Streamlining the Medicaid, Kid’s Health Insurance Program, and Basic Health Program Application, Eligibility Determination, Enrollment, and Renewal Processes

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Proposed rule.

CFR Part: “42 CFR Parts 431, 435, 457, and 600”

RIN Number: “RIN 0938-AU00”

Citation: “87 FR 54760”

Document Number: “CMS-2421-P”

Page Number: “54760”

“Proposed Rules”

Agency: “Centers for Medicare & Medicaid Services (CMS), HHS.”

SUMMARY: This rulemaking proposes changes to simplify the processes for eligible individuals to enroll and retain eligibility in Medicaid, the Kid’s Health Insurance Program (CHIP), and the Basic Health Program. This proposed rule would remove barriers and facilitate enrollment of recent applicants, particularly those dually eligible for Medicare and Medicaid; align enrollment and renewal requirements for most people in Medicaid; establish beneficiary protections related to returned mail; create timeliness requirements for redeterminations of eligibility in Medicaid and CHIP; make transitions between programs easier; eliminate access barriers for kids enrolled in CHIP by prohibiting premium lock-out periods, waiting periods, and profit limitations; and modernize recordkeeping requirements to make sure proper documentation of eligibility and enrollment.

   DATES:

To be assured consideration, comments have to be received at considered one of the addresses provided below, no later than 5 p.m. on November 7, 2022.

   ADDRESSES: In commenting, please discuss with file code CMS-2421-P.

Due to staff and resource limitations, we cannot accept comments by facsimile (FAX) transmission.

Comments, including mass comment submissions, have to be submitted in considered one of the next 3 ways (please select only considered one of the ways listed):

1. Electronically. Chances are you’ll submit electronic comments on this regulation to http://www.regulations.gov. Follow the “Submit a comment” instructions.

2. By regular mail. Chances are you’ll mail written comments to the next address ONLY: Centers for Medicare & Medicaid Services, Department of Health and Human Services, Attention: CMS-2421-P, P.O. Box 8016, Baltimore, MD 21244-8016.

Please allow sufficient time for mailed comments to be received before the close of the comment period.

3. By express or overnight mail. Chances are you’ll send written comments to the next address ONLY: Centers for Medicare & Medicaid Services, Department of Health and Human Services, Attention: CMS-2421-P, Mail Stop C4-26-05, 7500 Security Boulevard, Baltimore, MD 21244-1850.

For information on viewing public comments, see the start of the SUPPLEMENTARY INFORMATION section.

   FOR FURTHER INFORMATION CONTACT: Stephanie Bell, (410) 786-0617, [email protected].

   SUPPLEMENTARY INFORMATION:

Inspection of Public Comments: All comments received before the close of the comment period can be found for viewing by the general public, including any personally identifiable or confidential business information that’s included in a comment. We post all comments received before the close of the comment period on the next website as soon as possible after they’ve been received: http://www.regulations.gov. Follow the search instructions on that website to view public comments.

I. Background Since 1965, Medicaid has been a cornerstone of America’s health care system. This system provides free or low-cost health coverage to low-income individuals and families and helps to satisfy the various health care needs of kids, pregnant individuals, parents and other caretaker relatives, older adults, and other people with disabilities. For 25 years, the Kid’s Health Insurance Program (CHIP) has served as a bridge from Medicaid to personal insurance for somewhat higher-income children. As of May 2022, probably the most recent month for which enrollment data can be found, nearly 89 million individuals were enrolled in Medicaid and CHIP. /1/

   FOOTNOTE 1 May 2022 Medicaid & CHIP Enrollment Data Highlights–https://www.medicaid.gov/medicaid/national-medicaid-chip-program-information/medicaid-chip-enrollment-data/monthly-medicaid-chip-application-eligibility-determination-and-enrollment-reports-data/index.html. END FOOTNOTE

Access to health coverage expanded significantly in 2010 with enactment of the Patient Protection and Reasonably priced Care Act (Pub. L. 111-148, enacted on March 23, 2010), as amended by the Health Care and Education Reconciliation Act of 2010 (Pub. L. 111-152, enacted on March 30, 2010), together known as the Reasonably priced Care Act (ACA). The ACA expanded Medicaid eligibility to low-income adults under age 65 without regard to parenting or disability status, simplified Medicaid and CHIP enrollment processes, and established medical health insurance Marketplaces where individuals without access to Medicaid, CHIP, or other comprehensive coverage could purchase coverage in a Qualified Health Plan (QHP). Many individuals with household income above the Medicaid and CHIP income standards became eligible for premium tax credits and/or cost-sharing reductions to assist cover the fee of the coverage. As well as, the ACA provided States with the choice of creating a Basic Health Program (BHP), which provides reasonably priced health coverage to individuals whose household income exceeds 133 percent but doesn’t exceed 200 percent of the Federal Poverty Level (FPL) (that’s, lower income individuals who would otherwise be eligible to buy coverage through the Marketplaces with financial subsidies). BHPs allow States to supply cheaper coverage for these individuals and to enhance the continuity of look after those whose income fluctuates above and below the Medicaid and CHIP levels. So far, two States, Recent York and Minnesota, have established BHPs, covering over 1 million people. /2/

   FOOTNOTE 2 https://www.cms.gov/files/document/health-insurance-exchanges-2022-open-enrollment-report-final.pdf. END FOOTNOTE

Along with coverage expansion, the ACA also required the establishment of a seamless system of coverage for all insurance affordability programs (that’s, Medicaid, CHIP, BHP, and the insurance affordability programs available through the Marketplaces). In accordance with sections 1943 and 2107(e)(1)(T) of the Social Security Act (the Act) and sections 1413 and 2201 of the ACA, individuals must give you the chance to use for, and enroll in, this system for which they qualify using a single application submitted to any program. Within the March 23, 2012 Federal Register, CMS issued implementing regulations titled “Medicaid program; Eligibility Changes Under the Reasonably priced Care Act of 2010” final rule, (77 FR 17144) (referred to hereafter because the “2012 eligibility final rule”), and the “Medicaid and Kid’s Health Insurance Programs: Essential Health Advantages in Alternative Profit Plans, Eligibility Notices, Fair Hearing and Appeal Processes, and Premiums and Cost Sharing; Exchanges: Eligibility and Enrollment” final rule titled in July 2013 (78 FR 42160) (referred to hereafter because the “2013 eligibility final rule”). These regulations focused on establishing a single streamlined application, aligning financial methodologies and procedures across insurance affordability programs, and maximizing electronic verification to be able to create a streamlined, coordinated, and efficient eligibility and enrollment process for eligibility determinations based on Modified Adjusted Gross Income (MAGI).

Significant progress has been made in simplifying eligibility, enrollment, and renewal processes for applicants and enrollees, in addition to reducing administrative burden on State agencies administering Medicaid, CHIP, and BHP, for the reason that promulgation of those regulations. The dynamic online applications developed by States and the Federally Facilitated Marketplaces, which ask only those questions needed to find out eligibility have reduced burden on applicants. Greater reliance on electronic verifications has reduced the necessity for people to search out and submit, and for eligibility employees to review, copies of paper documentation, decreasing burden on each States and individuals and increasing program integrity. Renewals accomplished using electronic information available to States have increased retention of eligible individuals, while also decreasing the executive burden on each States and enrollees.

Following a period of regular growth attributed to the ACA, enrollment in Medicaid and CHIP declined from 2017 through 2019. Evidence suggests that the economy was the first driver of this decline. Nevertheless, we also know that more restrictive State enrollment policies contribute to coverage disruptions and create churning as people lose their Medicaid or CHIP coverage after which re-enroll inside a brief time frame. /3/ The Georgetown University Center for Children and Families estimated that 4.4 million children were uninsured in 2019, a rise from 2016 of 726,000 uninsured children. uninsurance amongst children by income, those with household income below 138 percent of the FPL (133 percent of the FPL is the minimum income standard that States may establish for kids in Medicaid, plus a 5 percentage point disregard), the proportion of Medicaid-eligible children who didn’t have any medical health insurance coverage increased from 6.8 percent in 2016 to 7.7 percent in 2019. /4/ Based on probably the most recently available data from the American Community Survey, children in poverty continued to experience a rise in uninsurance from 2018 through 2020 because the uninsurance rate increased by 1.6 percentage points to 9.3 percent. /5/ The raw numbers represented by these percentage changes correspond to numerous individual children who were uninsured despite having a household income low enough to be eligible for Medicaid and who can have deferred or foregone needed health care because of this.

   FOOTNOTE 3 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. END FOOTNOTE

   FOOTNOTE 4 Alker, Joan and Corcoran, Alexandra. 2020. “Kid’s Uninsured Rate Rises by Largest Annual Jump in Greater than a Decade.” Accessed on 03/16/2022 at https://ccf.georgetown.edu/wp-content/uploads/2020/10/ACS-Uninsured-Kids-2020_10-06-edit-3.pdf. END FOOTNOTE

   FOOTNOTE 5 Katherine Keisler-Starkey and Lisa N. Bunch, U.S. Census Bureau Current Population Reports, P60-274, Health Insurance Coverage in the USA: 2020, U.S. Government Publishing Office, Washington, DC, September 2021. END FOOTNOTE

Moreover, enrollment in Medicare Savings Programs (MSPs), through which Medicaid provides coverage of Medicare premiums and/or cost-sharing for lower income Medicare beneficiaries, has remained relatively low. The MSPs are essential to the health and economic well-being of those enrolled, promoting access to care and helping liberate individuals’ limited income for food, housing, and other of life’s necessities. Yet a 2017 study conducted for Medicaid and CHIP Payment and Access Commission (MACPAC) estimated that only about half of eligible Medicare beneficiaries were enrolled in MSPs. /6/

   FOOTNOTE 6 Medicare Savings Program Enrollees and Eligible Non-Enrollees, Kyle J. Caswell, Timothy A. Waidmann, The Urban Institute, June 2017: https://www.macpac.gov/wp-content/uploads/2017/08/MSP-Enrollees-and-Eligible-Non-Enrollees.pdf. END FOOTNOTE

The critical role of Medicaid and CHIP providing timely health care access to probably the most vulnerable individuals was highlighted because the Novel Coronavirus 2019 (“COVID-19”) spread across our country starting in 2020. Medicaid and CHIP helped to supply a lifeline for many who can have lost their jobs or been exposed to COVID-19, or each, they usually played a critical role within the national pandemic response. The Families First Coronavirus Response Act (Pub. L. 116-127) (FFCRA) conditioned a brief increase in Federal Medicaid funding on State compliance with several conditions, including maintaining enrollment for beneficiaries enrolled in Medicaid through the top of the month through which the COVID-19 public health emergency (PHE) ends (“continuous enrollment condition”). Moreover, the FFCRA, together with the Coronavirus Aid, Relief, and Economic Security Act (CARES Act; Pub. L. 116-135) and the American Rescue Plan Act of 2021 (ARP; Pub. L. 117-2), also ensured Medicaid and CHIP coverage of COVID-19 testing, treatment, and vaccines, in addition to vaccine administration.

The Biden-Harris Administration is committed to protecting and strengthening Medicaid and CHIP each during and following the COVID-19 PHE. On January 20, 2021, President Biden issued an Executive Order on advancing racial equity and support for underserved communities. It charged Federal agencies with identifying potential barriers that underserved communities may face to enrollment in programs like Medicaid and CHIP. /7/ This was followed on January 28, 2021, by Executive Order 14009 with a selected call to strengthen Medicaid and the ACA and take away barriers to obtaining coverage for the thousands and thousands of people who’re potentially eligible but remain uninsured. /8/ In April 2022, President Biden issued one other Executive Order, constructing on progress from the primary and reflecting latest Medicaid and CHIP flexibilities established by the ARP. The April 5, 2022 Executive Order 14070, “Continuing to Strengthen Americans’ Access to Reasonably priced, Quality Health Coverage” charges Federal agencies with identifying ways to assist more Americans enroll in quality health coverage. /9/ It calls upon Federal agencies to look at policies and practices that make it easier for people to enroll in and retain coverage. Following this charge, we reviewed the improvements made to implement the ACA, examined States’ successes and challenges in enrolling eligible individuals, considered the changes led to by the COVID-19 PHE, and searched for gaps in our regulatory framework that proceed to impede access to coverage.

