Proposed CMS rule would streamline Medicaid, CHIP enrollment

MM Curator summary

[MM Curator Summary]: New rules could standardize Medicaid eligibility and enrollment processes nationwide, but it would come at the cost of making it more difficult for states to right-size the rolls more than 1x a year.




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The exterior of the U.S. Department of Health and Human Service in Washington, DC. Alex Wong via Getty Images

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Dive Brief:

  • The CMS on Wednesday issued a proposed rule aimed at reducing coverage gaps by streamlining the application and renewal process for Medicaid enrollees and other programs like the Children’s Health Insurance Program.
  • Among other things, the proposed rule aims to make CHIP and Medicaid enrollment easier for children, older adults and those with lower incomes by limiting renewals to once a year, establishing standardized statewide renewal processes and giving applicants 30 days to respond to information requests.
  • The proposed rule comes as states begin to notify Medicaid beneficiaries about potential losses of coverage due to the impending end of the COVID-19 public health emergency.

Dive Insight:

The COVID-19 PHE created a continuous coverage requirement for Medicaid enrollees in states that accepted matching rates for Medicaid payments, allowing those with Medicaid coverage to forgo renewing for eligibility and retain their coverage.

Enrollment in CHIP and Medicaid programs jumped 24% during the PHE, making it the largest source of health coverage in the U.S. Estimates on how many could get kicked off coverage once the PHE ends range between 5 million and 14 million beneficiaries.

The proposed rule would make it easier to enroll and retain Medicaid coverage as some states begin notifying Medicaid beneficiaries that they may lose coverage when the COVID-19 public health emergency ends.

In addition to standardizing procedural enrollment and renewal processes for states, the proposed rule also attempts to lower coverage disruptions and churning, which can occur when people lose coverage and re-enroll quickly by simplifying the enrollment process and maintaining continuity of coverage for those eligible.

It initiates applications for Medicare Savings Programs, allowing those who use low-income subsidies to be eligible for MSP coverage “to the maximum extent possible.” Currently, there are no regulations that ensure efficient enrollment processes for MSPs, resulting in “millions” of eligible individuals to miss out on potential savings, according to the CMS.

“This proposed rule will ensure that these individuals and families, often from underserved communities, can access the health care and coverage to which they are entitled — a foundational principle of health equity,” CMS Administrator Chiquita Brooks-LaSure said in a news release.

People over 65 and with blindness or a disability, who are excluded from enrollment simplifications, would also have access to an easier enrollment process in the proposed rule. Renewals would occur no more than once a year, with the rule also proposing to eliminate in-person interviews and provide a minimum 90-day reconsideration period after termination for “failure to return information needed to redetermine eligibility.”

In the proposed rule, states would also see more federal oversight for their enrollment and renewal processes by establishing guidelines to check available data prior to determining eligibility if a beneficiary can’t be reached by mail and providing timelines for when renewals must be completed.

Other changes include:

  • Automatic enrolling, with some exceptions, for Supplemental Security Income recipients into Qualified Medicare Beneficiary groups.
  • Allowing projected and predictable medical expenses to be deducted from an applicant’s income when determining financial eligibility, including home care and prescription drugs.
  • Eliminating the requirement to apply for other benefits as a condition of Medicaid eligibility to reduce administrative hurdles.
  • Requiring states to keep Medicaid and CHIP records and case documentation from the time the case is active plus three years thereafter.
  • Establishing a clear process to prevent eligible termination for 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 if the beneficiary fails to respond to requests for information.


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