4 Medicaid Eligibility, Enrollment Processes States Must Address

Six months after the public health emergency ends, states will need to have completed certain Medicaid eligibility and enrollment processes, CMS has indicated. They must prepare in advance in order to meet these expectations, a Kaiser Family Foundation issue brief explained.

As the coronavirus vaccines start to roll out and the end of the public health emergency seems to be in sight, state Medicaid programs must consider how they will return to normal policies.

During the coronavirus pandemic, CMS established waivers meant to streamline administrative processes while states were addressing urgent coronavirus-related demands. These will end with the public health emergency.

The agency also set in place certain regulations to strengthen Medicaid’s role as safety net insurance during the crisis. Primarily, this meant that states had to provide maintenance of eligibility.

In order to comply with the maintenance of eligibility rule, states had to maintain standards of eligibility that were no more strict than those in place on January 1, 2020. States also had to offer continuous coverage for beneficiaries enrolled in Medicaid on March 18, 2020. Medicaid programs could not drop beneficiaries’ coverage during the public health emergency.

Additionally, states kept Medicaid premiums the same as they were on January 1, 2020—with certain exceptions—and reimbursed beneficiaries who paid more. Under maintenance of eligibility, Medicaid programs had to cover coronavirus testing and treatment. Lastly, maintenance of eligibility restricted political subdivision contributions.

The Trump administration pushed the public health emergency into April 2021 and the Biden administration is expected to extend it. States will receive an advance notice 60 days before the public health emergency’s official end date, but they can begin preparing a timeline for this effort even now.

States will have to address four areas related to eligibility and enrollment when the public health emergency ends and when maintenance of eligibility is no longer required: applications, verifications, redeterminations, and renewals.

First, states must handle new Medicaid applications. This should begin during the public health emergency, as Medicaid programs have the bandwidth.

When the public health emergency ends, states will continue to receive applications as they work through a backlog of administrative processes. These new applications should receive priority, CMS has indicated.

Second, states will need to address verifications. Medicaid programs should start processing pending post-enrollment verifications and self-attestations during the public health emergency to make headway on the backlog.

After the public health emergency, states have six months to complete the pending verifications. This process should be states’ second priority, along with fulfilling redeterminations and renewals.

Once these are complete, states may consider streamlining their eligibility and enrollment processes by improving verifications. CMS has recommended fortifying the verifications processes in the past in order to crack down on fraud and eligibility inaccuracies.

Third, states should process redeterminations.

Due to expanded eligibility during the public health emergency and shifting economic circumstances, individuals who qualified for Medicaid coverage during the crisis may no longer be eligible after the public health emergency ends. This is particularly true in states that do not incorporate eligibility guidelines from the public health emergency into their normal guidelines.

Four months after the public health emergency ends, states will be expected to resume timely eligibility determinations and redeterminations should be complete within six months of the end of the crisis. If redetermination guidelines will be stricter following the public health emergency, states have to alert impacted enrollees at least 30 days before they lose coverage.

Additionally, if a Medicaid program conducted a redetermination and found a beneficiary no longer qualified for coverage and have not received a response from the individual in six months, then the state does not have to conduct the redetermination again in order to terminate the beneficiary after the public health emergency.

Lastly, states must address renewals. If possible, Medicaid programs should start processing renewals during the public health emergency. However, as with redeterminations and verifications, they have six months after the public health emergency in which to conduct the process.

In order to streamline the process, CMS suggested prioritizing applications by population, time that the application has been pending, or a hybrid of these two models. Alternatively, states can create their own strategies to sift through applications that are most likely to be ineligible.

Kaiser Family Foundation also outlined strategies to extend or end policies.