   FOOTNOTE 7 E.O. 13985, 86 FR 7009. Accessed online on July 19, 2022 at https://www.whitehouse.gov/briefing-room/presidential-actions/2021/01/20/executive-order-advancing-racial-equity-and-support-for-underserved-communities-through-the-federal-government/. END FOOTNOTE

   FOOTNOTE 8 E.O. 14009, 86 FR 7793. Accessed online on July 19, 2022 at https://www.whitehouse.gov/briefing-room/presidential-actions/2021/01/28/executive-order-on-strengthening-medicaid-and-the-affordable-care-act/. END FOOTNOTE

   FOOTNOTE 9 E.O. 14070, 87 FR 20689. Accessed online on July 19, 2022 at https://www.whitehouse.gov/briefing-room/presidential-actions/2022/04/05/executive-order-on-continuing-to-strengthen-americans-access-to-affordable-quality-health-coverage/. END FOOTNOTE

Now we have learned through our experiences working with States and other stakeholders that certain policies proceed to end in unnecessary administrative burden and create barriers to enrollment and retention of coverage for eligible individuals. For instance:

* There are not any regulations to facilitate enrollment within the MSPs. Particularly, CMS doesn’t have regulations to link enrollment in other Federal programs with the MSPs, despite the high likelihood that individuals in such programs are eligible for the MSPs. This hinders States’ ability to enroll those known to be eligible. Moreover, stakeholders report that burdensome documentation requirements substantially impede eligible individuals from enrolling within the MSPs. /10/

   FOOTNOTE 10 In October 2020, CMS engaged with 55 stakeholders across 4 States to higher understand experiences when applying for the MSPs. One among the predominant findings was that burdensome documentation requirements substantially impede eligible individuals from enrolling within the MSPs and that easing these requirements is a critical step to making sure individuals can obtain and retain these critical advantages. END FOOTNOTE

    * Individuals whose eligibility just isn’t based on MAGI (non-MAGI individuals)–for example, those whose eligibility relies on being age 65 or older, having blindness, or having a disability–generally weren’t included within the enrollment simplifications established under the ACA or our implementing regulations (the 2012 and 2013 eligibility final rules), leaving such individuals at greater risk of being denied or losing coverage resulting from procedural reasons than their MAGI-based counterparts, despite the fact that, we consider, many usually tend to remain Medicaid eligible resulting from lower likelihood of changes of their income or other circumstances.

    * Current regulations don’t consistently provide clear timeframes for applicants and enrollees to return information needed by the State to make a determination of eligibility or for States to process and act upon information received. This may occasionally result in unnecessary delay in processing applications and renewals, some ineligible individuals retaining coverage, and a few individuals being denied increased assistance for which they’ve change into eligible.

    * Our recordkeeping regulations, that are critical to making sure appropriate and effective oversight to discover errors in State policies and operations, were last updated in 1986 and are each outdated and lacking in needed specificity. We consider these outdated requirements have contributed to inconsistent documentation policies across States, which can have furthered the incidence of Medicaid improper payments.

    * Barriers to coverage that should not permitted under some other insurance affordability program–including lock-outs for people terminated resulting from non-payment of premiums, required periods of uninsurance prior to enrollment, and annual or lifetime caps on benefits–remain a State option in separate CHIPs.

On this rulemaking, we seek to shut these and other gaps, thereby streamlining Medicaid and CHIP eligibility and enrollment processes, reducing administrative burden on States and enrollees, and increasing enrollment and retention of eligible individuals. We also seek to enhance the integrity of Medicaid and CHIP. Through the PERM program, the Medicaid Eligibility Quality Control (MEQC) program, and other CMS eligibility reviews, we’ve regular opportunities to work with States in reviewing their eligibility and enrollment processes. Consequently of those reviews, and other internal program integrity efforts, States are continually bettering their eligibility and enrollment systems each to boost functionality and to correct any newly identified issues. We consider the changes proposed on this rule will further these program integrity efforts, and we’ll proceed to work closely with States throughout implementation.

Current regulations at 42 CFR 433.112 establish conditions that State eligibility and enrollment systems must meet to be able to qualify for enhanced Federal matching funds. Amongst these conditions, SEC 433.112(b)(14) requires that every State system support accurate and timely processing and adjudications/eligibility determinations. As States submit proposed changes to their eligibility and enrollment systems and implement latest and/or enhanced functionality, we’ll proceed to supply them with technical assistance on the policy requirements, conduct ongoing reviews of each the State policy and State systems, and make sure that all proposed changes support more accurate and timely processing of eligibility determinations.

We may also proceed to explore other opportunities for reducing the incidence of beneficiary eligibility-related improper payments, including leveraging the improved funding available for design, implementation, and operation of State eligibility and enrollment systems, in addition to mitigation and corrective motion plans that address specific State challenges. Our goal is to make sure that eligible individuals can enroll and stay enrolled without unnecessary burden and that ineligible individuals are redirected to the suitable coverage programs as quickly as possible.

Finally, we recognize that the COVID-19 PHE and the continual enrollment condition have disrupted routine eligibility and enrollment operations for Medicaid, CHIP, and BHP. As States look ahead toward the eventual end of the PHE and the resumption of routine operations, they’re faced with providing coverage for a significantly larger pool of enrollees than they’ve ever had to administer previously. From February 2020 through May 2022, enrollment in Medicaid and CHIP increased by 25.9 percent, or 18.3 million individuals, and latest applications proceed to be submitted. In May 2022, about 2.1 million latest applications for Medicaid and CHIP were submitted to States. At the identical time, many States report a shortage of eligibility employees.

CMS is actively engaged with States as they plan for initiating eligibility and enrollment work over the course of a 12-month unwinding period when the COVID-19 PHE ends (hereinafter known as the “unwinding period”). A March 2022 report by the Urban Institute projected that as many as 15.8 million people could lose their Medicaid coverage when the PHE ends and the continual enrollment requirement is not any longer in effect. /11/ It’s a CMS priority to make sure that renewals of eligibility and transitions between coverage programs occur in an orderly process that minimizes beneficiary burden and promotes continuity of coverage.

   FOOTNOTE 11 Buettgens, M. and Green, A. 2022. What is going to Occur to Medicaid Enrollees’ Health Coverage after the Public Health Emergency. Washington, DC: Urban Institute. Accessed on July 19, 2022 at https://www.urban.org/research/publication/what-will-happen-medicaid-enrollees-health-coverage-after-public-health-emergency. END FOOTNOTE

As we consider the challenges faced by States through the unwinding period, we seek comment on reasonable implementation timelines for the provisions on this proposed rule, which might allow States to maneuver these vital protections forward without negatively impacting the resumption of routine eligibility and enrollment operations. Certain provisions designed to enhance the retention of eligible individuals, resembling the potential deduction of medical expenses for medically needy individuals, agency actions on returned mail, and transitions between coverage programs, could reduce the likelihood of eligible individuals losing health coverage during unwinding. Nevertheless, if implementing such provisions early would divert needed resources away from critical unwinding-related activities, then a compliance date following the unwinding period could also be preferred.

We recognize that every State faces a singular set of challenges related to the unwinding period, with differing needs and opportunities. As we contemplate the timing of a final rule, we’re considering adopting an efficient date of 30 days following publication and a separate compliance date, which can vary by requirement, with full compliance no later than 12 months following the effective date of the ultimate rule. This approach would offer States with immediate access to latest options, just like the option to ascertain an earlier effective date for coverage provided to individuals eligible within the QMB group. This approach also would allow States to right away extend temporary options authorized under section 1902(e)(14)(A) of the Act as they prepare for unwinding, just like the choice to depend on certain third-party information to update a beneficiary’s mailing address. And it might permit States with greater capability to implement latest system changes to right away adopt simplifications like removal of the requirement to use for other advantages as a condition of Medicaid eligibility.

At the identical time, we recognize that certain changes proposed on this rule may require States to make changes to their very own statute and/or regulations, in addition to systems changes prior to implementation, and this process can take time. For instance, if the proposed prohibition on premium lock-out periods, which delay a baby’s ability to re-enroll in a separate CHIP following termination of coverage resulting from the family’s failure to pay premiums, is finalized, we would offer CHIPs that currently impose such lockout periods with the time needed to comply with the brand new prohibition. At the identical time, by making the ultimate rule effective 30 days following enactment, States couldn’t newly adopt a premium lock-out period.

We seek comment on whether an efficient date of 30 days following publication could be appropriate when combined with a later date for compliance for many provisions. We seek comment on the timeframe that may be only for compliance with each provision and whether the compliance date should vary by provision. We consider compliance with the proposed provision implementing current statutory requirements (the requirement to utilize Medicare Part D Low-Income Subsidy “leads” data from SSA to initiate an MSP application) needs to be required 30 days following publication of the ultimate rule, because we do not need flexibility to delay what’s required under the statute. Recent State options established under the ultimate rule could be effective 30 days following publication, but don’t require a compliance date, since States should not required to adopt optional policies. We might encourage States to return into compliance with all other latest requirements as expeditiously as possible, not only because they might improve access for brand spanking new applicants and improve retention of eligible enrollees, but in addition because they might streamline eligibility and enrollment processes and promote the general integrity of Medicaid and CHIP. Nevertheless, for proposed provisions that don’t create State options and should not implementing statutory requirements, we’re considering compliance dates of 90 days, 6 months, and/or 12 months following the effective date of the ultimate rule. We seek comment on the suitable compliance timeframe for every provision, and request that commenters explain why they consider finalizing a shorter or longer compliance timeframe is most appropriate.

II. Provisions of the Proposed Regulations

A. Facilitating Medicaid Enrollment

1. Facilitate Enrollment Through Medicare Part D Low-Income Subsidy “Leads” Data ([Sec.] SEC 435.4, 435.601, 435.911, and 435.952)

The MSPs consist of several mandatory Medicaid eligibility groups that cover Medicare Part A and/or B premiums and, in some cases, cost-sharing. State Medicaid agencies receive applications and adjudicate eligibility for full Medicaid, in addition to MSP-only advantages. Currently, the MSP eligibility groups cover over 10 million low-income individuals. There are three primary MSP eligibility groups: /12/ the Qualified Medicare Beneficiary (QMB) group, which pays all of a person’s Medicare Parts A and B premiums and assumes liability for many associated Medicare cost-sharing charges for individuals with income that doesn’t exceed 100% of the FPL; the Specified Low-Income Medicare Beneficiary (SLMB) group, which pays the Part B premium for individuals with income that exceeds 100%, but is lower than 120 percent, of the FPL; and the Qualifying Individuals (QI) group, which pays Part B premiums for individuals with income at the least 120 percent but lower than 135 percent of the FPL. Individuals also must meet corresponding resource criteria to be able to be eligible for an MSP. The income and resource requirements for coverage under the MSPs, and the advantages to which eligible individuals are entitled, are set forth at sections 1905(p)(1) and 1902(a)(10)(E) of the Act. Amongst other things, section 1905(p) of the Act directs that the income and resource methodologies applied by the Social Security Administration (SSA) in determining SSI eligibility per sections 1612 and 1613 of the Act be used to find out financial eligibility for the MSPs, except that States may employ less restrictive income and/or resource methodologies than those applied in determining SSI eligibility under the authority of section 1902(r)(2) of the Act.

