The Centers for Medicare & Medicaid Services (CMS) recently sent another letter (PDF) to state Medicaid directors regarding the resumption of Medicaid eligibility checks following the “unwinding” of continuous enrollment provisions instituted during the COVID-19 public health emergency.
This letter focused on a new “operational issue affecting multiple states,” specifically how states may be improperly conducting ex parte, or automatic, renewals at the household level, without regard to differing eligibility statuses and income thresholds for individuals within the household. Some states are disenrolling all members of a household if one member fails to return a renewal form, for example, despite other individuals in the household being eligible. The letter notes that federal regulations require states to complete a redetermination of eligibility based on available information for each individual in the household, regardless of the eligibility of others in the household unit, and that not doing so is a violation of federal law. The letter goes on to point out that Medicaid and CHIP eligibility levels for children are generally higher than those for adults and reiterates that states are required by law to renew Medicaid or CHIP coverage for these eligible children based on available income information obtained during the ex parte process.
CMS is instructing all Medicaid and CHIP agencies to review their renewal systems and processes to ensure that they are in compliance with individual, as opposed to household-level assessments, and if they are not, to immediately pause procedural determinations for affected individuals, reinstate coverage retroactively for affected individuals, fix their systems and processes, and implement one or more mitigation strategies described in detail in the letter. Those who fail to comply will be subject to possible corrective action plans, civil money penalties and disqualification for the temporary FMAP increase. Additional questions may be directed to [email protected].