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Medicaid Enrollment and Eligibility Changes

CMS has proposed simplifying Medicaid enrollment and increasing the number of people eligible to obtain and maintain coverage. Overall the goal is to streamline applications, verifications, enrollments, and renewals, standardize processes, and reduce red tape. These proposals are a response to the Biden Administration’s January 2021 and April 2022 executive orders to increase access to quality, affordable health coverage by strengthening Medicaid.

Some Medicaid enrollment policies can contribute to participation churn due to coverage disruption. It causes people to lose their coverage only to re-enroll while losing access to vital health services in the interim. By identifying opportunities to lessen the administrative burden for states and reducing roadblocks to enrollment and retention, CMS is broadening opportunities to offer better service to millions of Americans.

Some barriers being addressed include:

  • Individuals with eligibility based on age 65 or older, blindness, or disability are currently excluded from many CMS enrollment simplifications under the Affordable Care Act (ACA). Fixing this reduces the risk of losing or being denied coverage for procedural reasons, even when an individual meets eligibility requirements.
  • Regulations must ensure consumers have efficient access to the streamlined enrollment process for the Medicare Savings Programs (MSPs). These programs allow Medicaid to cover the cost of Medicare premiums or cost sharing for Medicaid participants based on receipt of other program benefits (i.e., Extra Help for Medicare Part D). Millions of unenrolled individuals are eligible but need better access to Medicare Savings Programs.
  • Recordkeeping regulations created to provide appropriate oversight and identify mistakes in state operations and policies. These regulations were last updated more than thirty years ago, resulting in inconsistent practices among states that contribute to errors in eligibility rates.
  • Clear guidance and consistent timeframes for applicants and beneficiaries to provide the information required to determine eligibility. This change will reduce unnecessary application and renewal processing delays and create stronger oversight for states to process the information they receive.

Because the administrative process of applying for Medicaid can seem burdensome, overly complicated, and unnecessarily delayed, making changes to the system is crucial. Specific aspects of streamlining application and enrollment include:

  • Allow the projection of predictable medical expenses of individuals and deduct the expenses from the applicant’s income when determining financial eligibility. These expenses may include prescription drugs and home care.
  • Eliminate application requirements for other benefits as a condition of Medicaid eligibility. This change prevents eligible individuals (especially those without an income test) from facing unnecessary administrative roadblocks.
  • With limited exceptions, ensure automatic enrollment for Supplemental Security Income (SSI) beneficiaries into the Qualified Medicare Beneficiary (QMB) group.
  • For individuals enrolling in conditional Part A during the General Enrollment Period, clarify the effective date of QMB coverage. This coverage can start as early as the month Part A entitlements begin.

Ensuring eligible individuals retain coverage offers equitable access. Many individuals slip through the cracks, losing coverage for a time that may significantly impact their medical care options. CMS seeks to improve retention rates and regular renewals by addressing those individuals exempt from the Modified Adjusted Gross Income (MAGI) income counting rules, including those 65 and older, blind or disabled. The new rule would require states to:

  • With limited exceptions, only conduct renewals once every twelve months.
  • Provide pre-populated renewal forms to ease the application burden.
  • Eliminate the requirement for in-person interviews.
  • Limit information requests on a change in circumstances to information on the change only.
  • Create a clear process that prevents termination of eligible beneficiaries who require transitioning from CHIP (under 18) to Medicaid when participants’ income changes or the individual appears eligible for the other program. Termination should be prevented even when the beneficiary does not respond to a request for information.
  • Create state-specific guidelines checking available data before terminating eligibility when the beneficiary’s address returns mail as undeliverable.
  • Create state options to use available data to update addresses when beneficiaries move intrastate.
  • Offer sufficient time for beneficiaries to provide the needed documentation to retain enrollment.

CMS also seeks to enhance the integrity of Medicaid recordkeeping regulations that can lead to improper payments and eligibility errors. The proposed regulations include the following:

  • Clear definition of eligibility determination data types and documentation the states must maintain.
  • Requirements to preserve active Medicaid case records and documentation and retain them for three years.
  • Require record storage to be in an electronic format and remove references to outdated technology.
  • Have timeliness standards that expressly apply to renewals as well as applications.
  • Propose that states meet specific timelines to complete Medicaid renewals, including to ensure beneficiaries returning information late are still properly evaluated for other eligibility groups before being terminated.

The proposals for Medicaid changes to rules and regulations are still under review, but decisions will be finalized soon. There is a lot of new information to digest. Although most proposals seek to simplify and streamline Medicaid eligibility, enrollment, and retention, it can be confusing to adapt to the changes. An elder law attorney or disability lawyer can help you understand what the proposed changes mean to you. When the changes take full effect, your lawyer can also amend any of your retirement or estate plans to ensure that you receive the full benefits available to you. For assistance, please contact our Forty Fort office or call (570) 288-1800.

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