   FOOTNOTE 12 There may be a separate and fourth MSP eligibility group generally known as the “Qualified Disabled Working Individuals (QDWI) group,” or QDWI group. As described in 1902(a)(10)(E)(ii), eligibility within the QDWI group is proscribed to individuals whose incomes don’t exceed 200 percent of the FPL; whose resources don’t exceed twice the relevant SSI resource standard (that’s, for a single individual or couple); and who’re eligible to enroll in Part A under section 1818A of the Act. Section 1818A of the Act permits individuals who became entitled to Part A on the idea of their receipt of Social Security disability insurance (SSDI) and who subsequently lose SSDI after returning to work (and, hence, entitlement to Part A) to enroll in Part A contingent on paying the Part A premiums. The medical assistance available to QDWIs is the coverage of the Part A premiums. The QDWI group just isn’t included on this proposal, since the income limits of the QDWI group are significantly higher than LIS and there doesn’t exist the pliability to disregard resources which are available for the opposite MSPs. END FOOTNOTE

The MSPs are essential to the health and economic well-being of low-income Medicare enrollees, helping to liberate limited income for food, housing, and other life necessities. For instance, in 2022, the Part B premium is $170.10 a month, which is greater than 10 percent of the income of people who qualify for the QI group, and a good higher percentage of income for many who qualify for the QMB or SLMB groups. Despite the importance of the MSPs, a 2017 study conducted for MACPAC estimated that only about half of eligible individuals enrolled in Medicare were also enrolled within the MSPs. /13/ Which means thousands and thousands of Medicare enrollees living in poverty are paying over 10 percent of their income to cover Medicare premiums alone. Complex MSP enrollment processes contribute to this low participation rate.14 /15/ With a view to address the barriers to accessing MSP coverage, in 2008 Congress enacted the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA, Pub. L. 110-275). MIPPA included latest requirements for States to leverage the Medicare Part D Low-Income Subsidy (LIS) program to assist enroll likely-eligible individuals in MSPs.

   FOOTNOTE 13 Medicare Savings Program Enrollees and Eligible Non-Enrollees, Kyle J. Caswell, Timothy A. Waidmann, The Urban Institute, June 2017: https://www.macpac.gov/wp-content/uploads/2017/08/MSP-Enrollees-and-Eligible-Non-Enrollees.pdf. END FOOTNOTE

   FOOTNOTE 14 Lack of Medicare-Medicaid Dual Eligible Status: Frequency, Contributing Aspects, and Implications, Office of the Assistant Secretary for Planning and Evaluation, 2019. https://aspe.hhs.gov/basic-report/loss-medicare-medicaid-dual-eligible-status-frequency-contributing-factors-and-implications. END FOOTNOTE

   FOOTNOTE 15 Medicare Savings Programs: Implementation of Requirements Aimed toward Increasing Enrollment, Government Accountability Office, 2012. https://www.gao.gov/assets/gao-12-871.pdf. END FOOTNOTE

The Medicare Part D LIS program, also sometimes known as “Extra Help,” is run by SSA and pays Medicare Part D prescription drug premiums and cost-sharing for over 13 million individuals with low income. Full premium subsidy LIS (or “full LIS”) generally pays the Part D premiums and deductibles in full and sets co-payments for drugs at between $0 and $9.85 (in 2022) for individuals with incomes below 135 percent of the FPL 16 /17/ who also meet certain resource criteria. To receive this profit, individuals complete an application and submit it to SSA. Once received, SSA verifies the knowledge provided on the LIS applications and determines eligibility. Income, resources and other eligibility criteria for the LIS program are defined at section 1860D-14 of the Act. Under section 1860D-14(a)(3)(C)(i) of the Act, income shall be determined in the style described in section 1905(p)(1)(B) of the Act, without regard to the applying of section 1902(r)(2) of the Act and except that support and maintenance furnished in kind shall not be counted as income. Section 1860D-14 of the Act provides that, for purposes of determining eligibility for the LIS program, applicants’ resources be calculated “as determined under section 1613 of the Act for the needs of the supplemental security income (SSI) program subject to a life insurance exclusion policy.” The SSA has also adopted several other regulatory and sub-regulatory methodological simplifications for the LIS program that deviate from SSI rules. These include the exclusion of interest and dividend income and non-liquid resources and burial funds.

   FOOTNOTE 16 Section 1860D-14 of the Act [42 U.S.C. 1395w-114]. END FOOTNOTE

   FOOTNOTE 17 Partial premium subsidy LIS (or “partial LIS”) generally pays for premiums on a sliding scale, from 100% to 25 percent paid, and sets deductibles and co-payments for drugs at a reduced level for individuals with income below 150 percent of the FPL who meet certain resource criteria. END FOOTNOTE

The MSP and LIS programs each assist individuals with incomes below 135 percent of the FPL /18/ in accessing the Medicare advantages to which they’re entitled and, as illustrated above, generally use a standard methodology to find out income and resource eligibility. Current regulations at 42 CFR 423.773(c) require that individuals enrolled in MSPs be mechanically enrolled in LIS, however the reverse just isn’t true, and lots of people enrolled within the LIS program should not enrolled in an MSP, despite likely being eligible. As mentioned above, MIPPA included several provisions to advertise the enrollment of LIS applicants into the MSPs. As well as, section 112 of MIPPA amended section 1905(p)(1)(C) of the Act to extend the resource limit for the QMB, SLMB, and QI MSP eligibility groups to the identical resource limit applied for full LIS established at section 1860D-14(a)(3) of the Act. The resource standard for the complete LIS program and the QMB, SLMB, and QI eligibility groups for 2022 is $8,400 for a single individual and $12,600 for a pair.

   FOOTNOTE 18 Section 11404 of the Inflation Reduction Act of 2022 (Pub. L. 117-169, enacted on August 16, 2022) increases the income limit for the complete LIS program to income below 150 percent of the FPL and increases the resource limit to the identical resource limit as applied for partial LIS program at section 1860D-14(a)(3)(E) of the Act starting January 1, 2024. END FOOTNOTE

Section 113 of MIPPA amended section 1144 of the Act to further eliminate barriers to enrollment within the MSP and LIS programs. Section 1144(c)(3) of the Act requires SSA to transmit data from LIS applications (“leads data”) to State Medicaid agencies. Section 1144(c)(3) of the Act also provides that the electronic transmission from SSA “shall initiate” an MSP application. MIPPA section 113 also added a latest paragraph at section 1935(a)(4) of the Act that, starting January 1, 2010, required States to just accept leads data and “act upon such data in the identical manner and in accordance with the identical deadlines as if the info constituted” an MSP application submitted by the person. As such, under SEC 435.912, States have 45 days to make an MSP eligibility determination based on the LIS data. The date of the MSP application is defined because the date of the person’s application for LIS under section 1935(a) of the Act.

Despite these statutory requirements, not all States initiate an MSP application upon receipt of leads data from SSA. CMS data reflect that over one million individuals enrolled in full LIS should not enrolled in an MSP. Given near alignment of MSP and LIS eligibility criteria, most of those individuals are likely eligible for an MSP eligibility group (See November 1, 2021 Center for Medicaid and CHIP Services Informational Bulletin, “Opportunities to Increase Enrollment in Medicare Savings Programs”). /19/

   FOOTNOTE 19 Available at https://www.medicaid.gov/federal-policy-guidance/downloads/cib11012021.pdf. END FOOTNOTE

The January 28, 2021 Executive Order on Strengthening Medicaid and the ACA directs agencies to deal with policies and practices which will present unnecessary barriers to individuals and families attempting to access Medicaid coverage, /20/ the April 5, 2022 Executive Order on Continuing to Strengthen Americans’ Access to Reasonably priced, Quality Health Coverage charges Federal agencies with identifying ways to assist more Americans enroll in quality health coverage, /21/ and the December 13, 2021 Executive Order on Transforming Federal Customer Experience and Service Delivery to Rebuild Trust in Government supports streamlining State enrollment and renewal processes and removing barriers to make sure eligible individuals are mechanically enrolled in and retain access to critical profit programs. /22/ As such, we’ve evaluated CMS’s regulatory authority to cut back barriers to enrollment of eligible individuals into the MSPs. Under the authority in section 1902(a)(4) of the Act to specify “methods of administration” that the Secretary finds to be “mandatory for the right administration” of State plans, we propose several regulatory changes to advertise efficient enrollment within the MSPs by maximizing State use of LIS leads data. We consider these proposals may also have a positive impact on health equity by helping to supply more low-income individuals with access to additional health coverage consistent with the January 20, 2021 Executive Order. /23/

   FOOTNOTE 20 https://www.whitehouse.gov/briefing-room/presidential-actions/2021/01/28/executive-order-on-strengthening-medicaid-and-the-affordable-care-act/. END FOOTNOTE

   FOOTNOTE 21 https://www.whitehouse.gov/briefing-room/presidential-actions/2022/04/05/executive-order-on-continuing-to-strengthen-americans-access-to-affordable-quality-health-coverage/. END FOOTNOTE

   FOOTNOTE 22 https://www.whitehouse.gov/briefing-room/presidential-actions/2021/12/13/executive-order-on-transforming-federal-customer-experience-and-service-delivery-to-rebuild-trust-in-government/. END FOOTNOTE

   FOOTNOTE 23 https://www.whitehouse.gov/briefing-room/presidential-actions/2021/01/20/executive-order-advancing-racial-equity-and-support-for-underserved-communities-through-the-federal-government/. END FOOTNOTE

Accepting LIS leads data as an MSP application. As noted above, under section 1935(a)(4) of the Act, SSA must transmit the LIS leads data to States, and States must use that data to initiate an application for the MSPs. On February 18, 2010, CMS issued a State Medicaid Director Letter (SMDL #10-003), “Medicare Improvements for Patients and Providers Act of 2008 (MIPPA),” explaining that, “starting January 1, 2010, the State is directed to treat the [leads] data as an application for MSP advantages, as if it had been submitted directly by the applicant.” Moreover, the guidance explained, “States must act on the info as an application for MSP advantages, even when the LIS application was denied by SSA.” /24/ We reiterated the 2010 guidance in 2020 through updates to the Manual for the State Payment of Medicare Premiums. /25/

   FOOTNOTE 24 State Medicaid Director Letter, #10-003, “Medicare Improvements for Patients and Providers Act of 2008 (MIPPA),” page 2. Available at https://www.medicaid.gov/federal-policy-guidance/downloads/smd10003.pdf. END FOOTNOTE

   FOOTNOTE 25 Chapter 1, section 1.11. END FOOTNOTE

On this rulemaking, we propose to codify in regulation the statutory requirements for States to maximise using leads data to ascertain eligibility for Medicaid and the MSPs. We anticipate that codifying these requirements will result in more eligible individuals enrolling in MSPs because we consider that some States can have been unaware or unclear of the steps required to meaningfully use the leads data to streamline eligibility and enrollment within the MSPs.

Currently, all States receive leads data from SSA each business day. This data includes information on the person’s address, income, resources and household size that SSA has verified. /26/ Per section 113 of MIPPA, States must accept, via secure electronic transfer, the SSA leads data and process that information to initiate an MSP application. Nevertheless, we’re aware that several States don’t use the leads data to start the applying process. For instance, upon receipt of the leads data, some States simply send the person a letter that encloses a blank application or instructions on find out how to apply for the MSPs. Such practices fall in need of States’ statutory obligation to treat receipt of leads data as an application and to judge individuals’ eligibility using the leads data.

   FOOTNOTE 26 The leads data also includes information on the LIS subsidy amount and denial reasons, which States can use to right away discover if the person is ineligible for MSPs. END FOOTNOTE

We propose so as to add a definition of LIS leads data at SEC 435.4 and a latest paragraph (e) to SEC 435.911 of the regulations to obviously delineate the steps States must take upon receipt of leads data from SSA. We propose to define LIS leads data to mean data from a person’s application for low-income subsidies under section 1860D-14 of the Act that the SSA electronically transmits to the suitable State Medicaid agency as described in section 1144 (c)(1) of the Act. Proposed SEC 435.911(e)(1) requires States to just accept, via secure electronic interface, the SSA LIS leads data. Proposed paragraph (e)(2) requires that States treat receipt of the leads data as an application for Medicaid and promptly and without undue delay, consistent with the timeliness standards at SEC 435.912, determine MSP eligibility without requiring submission of a separate application.

We recognize that State Medicaid agencies generally might want to request additional information to be able to make a determination of eligibility, as some differences remain in income and resource counting methodologies between the LIS and MSPs. As well as, the leads data transmitted to the State doesn’t include information on a person’s citizenship or immigration status, and subsequently, States might want to ask individuals for his or her status, which have to be verified in accordance with sections 1137(d), 1902(ee) or 1903(x) of the Act and [Sec.] SEC 435.956(a) and (b), 435.406 and 435.407, if such information just isn’t already within the casefile and has been verified in a previous application. As such, we propose at paragraph (e)(3) of SEC 435.911 that States must request additional information to be able to make a determination of eligibility for MSPs. We also recommend that when States request additional information from individuals, they include information on find out how to contact the local State Health Insurance Assistance Program (SHIP) for assistance.

