proposed rule, if finalized, will make the process of applying and enrolling easier through (among other updates) the following changes related to application and enrollment:
- Modify medically needy regulations to allow for the use of projected predictable medical expenses incurred by people living in the community for purposes of deducting these expenses from the applicant’s income when determining financial eligibility. Examples of these expenses include home care and prescription drugs.
- Eliminate the requirement to apply for other benefits as a condition of Medicaid eligibility to ensure eligible individuals, particularly those without an income test, are not facing unnecessary administrative hurdles.
- Ensure automatic enrollment, with limited exceptions, of Supplemental Security Income (SSI) recipients into the Qualified Medicare Beneficiary (QMB) group.
- Clarify the effective date of QMB coverage for an individual who enrolls in conditional Part A during the General Enrollment Period (GEP); such coverage may begin as early as the month Part A entitlement begins.
- Require use of low-income subsidy (LIS) “leads” from Medicare Part D to:
- Initiate applications for the MSP eligibility groups;
- Deem LIS recipients as eligible for MSP coverage to the maximum extent possible; and
- Accept attested information (with an option to conduct post-enrollment verification) to reduce documentation burden and streamline enrollment of eligible LIS recipients into MSP.
Improving Retention Rates at and Between Regular Renewals
Keeping eligible individuals covered is an important component of ensuring equity and access to coverage. We know there are many individuals who are eligible for coverage but fall through the cracks and lose coverage for a period of time. The following proposals would reduce the number of individuals who are eligible but not covered.
- For individuals who are exempt from the Modified Adjusted Gross Income (MAGI) income counting rules, including those whose eligibility is based on being 65 or older, blindness, or disability, the proposed rule would require states to:
- Conduct renewals no more than once every 12 months (with limited exception);
- Use prepopulated renewal forms;
- Provide a minimum 90-day reconsideration period after termination for failure to return information needed to redetermine eligibility;
- Eliminate required in-person interviews; and
- Limit requests for information on a change in circumstances to information on the change.
- Establish a clear process to prevent termination of eligible beneficiaries who should be transitioned between Medicaid and CHIP when their income changes or when the beneficiary appears to be eligible for the other program, even when the beneficiary fails to respond to a request for information.
- Establish specific guidelines for states to check available data prior to terminating eligibility when a beneficiary cannot be reached due to returned mail.
- Provide options for states to use available information to update addresses when beneficiaries move within the same state.
- Require that there be sufficient time for beneficiaries to provide the documentation needed to retain enrollment.
- Clarify that states are permitted to establish an optional eligibility group for all or a reasonable classification of individuals under age 21 whose eligibility is excepted from use of the MAGI-based methodology (e.g., those living with a disability), or whose MAGI-based eligibility is not otherwise described, and for which such coverage is not already permitted in regulation.
Removing Barriers Specific to CHIP Enrollment
CHIP, alongside Medicaid, has decreased the number of uninsured children by 70%, leaving only 3.7% of all children uninsured. CHIP is a vital program for children, as well as pregnant and postpartum individuals, and this proposed rule also focuses on removing barriers to allow children to enroll. This rule would:
- Allow CHIP beneficiaries to remain enrolled or re-enroll without a lock-out period for failure to pay premiums.
- Remove the option to allow a waiting period as a substitution of coverage prevention strategy in CHIP.
- Prohibit annual and/or lifetime limits on benefits in CHIP.
Enhancing Integrity of Medicaid and CHIP
Updating outdated recordkeeping regulations is critical to appropriate oversight of CMS programs and identifying errors that lead to improper payments. Providing states with standardized timeframes for when renewals must be completed and how information returned by the beneficiary should be considered by the state are also important components of the proposed rule. CMS has proposed important steps to update Medicaid and CHIP recordkeeping regulations and enhance the integrity of Medicaid and CHIP.
- Clearly define the types of eligibility determination information and documentation to be maintained by states.
- Remove references to outdated technology and require records to be stored in an electronic format.
- Require Medicaid and CHIP records and case documentation be retained for the time the case is active plus three years thereafter.
- Revise timeliness standards to apply expressly at renewal as well as application.
- Propose specific timelines for states to complete Medicaid and CHIP renewals, including guidelines to ensure beneficiaries who return information late are properly evaluated for other eligibility groups prior to being terminated.
 Medicaid Churning and Continuity of Care: Evidence and Policy Considerations Before and After the COVID-19 Pandemic; accessed on 8/30/21 at https://aspe.hhs.gov/sites/default/files/private/pdf/265366/medicaid-churning-ib.pdf.