Nevertheless, consistent with existing regulations at [Sec.] SEC 435.907(e) and 435.952(c), we propose at paragraph (e)(4) of SEC 435.911 that States may only require that individuals provide information needed to finish an eligibility determination if information needed for such determination just isn’t available to the agency or if information available to the agency through an electronic data match or other means just isn’t reasonably compatible with information provided by or on behalf of the person. Thus, under the proposed rule, States may not request that individuals attest or otherwise provide documentation to ascertain information contained in leads data, which SSA has already verified and confirmed for the LIS eligibility determination.

Note that a State just isn’t in compliance with the statutory requirement in section 1935(a)(4) of the Act to initiate an application based on leads data or with the proposed regulation if it requires the person to file a latest application for MSP, for the reason that leads data already provides much of the knowledge that may otherwise be requested on an application. Further, as discussed in additional detail below, States have the pliability under section 1902(r)(2) of the Act to align the methodologies applied in determining MSP eligibility with the methodologies for determining eligibility for LIS. Moreover, we highly recommend completely aligning financial methodologies for determining LIS and MSP eligibility as a program integrity best practice. If a State chooses such complete alignment in financial methodologies between the LIS and MSP programs, under the proposed rule the State may not require additional financial information from a person for whom the State has received leads data to be able to make a determination of MSP eligibility.

The LIS leads data that’s transferred to State agencies has been verified by the SSA. Thus, we consider that State verification of this data prior to adjudicating eligibility is duplicative and inefficient. Consistent with the Secretary’s authority under section 1902(a)(4) of the Act (regarding establishment of such methods of administration because the Secretary determines “mandatory for correct and efficient administration” of the Medicaid program) and section 1902(a)(19) of the Act (regarding simplicity of administration and the most effective interests of recipients), we also propose at SEC 435.911(e)(5) that States accept the knowledge verified by SSA and provided through the leads data as verified, provided that the knowledge provided through the LIS leads data supports a determination of eligibility under section 1902(a)(10)(E) of the Act.

The Computer Matching and Privacy Protection Act at 5 U.S.C. 522a(p)(1) requires States to take actions to independently confirm information that SSA provides before the State may terminate, suspend, reduce, deny, or take other antagonistic motion against a person. Subsequently, in instances through which the leads data wouldn’t support a determination of eligibility for MSPs, we propose at SEC 435.911(e)(7) to require that States use the attested information provided by the applicant to SSA through the LIS application process and individually confirm the person’s eligibility for Medicaid in accordance with the State’s verification policies. Specifically, under proposed SEC 435.911(e)(7), the State could be required to (1) determine whether additional information is required to make a determination of eligibility for an MSP; (2) if additional information is required, notify the person who they might be eligible for assistance with their Medicare premium and/or cost sharing charges, but that additional information is required for the agency to make a determination of such eligibility; (3) provide the person with a minimum of 30 days to furnish any information needed by the agency to find out MSP eligibility; and (4) confirm the person’s eligibility for an MSP in accordance with the State’s verification plan developed in accordance with SEC 435.945(j). We note that, within the case of an applicant who has attested to income or assets over the applicable income or resource standard, States can, but should not required to, request additional information from the person to substantiate ineligibility for coverage.

We note that, under our proposal, States may proceed to request from the person information mandatory to make an eligibility determination but that’s missing from the leads data or other third-party sources. Pursuant to SEC 435.952(c), States can also seek information from the person if the State has other information that just isn’t reasonably compatible /27/ with the leads data; nonetheless, we anticipate such circumstances with respect to financial eligibility shall be extremely rare since SSA generally relies on the identical sources for financial eligibility data also relied upon by States and the info from SSA will in most instances be probably the most current.

   FOOTNOTE 27 Under 42 CFR 435.952(c)(1), income information obtained through an electronic data match shall be considered “reasonably compatible” with income information provided by or on behalf of a person if each are either above or at or below the applicable income standard or other relevant income threshold. END FOOTNOTE

Finally, individuals eligible for the LIS program could also be eligible for full Medicaid advantages, along with the help with Medicare premiums and cost-sharing available under the MSPs. Under the present regulations at SEC 435.911, for people who submit the one streamlined application used for people applying for Medicaid on the idea of MAGI, but who could also be eligible on a basis apart from MAGI, States are required to gather any additional information that is required to make a determination on a non-MAGI basis, and to make such determination if the person provides the needed information. Consistent with sections 1902(a)(4) and (a)(19) of the Act, we propose an identical requirement with respect to individuals whose application was initiated by receipt of LIS leads data. Specifically, under proposed SEC 435.911(e)(6), States could be required to gather such additional information as could also be needed to find out whether such individuals are eligible for Medicaid in some other eligibility groups (that’s, apart from the MSPs), including other non-MAGI groups and MAGI-based groups as well. We consider this proposal would codify a pathway for efficient enrollment of LIS enrollees into each the suitable MSP eligibility group, in addition to right into a full-benefit group if eligible without imposing undue administrative burdens on States. We consider this could also promote program integrity. We note that individuals could be eligible for each an MSP and an eligibility group that confers full Medicaid advantages. Subsequently, the requirement under proposed SEC 435.911(e)(6) is along with the requirement to find out the person’s eligibility for an MSP.

Streamlining Methodologies. As mentioned previously, the income standard for the LIS program and the very best income standard for the MSPs is analogous, the resource standard for all MSPs and the LIS is similar until January 1, 2024, and the methodologies for each programs are very closely aligned. Nevertheless, the differences in income and resource methodologies prevent LIS enrollees from being seamlessly enrolled into the MSPs unless the State has elected to align the MSP methodologies with LIS methodologies by adopting certain income and resource disregards under section 1902(r)(2) of the Act.

As discussed above, the 2 methodologies differ barely in that several varieties of income and resources which are counted in determining MSP eligibility should not counted in determining LIS eligibility. /28/ States have the pliability to attain full alignment of the MSP and LIS methodologies. Specifically, under section 1902(r)(2) of the Act, codified in regulation at SEC 435.601(d), States have the choice to make use of less restrictive income and resource methodologies in making eligibility determinations for many non-MAGI eligibility groups, including the MSPs. States can use this authority to align MSP methodologies with LIS methodologies by adopting less restrictive methodologies to disregard income and resources which are counted in determining MSP but not LIS eligibility. These include: (1) the next varieties of income: in-kind support and maintenance, dividend income, and interest income; and (2) the worth of the next varieties of resources: non-liquid resources, burial funds, and life insurance. We expect that States haven’t maximized this chance resulting from competing priorities and the complexity of eligibility policy.

   FOOTNOTE 28 For instance, section 116 of MIPPA directs SSA to not count in-kind support and maintenance as income, and never to count the money give up value of life insurance policies as a resource, when determining eligibility for LIS. These statutory disregards apply only to LIS eligibility determinations and never to MSP eligibility groups. END FOOTNOTE

Under proposed SEC 435.911(e), States that adopt less restrictive MSP eligibility methodologies to completely align with the LIS methodologies would give you the chance to make use of leads data to make a determination of MSP financial eligibility without requesting additional information from the person (as noted above, information on citizenship and immigration status would still be needed), thus reducing administrative burden for the State and relieving LIS recipients of the necessity to navigate a posh application process.

States which have not fully aligned methodologies must proceed to request the extra information needed to find out financial eligibility which just isn’t provided through the leads data. As well as, as noted above, States must request information regarding U.S. citizenship and immigration status to be able to confirm such status in accordance with the State’s usual processes. In accordance with SEC 435.406(a) and section 1137(d) of the Act, individuals must first make a declaration of U.S. citizenship or satisfactory immigration status in accordance with SEC 435.406(a). After the declaration is made, per regulations at SEC 435.956, States must try to electronically confirm U.S. citizenship or satisfactory immigration status and, if such status can’t be promptly verified, the State must provide the person with an inexpensive opportunity period to supply documentation or other information needed to confirm their status. In the course of the reasonable opportunity period, the State must furnish advantages to individuals who otherwise meet all eligibility requirements and must itself proceed efforts to confirm the person’s status. These requirements apply equally to individuals being determined for eligibility within the MSPs following the State’s receipt of leads data from SSA.

Nevertheless, in accordance with the authority at section 1902(a)(4) of the Act to advertise the executive efficiency of this system and section 1902(a)(19) of the Act regarding simplicity of administration and the most effective interests of beneficiaries, we propose so as to add a latest paragraph (e) to SEC 435.952 to require that States adopt numerous enrollment simplification policies related to the income and resources which are counted in determining MSP, but not LIS, eligibility that may enable State agencies to make use of the leads data more efficiently, reduce burden on applicants and States, and increase the variety of LIS enrollees successfully enrolled within the MSPs. We also anticipate these policies would have a positive health equity impact by increasing access to Medicare coverage for low-income individuals and increasing the financial security of those that successfully enroll consistent with the January 20, 2021 Executive Order. /29/

   FOOTNOTE 29 https://www.whitehouse.gov/briefing-room/presidential-actions/2021/01/20/executive-order-advancing-racial-equity-and-support-for-underserved-communities-through-the-federal-government/. END FOOTNOTE

Finally, we anticipate that these enrollment simplifications will help reduce the high rate of churn that dually eligible individuals experience, largely resulting from administrative reasons resembling providing documentation of certain income and assets to display their continued eligibility. Evaluation by the Assistant Secretary for Planning and Evaluation (ASPE) for the Department of Health and Human Services in 2019 examined data from years 2007 through 2009 and located that 29.1 percent of people lost Medicaid eligibility for at the least 1 month through the first 12 months of transitioning to full-benefit dual eligibility and 21.1 percent lost Medicaid eligibility for at the least 3 months following the transition despite dually eligible individuals’ relatively stable income and assets over time. /30/ Experts interviewed noted that dually eligible beneficiaries most frequently lost coverage due to failing to comply with administrative requirements versus changes in income, assets, or functional status. In 2021, CMS performed similar evaluation on data from years 2015 through 2018 and located similar results: 29.1 percent of people lost Medicaid eligibility for at the least 1 month through the first 12 months of transitioning to full-benefit dual eligibility and 24.1 percent lost Medicaid eligibility for at the least 3 months following the transition. /31/ The proposed simplifications for every source of income and resource are discussed below.

   FOOTNOTE 30 Assistant Secretary for Planning and Evaluation (ASPE) (2019). Lack of Medicare-Medicaid dual eligible status: Frequency, contributing aspects and implications. https://aspe.hhs.gov/system/files/pdf/261716/DualLoss.pdf. END FOOTNOTE

   FOOTNOTE 31 CMS accomplished an updated internal evaluation of ASPE’s study in 2021 using data from 2015-2018 that shows that dually eligible individuals proceed to lose Medicaid at a high rate of their first 12 months resulting from administrative reasons. END FOOTNOTE

We note that our proposals wouldn’t change the income and resource rules for people applying for non-MAGI eligibility groups apart from the MSPs. We propose simplifying income and resource policies for the MSP eligibility groups given the narrow scope of assistance available under these groups (limited to assistance with Medicare premiums and/or cost-sharing assistance), their smaller numbers of eligible and enrolled individuals relative to other non-MAGI eligibility groups, and MIPPA provisions which closely align them with the LIS program, which doesn’t count some of these income and resources. We seek comment on extending the proposals below to all individuals in search of eligibility on a non-MAGI basis. We also seek comment on extending the proposal regarding verification of dividend and interest income to individuals in search of eligibility based on MAGI, in addition to whether there are additional income or resource types to which the proposals below might be prolonged for all individuals.

Interest and Dividend Income. Regulations governing LIS eligibility determinations at 20 CFR 418.3350(d) exclude all interest and dividend income earned on resources owned by the applicant or their spouse. Nevertheless, under the SSI income methodologies applicable to MSP determinations, States must count interest and dividend income, unless they’ve elected to disregard such income using the authority provided under section 1902(r)(2) of the Act and 42 CFR 435.601(d).

Based on stakeholder reports and program experience, we consider that the overwhelming majority of people more likely to qualify for an MSP eligibility group do not need significant interest or dividend income, whereas the requirement to timely obtain and furnish acceptable statements from financial institutions, sometimes extending back over a lengthy time frame, to document interest and dividend income earned is unduly burdensome for applicants and provides negligible program integrity value. Subsequently, consistent with section 1902(a)(19) of the Act, to be able to minimize undue administrative burden on applicants, we’re proposing at SEC 435.952(e)(1)(i) and (ii) to ban States from requesting documentation of dividend and interest income prior to creating a determination of MSP eligibility, except when the agency has information that just isn’t reasonably compatible with the applicant’s attestation. Under the proposed rule, States could be required to just accept self-attestation of dividend and interest income for MSP applicants and their spouse, but would retain the choice to confirm such income after the person has been enrolled (a process, currently available at State option with respect to most eligibility criteria, which we discuss with as “post-enrollment verification”), including the choice to require the person to supply documentation of interest or dividend income if electronic verification just isn’t available.

We seek comment on the utility of post-enrollment verification and whether it leads to unnecessary procedural denials of eligible individuals. If a State chooses to conduct post-enrollment verification checks, under proposed SEC 435.952(e)(1)(iii) it must allow individuals at the least 90 calendar days to answer requests for documentation. We seek comment on the proposal to require that States provide individuals with at the least 90 calendar days to answer requests for extra information in this example and whether States needs to be required to supply, at a minimum, a shorter time frame, resembling at the least 30 or 60 calendar days. If a State found that a person has income exceeding the income standard through the post-enrollment verification process, the State would take appropriate motion consistent with regulations at SEC 435.916(d) (redesignated and revised at proposed regulations at SEC 435.919 on this rulemaking), including determining eligibility on other potential bases and, if not eligible on any basis, providing advance notice and fair hearing rights prior to terminating MSP coverage. Section 435.952(e)(1)(ii) clarifies that States must request documentation prior to creating an initial determination to disclaim eligibility in the event that they have information that just isn’t reasonably compatible with the applicant’s attestation in accordance with SEC 435.952(c)(2).

As discussed above, under section 1902(r)(2) of the Act, States even have the power to disregard interest and dividend income entirely, which might bring treatment of interest and dividend income in determining eligibility for MSPs into alignment with the LIS program. We encourage States to think about adoption of such an income disregard, because it is unlikely that an applicant could have each investments large enough to generate significant interest or dividend income and resources and still satisfy the resource test for the LIS or MSP advantages.

Non-liquid resources. For LIS eligibility determinations, under 20 CFR 418.3405, SSA only counts liquid resources, which it defines as money, financial accounts, and other financial instruments that could be converted to money inside 20 workdays. Non-liquid resources, resembling an automobile, should not counted for LIS eligibility. /32/ Nevertheless, SSI rules in section 1613 of the Act, which apply to MSP determinations, have a broader definition of countable resources that features non-liquid resources; for instance, while SSI excludes one automobile for resource-eligibility purposes, a second automobile is countable. This could be onerous for MSP applicants because it could possibly be difficult to timely determine, and furnish acceptable documentation of, the worth of something that can’t easily be sold. Just like interest and dividend income, consistent with section 1902(a)(19) of the Act and to be able to minimize administrative burdens on individuals, we’re proposing at SEC 435.952(e)(2)(i) to require that States accept applicants’ attestation of the worth of any non-liquid resources, except, as described at proposed SEC 435.952(e)(2)(ii), when the State has information that just isn’t reasonably compatible with the person’s attestation. Nevertheless, as with dividend and interest income, as described at proposed SEC 435.952(e)(2)(iii), States would retain the choice to conduct post-enrollment verification, including the choice to require the person to supply documentation of non-liquid resources if electronic verification just isn’t available, and to take appropriate motion, consistent with regulations at SEC 435.916(d) (redesignated and revised at proposed regulations at SEC 435.919 on this rulemaking), if the State determines the person greatly undervalued or did not disclose resources. If the agency elects to conduct verifications post-enrollment, and documentation is requested, the agency must provide the person with at the least 90 calendar days from the date of the request to reply and supply any mandatory information requested. As with dividend and interest income, SEC 435.952(e)(2)(ii) clarifies that States must request documentation prior to creating an initial determination denying eligibility in the event that they have information that just isn’t reasonably compatible with the applicant’s attestation in accordance with SEC 435.952(c)(2). Finally, States also may use authority at section 1902(r)(2) of the Act to disregard the worth of all non-liquid resources.

   FOOTNOTE 32 The exception to this rule is that the equity value of any real property than a person owns apart from the person’s primary place of residence is counted as a resource. END FOOTNOTE

Burial funds. Under section 1613(d)(1) of the Act, which applies to each LIS and MSP determinations, as much as $1,500 in burial fund are to be excluded for the applicant (and an extra $1,500 for his or her spouse) as long as the burial fund is “individually identifiable and has been put aside.” The statute doesn’t, nonetheless, prescribe how the funds have to be individually identifiable. Current SSA policy allows LIS applicants to attest to having $1,500 in burial funds, which could also be co-mingled with other funds in a single account (see SSA Program Operations Manual Systems [POMS] HI 03030.020 Resource Exclusions Section B.3.). Nevertheless, consistent with section 1905(p)(1)(C) of the Act, which directs that SSI’s resource methodologies be used to find out MSP-related resource eligibility, States typically require applicants to supply documentation that their burial funds are put aside in a separate account, as provided under SSI’s burial fund-related methodology described in 20 CFR 416.1231(b). This creates a misalignment between LIS and MSP methodologies and imposes additional burdens on MSP applicants.

We propose in SEC 435.952(e)(3)(i) to require that States, when determining eligibility for the MSPs, allow individuals to self-attest that as much as $1,500 of their resources, and as much as $1,500 of their spouse’s resources, are put aside as burial funds in a separate account and subsequently should not countable as resources for MSP determinations. Proposed SEC 435.952(e)(3)(ii) clarifies that States must request documentation prior to creating an initial determination of ineligibility in the event that they have information that just isn’t reasonably compatible with the applicant’s attestation in accordance with SEC 435.952(c)(2). As within the proposed provision for interest and dividend income and non-liquid resources, and described at SEC 435.952(e)(3)(iii), States would retain the choice to conduct post-enrollment verification, including obtaining documentation of resources in burial funds, and taking appropriate motion, consistent with regulations at SEC 435.916(d) (redesignated and revised at proposed regulations at SEC 435.919 on this rulemaking). If the agency elects to conduct verifications post-enrollment, and documentation is requested, the agency must provide the person with at the least 90 calendar days from the date of the request to reply and supply any mandatory information requested. Again, we seek comment on the 90-day response period in this example and whether States needs to be required to supply, at a minimum, a shorter time frame, resembling least 30 or 60 calendar days. Finally, States can also use authority at section 1902(r)(2) of the Act to disregard all or a greater amount of burial funds or to not require that the burial funds be held in a separate set-aside account.

Life Insurance Policies. Section 116 of MIPPA, codified at section 1860D-14(a)(3)(G) of the Act, eliminated the worth of life insurance policies as a countable resource for LIS determinations. Nevertheless, under the SSI resource methodologies described in section 1613(a) of the Act, which, as noted above, apply to MSP-related resource eligibility determinations per section 1905(p)(1)(C) of the Act, the money give up value of life insurance with a complete face value exceeding $1,500 is countable. Term life insurance policies do not need a money give up value and should not a countable resource under SSI methodologies described in 20 CFR 416.1230(a). Because term life insurance just isn’t relevant to the Medicaid eligibility determination, States should not permitted to request information concerning the face value of such policies.

Now we have received reports from advocates that getting documentation of a life insurance policy’s money give up value is extremely burdensome for applicants. A life insurance policy’s money give up value relies on the market, the length of time the policyholder has paid premiums, and other aspects. Further, the money give up value just isn’t knowable solely from the documents a policyholder is more likely to have. To acquire the present money give up value of a policy, an applicant generally must contact the corporate that has issued the policy, request a press release of the present money give up value after which submit that statement to the State agency once obtained. This may pose a big hurdle to applicants, resulting in denials for otherwise eligible applicants.

To cut back this burden on applicants, we encourage States to make use of their authority under section 1902(r)(2) of the Act to disregard the next face value of life insurance policies or to disregard the money give up value of life insurance policies altogether. Just a few States currently disregard policies with face values of at the least as much as $10,000, which eliminates administrative hurdles for most people, while ensuring that those comparatively few applicants who own substantial policies have the worth of those policies counted of their eligibility determinations.

Under proposed SEC 435.952(e)(4)(i), if a person attests to having a life insurance policy with a face value below $1,500, States must accept the attested face value for purposes of constructing an initial eligibility determination for MSP coverage, unless the State has information that just isn’t reasonably compatible with attested information. If the full face value of all of a person’s life insurance policies doesn’t exceed $1,500, the money give up value of the person’s policies just isn’t counted in determining MSP eligibility pursuant to sections 1613(a)(16) and 1905(p)(1)(C) of the Act. As with attested interest and dividend income, non-liquid assets, and burial funds, States could be required, as specified at proposed SEC 435.952(e)(4)(ii), to request additional information in the event that they have information not reasonably compatible with the attested value prior to enrolling the person in coverage in accordance with SEC 435.952(c)(2). Per current SEC 435.952(c)(2), the agency may accept an inexpensive explanation from the applicant or require documentation.

Under proposed SEC 435.952(e)(4)(i)(A), if a person attests to having a life insurance policy with a face value in excess of $1,500, consistent with current regulations at SEC 435.948, States may accept the attested money give up value. If the State has information that just isn’t reasonably compatible with the attested value of the policy, we propose, at SEC 435.952(e)(4)(ii), that the State must seek additional information from the person in accordance with SEC 435.952(c)(2). Per current SEC 435.952(c)(2), the agency may accept an inexpensive explanation from the applicant or require documentation.

Per proposed SEC 435.952(e)(4)(iii), States would have the choice to conduct post-enrollment verification for people enrolled based on an attested value. In conducting post-enrollment verification, if a State determines that the face value of the policy exceeds $1,500, then the State must redetermine the money give up value, consistent with regulations regarding changes in circumstances at SEC 435.916(d) (redesignated and revised at SEC 435.919 on this proposed rule), as described above and seek the money give up value on behalf of the person consistent with SEC 435.952(e)(4)(iv)(A). If, in redetermining eligibility, including the money give up value of the policy, once obtained, the State determines the person to be ineligible for an MSP, the State would wish to think about eligibility on other potential bases and supply advance notice and fair hearing rights in accordance with part 431 subpart E of the regulations prior to terminating MSP coverage.

We also propose at SEC 435.952(e)(4)(iv)(A) that when documentation of the money give up value of a life insurance policy is required, the State must assist the person with obtaining this information and documentation by requesting that the person provide the name of the insurance company and policy number and authorize the State to acquire such documentation on the person’s behalf, just like the help that SSA provides SSI applicants, through which SSA obtains from the applicant basic information concerning the policy and authorization to contact the insurer, after which confirms the money give up value directly with the life insurance company itself. /33/ The agency can also request, but may not require, additional information from the applicant to help the agency in obtaining documentation of the money give up value, resembling the name of an agent. If the person doesn’t provide basic information concerning the policy and an authorization, under proposed SEC 435.952(e)(4)(iv)(B), the State may require that the person provide documentation of the money give up value. Under proposed SEC 435.952(e)(4)(iv)(C), the State must provide the person with at the least 15 calendar days to supply such documentation if required pursuant to paragraph (e)(4)(i) or (ii) of this section (that’s, if documentation of the money give up value is required prior to the agency’s making a determination of eligibility) and at the least 90 calendar days if required pursuant to paragraph (e)(4)(iii) of this section (that’s, post-enrollment). We note that the minimum of 15 calendar days in proposed SEC 435.952(e)(4)(iv)(C) for applicants to supply documentation of money give up value of a life insurance policy is consistent with the minimum 15 calendar days that we propose States must generally provide applicants to supply required documentation under proposed at SEC 435.907(d), discussed in section II.B.3 of this proposed rule. We seek comment on whether 15 calendar days or an extended minimum period, resembling 20 calendar days or 30 calendar days, appropriately balances the complexity of determining and obtaining documentation of the money give up value with the 45-day limit for States to finish Medicaid eligibility determinations for people applying on a basis apart from disability status under SEC 435.912(c)(3). The 90 calendar days proposed for people to acquire documentation of the money give up value of a life insurance policy during a post-enrollment verification process is consistent with the 90 calendar days in proposed paragraphs (e)(1)(iii), (e)(2)(iii), and (e)(3)(iii) of SEC 435.952.

   FOOTNOTE 33 See SSA POMS SI 01130.300.D., Developing Life Insurance Policies at http://policy.ssa.gov/poms.nsf/lnx/0501.130300. END FOOTNOTE

We recognize this proposal would represent a big change for numerous States and will present some administrative challenges to implement. Nevertheless, documenting the money give up value of life insurance is a substantial hurdle for many candidates. Since the money give up value of most applicants’ policies is probably going very modest, the worth of any life insurance policy likely could have a minimal impact on their financial eligibility for coverage, whereas obtaining documentation of the money give up value may pose a considerable administrative barrier to access. We consider it’s within the interest of efficient administration of this system, consistent with section 1902(a)(4) of the Act, to implement a process that places fewer burdens on applicants. We also consider that States are higher in a position to navigate obtaining such documentation when needed. We seek comment on whether the burden shifted to States under the proposed rule is acceptable, or whether another approach could be preferable.

In-Kind Support and Maintenance. In-kind support and maintenance is assistance an applicant receives that’s paid for by another person, resembling groceries or utilities paid for by an adult child. Section 1860D-14(a)(3)(C)(i) of the Act, added by section 116 of MIPPA, excludes in-kind support and maintenance as countable income for LIS determinations. Under SSI methodologies at 20 CFR 416.1131, which apply to MSP determinations, the worth of in-kind support and maintenance, if each food and shelter are received by an applicant, is presumed to be one-third of the Federal profit rate (FBR) ($841 per 30 days in 2022 for a single person), unless the applicant provides documentation demonstrating a unique amount. While documenting the quantity of actual in-kind support and maintenance could be difficult for applicants, we don’t consider it is not uncommon for applicants to try to rebut the one-third FBR presumption, and subsequently, it’s rare that applicants are faced with providing documentation of this kind of income.

Under the proposed rule, States would proceed to be permitted to require documentation from individuals who seek to rebut the one-third FBR presumption. Nevertheless, we seek comment on if obtaining documentation to rebut the one-third presumption poses a barrier to eligibility and whether we should always require States to just accept self-attestation from individuals who seek to rebut a presumption of the quantity of in-kind support and maintenance they receive subject to post-enrollment verification as discussed above. Alternatively, States can, and are encouraged to, further streamline the MSP eligibility and enrollment process for people with in-kind maintenance and support by disregarding in-kind support and maintenance entirely under section 1902(r)(2) of the Act.

2. Define “Family of the Size Involved” for the Medicare Savings Program Groups Using the Definition of “Family Size” within the Medicare Part D Low-Income Subsidy Program (SEC 435.601)

To further facilitate alignment of methodologies used to find out eligibility for the Medicare Part D LIS and MSP groups and facilitate enrollment within the MSPs based on LIS data, we propose to amend SEC 435.601 (“Application of economic eligibility methodologies”) to create a latest paragraph (e), through which we propose to define “family size” for purposes of MSP eligibility.

Annually, the U.S. Department of Health and Human Services (HHS) issues the Federal poverty guidelines (also known as the Federal poverty level or FPL), a measure of poverty used as an eligibility criterion by Medicaid and numerous other Federal programs. The FPL is a dollar amount that increases with the family size of a person. For instance, in 2022, when it comes to annual income, the FPL is $13,590 for a single person, $18,310 for a pair, and $23,030 for a family of three.

Under section 1905(p)(2)(A) and (B) of the Act, QMB-eligible individuals have incomes that don’t exceed 100% of the FPL “applicable to a family of the scale involved.” Section 1905(s)(2) of the Act similarly directs that Qualified Disabled Working Individual (QDWI)-eligible individuals have incomes that don’t exceed 200 percent of the FPL “applicable to a family of the scale involved.” Section 1902(a)(10)(E)(iii) and (iv) of the Act also direct that the income standards for the SLMB and QI eligibility groups be percentages of the FPL “applicable to a family of the scale involved.” As described above, SLMBs have incomes greater than 100% of the FPL and lower than 120 percent of the FPL, and QIs have incomes at the least equal to 120 percent of the FPL and lower than 135 percent of the FPL. The statute doesn’t define the phrase “family of the scale involved” and CMS has historically permitted States to use their very own reasonable definition of this phrase. /34/

   FOOTNOTE 34 Memorandum from Director, Center for Medicaid and State Operations, to Regional Administrator, Re: Medicaid Eligibility–Policy Governing Family Size in Determining Eligibility for Qualified Medicaid Beneficiaries and Specified Low-Income Beneficiaries. Oct. 2, 1997. Available at https://www.medicaid.gov/sites/default/files/2019-12/medicaid-eligibilty-memo.pdf. END FOOTNOTE

Nevertheless, in light of the varied statutory provisions to facilitate enrollment of LIS recipients into MSPs and vice versa, we consider it is acceptable to ascertain Federal standards governing the phrase “family of the scale involved.”

Specifically, we propose for purposes of determining eligibility for the MSP groups, consistent with our authority under section 1902(a)(4) of the Act to facilitate methods of administration that promote the right and efficient administration of the Medicaid program, that “family of the scale involved” be defined to incorporate at the least the individuals included within the definition of “family size” within the LIS program. Under SEC 423.772 (“Definitions” regarding the LIS program), “family size” is defined to incorporate the applicant, the applicant’s spouse (if the spouse resides in the identical household with the applicant), and all other individuals living in the identical household who’re related to the applicant and depending on the applicant or applicant’s spouse for one-half of their financial support.

By proposing that a State’s definition of “family of the scale involved” include “at the least” the individuals described in SEC 423.772 for purposes of the MSP groups, States would retain flexibility to incorporate other individuals who should not described in SEC 423.772. Moreover, this proposal wouldn’t affect the States’ ability to adopt a unique reasonable definition of the phrase for purposes of other eligibility groups. For instance, to be able to be eligible under section 1902(a)(10)(A)(ii)(XIII) of the Act (providing coverage for working individuals with disabilities), a person will need to have income that’s lower than 250 percent of the FPL for a “family of the scale involved.” States wouldn’t be required to adopt the definition at proposed SEC 435.601(e) for purposes of determining income eligibility for this eligibility group. We seek comment on this proposal to define “family of the scale involved” for purposes of the MSP groups.

3. Robotically Enroll Certain SSI Recipients Into the Qualified Medicare Beneficiaries Group (SEC 435.909)

SSI is a Federal money assistance program that serves low-income individuals who’re age 65 or older, or have blindness or a disability. SSI recipients typically qualify for other Federal and State programs. For instance, many SSI recipients are entitled to Medicare under 42 CFR 406.5(a) and (b). Moreover, in most States, the receipt of SSI is a compulsory basis for Medicaid eligibility pursuant to section 1902(a)(10)(A)(i)(II)(aa) of the Act, implemented at SEC 435.120 (“Individuals receiving SSI group,” hereafter the “mandatory SSI group”). Thirty-three States and the District of Columbia (DC) that cover the mandatory SSI group have an agreement with SSA under section 1634(a) of the Act under which SSA completes the determination of eligibility for the mandatory SSI group, and the Medicaid agency mechanically enrolls the person in Medicaid following a knowledge exchange with SSA. These States commonly are known as “1634 States.” A minority of States that cover the mandatory SSI group apply the SSI program’s income and resource methodologies and disability criteria but require individuals to submit a separate application to the State Medicaid agency (“criteria States”).

Eight States don’t cover the mandatory SSI group. As a substitute, these States have elected the authority provided under section 1902(f) of the Act to use financial methodologies and/or disability criteria more restrictive than the SSI program in determining eligibility for people 65 years old or older or who’ve blindness or a disability, subject to certain conditions. These States are known as “209(b) States,” after the supply of section 209(b) of the Social Security Act Amendments of 1972 (Pub. L. 92-603), which enacted what became codified at section 1902(f) of the Act. The eligibility group authorized by section 1902(f) of the Act is implemented at SEC 435.121 (“Individuals in States using more restrictive requirements for Medicaid than the SSI requirements,” hereafter “mandatory 209(b) State group”).

Most Medicare-eligible SSI recipients also meet the eligibility requirements for the QMB eligibility group described in sections 1902(a)(10)(E) and 1905(p) of the Act, which provides Medicaid coverage of Medicare premiums (each Part A, if applicable, and Part B) and cost- sharing (copayments, coinsurance, and deductibles).

Section 1905(p)(1) of the Act provides that, to be eligible under the QMB group, a person have to be entitled to Medicare Part A or enrolled in Medicare Part B for coverage of immunosuppressive drugs under section 1836(b) of the Act, have income that doesn’t exceed 100% of the FPL for the applicable family size, and have resources that don’t exceed the bounds for the full-subsidy LIS program. As described at section 1860D-14(a)(3)(D) of the Act, the full-subsidy LIS resource limit is 3 times the SSI resource limit, adjusted annually based on changes to the Consumer Price Index. /35/ (See section II.A.1. of this proposed rule for discussion of the LIS program.) The income standard for SSI (that’s, SSI’s maximum Federal profit rate) is often 74 percent of the FPL for a person and 83 percent of the FPL for married individuals. Thus, since the income and resource standards for the QMB group exceed the income and resource standards for SSI, individuals entitled to Medicare Part A who meet the income and resource requirements for the mandatory SSI group or mandatory 209(b) group will at all times meet the income and resource requirements for the QMB group and be eligible for the QMB group.

   FOOTNOTE 35 The resource limit for LIS is 3 times the SSI limit with yearly updates since January 1, 2010 to reflect to reflect Consumer Price Index (CPI). Note that the MSP resource test is decided without regard to the life insurance policy exclusion for Part D LIS, in accordance with section 1902(p)(1)(C). END FOOTNOTE

Most people enrolled in Medicare qualify for Part A without paying a premium (premium-free Part A). SSA mechanically enrolls these individuals in premium-free Part A in the event that they are age 65 or over and receive Social Security or Railroad Retirement Board (RRB) retirement advantages under title II of the Act or are under age 65 and have received Social Security or RRB disability advantages for twenty-four months under title II of the Act. See 42 CFR part 406 subpart A. In 2021, roughly 2.6 million individuals (roughly one third) of SSI recipients were entitled to premium-free Part A. /36/

   FOOTNOTE 36 SSI Monthly Statistics, September 2021, Social Security Office of Retirement and Disability Policy 2021. https://www.ssa.gov/policy/docs/statcomps/ssi_monthly/2021-09/table01.html. END FOOTNOTE

Under SEC 406.20, many individuals who should not eligible for premium-free Part A should still enroll in Part A by applying for advantages at SSA and paying a premium (“premium Part A”). In 2022, the premium for Medicare Part A was $499; nonetheless, based on prior work history, some individuals may qualify for a reduced rate of $274. Individuals who should not eligible for premium-free Part A should not mechanically enrolled in premium Part A and they need to enroll in Part B prior to or concurrently they enroll in Part A. All Medicare beneficiaries must pay a monthly premium for enrollment in Part B, which is subject to an adjustment based on income. In 2022, the minimum Part B premium was $170.10.

All States currently have a buy-in agreement with the Secretary under section 1843 of the Act which requires them to pay the Part B premiums for certain Medicaid beneficiaries, including individuals enrolled within the QMB group and people receiving SSI (often known as “Part B buy-in”) as described within the Medicare regulations at SEC 407.42. A buy-in agreement permits States to directly enroll eligible individuals in Medicare Part B at any time of the 12 months (without regard for Medicare enrollment periods or late enrollment penalties if applicable) and to pay the Part B premiums on the person’s behalf. In 1634 States, when SSA determines a person eligible for each the mandatory SSI group and Medicare Part B, CMS mechanically initiates Part B buy-in for the person through a joint data exchange amongst CMS, the State Medicaid agency, and SSA (“buy-in data exchange”). /37/ In SSI criteria and 209(b) States, SSA notifies each the State and CMS that a person has been determined eligible for SSI and Medicare Part B; nonetheless, because such individuals must submit a separate Medicaid application for determinations of eligibility, CMS doesn’t mechanically initiate Part B buy-in. Relatively, once the State determines a person eligible for the mandatory SSI or 209(b) group, the State must initiate Part B buy-in for the person pursuant to its buy-in agreement through its day by day exchange of enrollment data with CMS. See 42 CFR 407.40(c)(4) and 407.42; CMS Manual for the State Payment of Medicare Premiums, chapter 2, section 2.5.1.

   FOOTNOTE 37 States with buy-in agreements must exchange buy-in enrollment data with CMS on a day by day basis under SEC 407.40(c)(4), and CMS also exchanges buy-in data with SSA on a day by day basis. CMS collectively refers to those data exchange processes because the “buy-in data exchange.” See Manual for the State Payment of Medicare Premiums, chapter 2, sections 2.0 and a pair of.1. END FOOTNOTE

While individuals enrolled within the mandatory SSI or 209(b) group receive full Medicaid advantages, enrollment within the QMB group provides these individuals with additional protection from out-of-pocket health care costs–specifically Medicare premiums and cost-sharing charges. Furthermore, Federal law prohibits all Medicare providers and suppliers, not only those participating in Medicaid, from charging QMBs for Medicare cost-sharing. Since 2018, CMS has notified Medicare providers and suppliers when a person is enrolled within the QMB group and protected against Medicare cost-sharing liability.

Maximizing the variety of Medicaid beneficiaries who’re also enrolled in Medicare just isn’t only advantageous to the person, but it could possibly also end in cost savings for States. As a third-party payer, Medicare pays primary to Medicaid for Medicare Part A (inpatient hospital and expert nursing facility services) and Medicare Part B (outpatient medical care). As well as, Medicaid beneficiaries who’re enrolled in each Medicare Parts A and B may join Medicare-Medicaid integrated care plans, which give more coordinated care across the 2 payers and will generate savings to the State by helping beneficiaries avoid institutional placement and by providing supplemental advantages, resembling dental, transportation, hearing, or other advantages that otherwise would have been covered by Medicaid.

Despite the potential advantages for Medicaid beneficiaries and State agencies, CMS data from 2022 indicates that over 500,000 or 16 percent of SSI recipients who’re eligible to enroll in Medicare should not enrolled within the QMB eligibility group. We consider a serious driver of eligible but unenrolled QMBs is that many States require SSI recipients to file a separate application with the State Medicaid agency to be able to be evaluated for eligibility for the QMB group, despite the fact that they’ve been determined eligible for the mandatory SSI or 209(b) groups, and all SSI recipients who’re entitled or able (with a premium) to enroll in Part A necessarily meet the necessities for QMB eligibility.

To facilitate the enrollment of SSI recipients into the QMB eligibility group we propose, consistent with section 1902(a)(4) of the Act to advertise the right and efficient administration of the Medicaid program, the January 28, 2021 Executive Order on Strengthening Medicaid and the Reasonably priced Care Act, the April 5, 2022 Executive Order on Continuing to Strengthen Americans’ Access to Reasonably priced, Quality Health Coverage, and the December 13, 2021 Executive Order on Transforming Federal Customer Experience and Service Delivery to Rebuild Trust in Government, so as to add a latest paragraph (b) at SEC 435.909 that generally would require States to deem a person enrolled within the mandatory SSI or 209(b) group eligible for the QMB group the month the State becomes accountable for paying the person’s Part B premiums under its buy-in agreement pursuant to SEC 407.47(b). We also propose technical changes to remove reserved paragraph (a) at SEC 435.909, redesignate SEC 435.909 paragraph (b) as (a) and add a latest header to latest SEC 435.909(a).

We note that under section 1902(e)(8) of the Act, QMB eligibility is effective the month following the month through which the determination of eligibility for the QMB group is made. Thus, under our proposal, QMB coverage would start the month following the month the State deems (that’s, determines) a person eligible for the QMB group and starts paying the person’s Part B premiums under the buy-in agreement. For instance, if a person is first enrolled in each the mandatory SSI or 209(b) Medicaid group and entitled to Part A in January 2025, the State would start paying the person’s Part B premiums under the buy-in agreement and deem the person eligible for the QMB group in January 2025. The person’s QMB coverage would start February 1, 2025.

SSI Recipients Who Have Premium-Free Medicare Part A

As noted above, SSA mechanically enrolls individuals who receive Social Security or RRB retirement advantages or disability advantages for twenty-four months into premium-free Part A. SSA data for States (including those with a 1634 agreement and people and not using a 1634 agreement) indicates whether an SSI recipient is entitled to premium-free Part A. As discussed above, because all SSI recipients meet the financial eligibility requirements for the QMB group, proposed SEC 435.909(b)(1)(i) would require all States to deem SSI recipients who’re determined eligible for either the mandatory SSI group at SEC 435.120 or the mandatory 209(b) group at SEC 435.121 as eligible for the QMB group in the event that they are entitled to premium-free Medicare Part A. Under the proposed rule, when a 1634 State (which has delegated authority to SSA to make Medicaid eligibility determinations for SSI recipients) receives from CMS the Part B buy-in enrollment for an SSI recipient who’s entitled to premium-free Medicare Part A, the State would mechanically enroll the person in each the mandatory SSI group and the QMB group; such individuals wouldn’t be required to submit a separate application to the Medicaid agency to find out eligibility for the QMB group.

Criteria States and 209(b) States also obtain from CMS information that an SSI recipient is Medicare-eligible and entitled to premium-free Medicare Part A. Nevertheless, in these States SSI recipients must submit a separate application to the Medicaid agency which determines eligibility for either the mandatory SSI or the 209(b) group. Under proposed SEC 435.909(b)(1)(i), once the State has determined an SSI recipient eligible for the mandatory SSI or the 209(b) group, the State also would start paying the Part B premiums for the person the primary month they’re entitled to Part A and receiving SSI-based Medicaid and begin QMB group coverage the primary day of the next month.

Every now and then, individuals enrolled within the mandatory SSI or 209(b) group change into retroactively entitled to premium-free Medicare Part A based on a retroactive award of Social Security Disability Insurance (SSDI). Under the Medicare regulations at SEC 407.47(b), States generally change into accountable for retroactive Part B premiums for such individuals dating back to the primary month they were enrolled within the mandatory SSI or 209(b) group and eligible for Part B. /38/ In an April 27, 2022 proposed rule entitled, “Implementing Certain Provisions of the Consolidated Appropriations Act and other Revisions to Medicare Enrollment and Eligibility Rules” (87 FR 25090) (referred to hereafter because the “2022 Medicare eligibility and enrollment proposed rule”), we proposed adding a latest paragraph (f) at SEC 407.47 to limit State liability for retroactive Part B premiums for full-benefit Medicaid beneficiaries, including individuals receiving SSI-based Medicaid, to a period of no greater than 36 months prior to the date of the Medicare enrollment determination. At 87 FR 25114 through 25115 of the proposed rule, we noted that this deadline would scale back burden on providers, help State Medicaid programs and the Medicare program run more efficiently, be consistent with a legal ruling in favor of States in at the least one Federal court, and never harm Medicaid beneficiaries since Medicaid would have covered any medical costs the beneficiary incurred for periods previously.

   FOOTNOTE 38 Individuals who’re entitled to premium-free Part A are eligible to enroll in Medicare Part B under SEC 407.10(a)(1). END FOOTNOTE

To align with that change, under SEC 435.909(b)(3), we propose that retroactive QMB coverage for people within the mandatory SSI or 209(b) group be limited to the identical period for retroactive Part B premium liability proposed at SEC 407.47(f) within the 2022 Medicare eligibility and enrollment proposed rule. For instance, if SSA determines a person enrolled within the mandatory SSI or 209(b) group eligible for premium-free Part A in January 2025 with an efficient date back to January 2023, the State would deem the person eligible for the QMB group retroactive to January 2023. Because coverage under the QMB group begins the month after the month of the eligibility determination, QMB coverage in this instance could be effective February 1, 2023. Alternatively, if SSA determines a person enrolled within the mandatory SSI or 209(b) group eligible for premium-free Part A in January 2025 with an efficient date back to January 2021, the State would deem the person eligible for the QMB group retroactive to January 2022, with QMB coverage effective February 1, 2022. We invite comment on this limit on retroactive QMB eligibility.

Moreover, we remind States that individuals deemed eligible for Medicaid should not exempt from regularly-scheduled renewals of Medicaid eligibility in accordance with SEC 435.916. Nevertheless, for a person eligible under each the mandatory SSI and QMB groups, the State need only confirm that the person still receives SSI and is entitled to Medicare Part A to be able to renew their eligibility in each groups. States can do that verification electronically by confirming receipt of SSI within the State Verification Exchange System or State Online Query System, and we encourage them to achieve this to attenuate burden. When a beneficiary now not meets the eligibility requirements for the eligibility group under which they’ve been receiving coverage, the State must determine eligibility on all bases before terminating eligibility.

SSI Recipients Eligible for Premium Part A

As mentioned above, individuals age 65 and over who lack the sufficient work history for premium-free Part A may qualify to pay, or have paid on their behalf, a monthly premium to receive Medicare Part A advantages. /39/ To fulfill the necessities for premium Part A at SEC 406.20(b), the person have to be: age 65 or older, a U.S. resident, not otherwise entitled to Part A, entitled to Part B or within the technique of enrolling in it, and a U.S. citizen or lawful everlasting resident who has resided within the U.S. constantly through the 5 years immediately preceding the month they enrolled in Medicare.

   FOOTNOTE 39 Note that every one individuals receiving title II advantages based on disability who’ve met the 24-month waiting period to enroll in Medicare are entitled to premium-free Part A. END FOOTNOTE

All States must pay the Part A premium for people who’re enrolled within the QMB eligibility group. Nevertheless, States can select considered one of two methods to pay the Part A premium for QMBs. /40/ First, States can expand their buy-in agreement with CMS under section 1818(g) of the Act to incorporate enrollment and payment of Part A premiums for QMBs who do not need premium-free Part A. Currently, 36 States and the District of Columbia have chosen this feature. States that include payment of Part A premiums for QMBs of their buy-in agreements are called “Part A buy-in States.” In Part A buy-in States, individuals determined eligible for the QMB group can enroll in premium Part A at any time of the 12 months and without regard to late enrollment penalties. Fourteen States don’t include Part A of their buy-in agreements and as an alternative pay the Part A premiums for QMBs using a bunch payer arrangement, which allows certain third parties (for instance, States) to pay the Part A premiums for a category of beneficiaries. /41/ States that use a bunch payer arrangement for QMBs are often known as Part A “group payer States.”

   FOOTNOTE 40 See chapter 1, section 1.2 of the CMS Manual for the State Payment of Medicare Premiums. END FOOTNOTE

   FOOTNOTE 41 See Program Operations Manual System (POMS) HI 01001.230 Group Collection-General at http://policynet.ba.ssa.gov/poms.nsf/lnx/0601001230. END FOOTNOTE

As previously noted, to be able to qualify for the QMB eligibility group under section 1905(p)(1) of the Act, a person have to be entitled to hospital insurance advantages under Part A of title XVIII. Being “entitled to” Part A signifies that if a person receives Part A-covered services, the prices of those services shall be covered by Medicare. See 42 CFR 406.3. Generally, a person becomes so entitled to Part A if–(1) they’re eligible for premium-free Part A based on payment of a payroll tax; or (2) are eligible to enroll in Premium Part A and do enroll (making a Part A premium obligation). The premium payment is due for every month starting with the primary month of coverage. 42 CFR 406.32(f).

Further, section 1905(a) of the Act specifies that payments of Medicare cost-sharing for QMBs (including Part A premiums) are “medical assistance” for purposes of FFP, if made within the month following the month through which the person becomes a QMB. (Per the introductory paragraph of section 1905(a) of the Act, payments for Medicare premiums and value sharing only qualify as medical assistance within the case of Medicare cost-sharing with respect to a QMB described in section 1905(p)(1) of the Act, if provided after the month through which the person becomes such a beneficiary). Thus, under a literal reading of the words of the statute, a State cannot claim FFP under the QMB group until the month after the month through which the person is “entitled to Part A,” which requires first that a Part A premium be paid. This creates a “catch 22” through which low-income individuals can only be eligible for QMB coverage that makes Part A enrollment reasonably priced in the event that they first became responsible for its premium.

This result would eviscerate the aim of sections 1843 and 1818(g) of the Act (“buy-in statute”). Under a literal read, States with a Part A buy-in agreement could theoretically use State-only funds to pay Part A premiums the primary month to permit the person to change into entitled to Part A and begin QMB coverage the subsequent month. Nevertheless, in Harris v. McCrae, 448 U.S. 297 (1980), the U.S. Supreme Court held that States can’t be required to supply Medicaid using only State funds. Further, while individuals can enroll in Part A at any time of the 12 months without regard for Medicare enrollment periods or late enrollment if the State pays their Part A premium under its buy-in agreement, this just isn’t the case for people who’re paying the premium themselves. Individuals who must pay the Part A premium themselves must wait until a Medicare enrollment period to enroll in Part A and will be subject to late enrollment penalties. Thus, a literal read of the statute would defeat the aim of buy-in statute–to avoid delays in QMB enrollment by allowing QMB-eligible individuals who reside in Part A buy-in States to enroll in Part A at any time of the 12 months, without regard to Medicare enrollment penalties.

Recognizing that a literal read of the statute would produce a result that essentially nullifies the impact of the QMB and buy-in statutory provisions, CMS instituted a policy roughly 30 years ago under which States can receive FFP for paying a person’s Part A premium the primary month of entitlement, thereby triggering each Part A entitlement and QMB coverage. Under this policy, Part A buy-in States can determine a person eligible for QMB status, and thus for his or her Part A premiums to be paid, in the event that they are enrolled in Part B but not yet entitled to Part A. /42/ Group payer States similarly can approve eligibility for people under the QMB eligibility group if SSA has determined them conditionally eligible for premium Part A, through a process often known as “conditional enrollment.” The conditional enrollment process enables low-income individuals to use at SSA for premium Part A on the condition that they’ll only be enrolled in Part A if the State determines they’re eligible for the QMB group. /43/ Most group payer States recognize conditional enrollment in Part A for purposes of determining QMB eligibility, but they should not required to achieve this.

   FOOTNOTE 42 Chapter 1, section 1.10 of the CMS Manual for the State Payment of Medicare Premiums and SSA Program Operations Manual System (POMS) HI 00801.140.C Premium Part A Enrollments for Qualified Medicare Beneficiaries (QMBs)–Part A Buy-In States and Group Payer States at http://policynet.ba.ssa.gov/poms.nsf/lnx/0600801140. END FOOTNOTE

   FOOTNOTE 43 The conditional enrollment process is described in chapter 1, section 1.11 of the CMS Manual for the State Payment of Medicare Premiums and in SSA Program Operations Manual System (POMS) HI 00801.140 Premium Part A Enrollments for Qualified Medicare Beneficiaries (QMBs)–Part A Buy-In States and Group Payer States at http://policynet.ba.ssa.gov/poms.nsf/lnx/0600801140. END FOOTNOTE

Individuals who lack premium-free Part A usually tend to have worked within the informal economy in low wage jobs. /44/ Internal evaluation by CMS from 2017 found that, as in comparison with their QMB-eligible counterparts with premium-free Part A, QMB-eligible individuals who qualify for premium Part A are inclined to be poorer and more more likely to be non-native English speakers. For multiple many years, the conditional enrollment policy has helped tons of of hundreds of people obtain essential assistance with Medicare premiums and cost-sharing by allowing States to pay the primary month’s premium needed to trigger Medicare Part A entitlement. Without this policy, the subsidies available under the QMB group to make Part A reasonably priced would only be available to individuals who one way or the other found a method to pay the initial Part A premium (including a late enrollment penalty if applicable) themselves. We estimate that precluding coverage of Part A premium payments under the QMB group until the month after a person has change into entitled to Part A would prevent over 78,000 individuals annually from enrolling in Part A with State payment of Part A premiums. /45/

   FOOTNOTE 44 Streamlining Medicare and QMB Enrollment for Recent Yorkers: Medicare Part A Buy-In Evaluation and Policy Recommendations, Medicare Rights Center, February 2011. https://www.medicarerights.org/pdf/Part-A-Buy-In-Evaluation.pdf. END FOOTNOTE

   FOOTNOTE 45 Based on internal CMS data from 2015-2019. END FOOTNOTE

We consider that we should always implement the statute in a way that offers full effect to what we consider to be Congress’ intended policy on this rare instance through which implementing the plain meaning of the words of the statute would produce a result that’s at odds with this statutory purpose. In United States v. Ron Pair Enterprises, Inc., 489 U.S. 235 (1989), the U.S. Supreme Court found, “The plain meaning of laws needs to be conclusive, except within the “rare cases [in which] the literal application of a statute will produce a result demonstrably at odds with the intentions of its drafters.” Griffin v. Oceanic Contractors, Inc., 458 U.S. 564, 571 (1982). In such cases, the intention of the drafters, quite than the strict language, controls. Ibid.”

More recently, in Donovan v. First Credit, Inc., 983 F.3d 246, 254 (sixth Cir. 2020) the Sixth Circuit reformulated this idea as follows: “Thus, the absurd-results doctrine sanctions using extra-textual sources to contravene statutory text provided that there is no such thing as a alternative and reasonable interpretation available that, consistent with legislative purpose, would avoid the absurd result.” See id.; In re Corrin, 849 F.3d 653 at 657 (“When the language is ambiguous or results in an absurd result, the court may have a look at the legislative history of the statute to assist determine the meaning of the language.”).”

We note that there’s precedent, within the Medicare Part D context, for not applying the plain meaning of the words of the statute when it results in what we consider to be an absurd result contrary to the aim of the statute. The next language from the preamble to the January 28, 2005 final rule implementing Medicare part D explains:

Section 1860D-1(b)(1)(C) of the Act requires CMS to auto-enroll into PDPs a person “who’s a full profit dual eligible individual” who “has did not enroll in a prescription drug plan or an MA-PD plan.” Although this statutory provision specifically references the statutory definition of “full-benefit dual eligible individual” under section 1935(c)(6) of the Act, if interpreted literally, section 1860D-1(b)(1)(C) of the Act would require CMS to auto-enroll into Part D plans only individuals receiving full-benefits under Medicaid who’re already enrolled in Part D but who’ve “did not enroll in” a Part D plan, a patently absurd result. Now we have an obligation to interpret the statute in order to avoid an absurd result and provides full effect to the Congress’ intended policy. We expect it is obvious that the Congress required CMS to ascertain an auto-enrollment process to make sure that individuals who currently receive coverage for Part D drugs under Medicaid proceed to receive coverage for such drugs through enrollment in Part D starting in 2006. /46/

   FOOTNOTE 46 70 FR 4194 at 4370 and 4371 (January 28, 2005). https://www.govinfo.gov/content/pkg/FR-2005-01-28/pdf/05-1321.pdf. END FOOTNOTE

For the explanations set forth above, we consider that on this case also, reading the statute literally to require a person to pay their first month’s Part A premium to be able to change into eligible to receive coverage of Part A premiums under the QMB group could be contrary to the basic purpose of the QMB statutory provisions: to enable low-income individuals to realize Medicare advantages they might not otherwise afford. A literal read of the statute can also be at odds with the intent of the buy-in statute to avoid undue delays in QMB enrollment. Subsequently, we propose to include within the regulations our longstanding practice of providing FFP for State payments of the primary month of a person’s Part A premium for people who’re eligible for the QMB group based on conditional enrollment in Part A. This also will facilitate enrollment into the QMB group for SSI recipients who must pay a premium to enroll in Part A.

In keeping with internal CMS estimates, in 2022 roughly 800,000 SSI recipients were eligible for Part A by paying a premium. When a person age 65 or older is decided eligible for SSI and Medicare Part B but lacks sufficient work history for premium-free Part A, SSA transmits the person’s record to CMS. In 1634 States, CMS mechanically initiates Part B buy-in (that’s, enrollment in Part B with the State paying the Part B premium); in criteria and 209(b) States, CMS alerts the State that the person is eligible for SSI and Medicare. As described above, States must pay the Part B premiums for people once they’re eligible for Part B and have been determined eligible for the mandatory SSI or 209(b) group under [Sec.] SEC 407.42 and 407.47(b). Once the SSI recipient is enrolled in Part B buy-in, CMS notifies SSA, which also updates its SSI records to reflect Part B buy-in for the person.

As mentioned above, in Part A buy-in States, CMS considers enrollment in Part B sufficient to treat the person as meeting the requirement that the person be entitled to Part A for the needs of the State’s QMB eligibility determination. Since the SSI income and resource standards are below the standards for eligibility under the QMB group, individuals eligible for the mandatory SSI or 209(b) group will meet the financial eligibility requirements for the QMB group. Thus, in Part A buy-in States, when an SSI recipient who lacks sufficient work history for premium-free Part A has been determined eligible for the mandatory SSI or 209(b) group and is enrolled in Part B, the State can determine the person eligible for the QMB eligibility group and enroll the person in Part A buy-in.

To streamline QMB enrollment for SSI recipients who must pay a premium to enroll in Part A, we propose at SEC 435.909(b)(1)(ii) to require Part A buy-in States to deem those individuals who’re determined eligible for the mandatory SSI or 209(b) groups as eligible for the QMB group and initiate their enrollment into Medicare Part A, pursuant to their buy-in agreement, the month they’re enrolled in Part B buy-in.

As noted, in States which have a 1634 agreement with SSA, when SSA determines a person eligible for the mandatory SSI group, SSA also notifies CMS that a person eligible for Medicare Part B has been determined eligible for the mandatory SSI group. CMS initiates the person’s enrollment in Medicare Part B buy-in and notifies the State after doing so. In Part A buy-in States with a 1634 agreement, once the State receives the automated Part B buy-in enrollment from CMS for an SSI recipient who lacks a sufficient work history for premium-free Part A, under proposed SEC 435.909(b)(1)(ii) the State would enroll the person within the mandatory SSI group, deem the person eligible for the QMB group, and effectuate enrollment in Medicare Part A through the buy-in agreement.

As discussed above, in criteria and 209(b) States, when CMS receives information from SSA that a person is eligible for SSI and Medicare Part B, CMS doesn’t mechanically initiate Part B enrollment, which is a prerequisite for entitlement to Part A for people subject to a Part A premium. In a Part A buy-in State and not using a 1634 agreement (that’s, a criteria or 209(b) State), once the person applies to the Medicaid agency, some States currently only determine eligibility for the mandatory SSI or 209(b) group, as applicable, and initiate Part B enrollment per their buy-in agreement. Under proposed SEC 435.909(b)(1)(ii), these Part A buy-in States also could be required to deem any individuals determined by the State to be eligible for the mandatory SSI or 209(b) groups as eligible for the QMB group and initiate enrollment in each Medicare Part A and Part B buy-in.

Within the 14 group payer States, it is tougher for SSI recipients to enroll in Medicare Part A and the QMB eligibility group. Unlike in Part A buy-in States, individuals determined eligible for the mandatory SSI or 209(b) group in group payer States who’re enrolled in Part B pursuant to the State’s buy-in agreement won’t necessarily satisfy the eligibility requirement for the QMB group that the person be entitled to Part A. Despite the fact that the State will initiate enrollment of the person in Part B, pursuant to its buy-in agreement, it’ll not cover the person’s Part A premium or initiate Part A enrollment under the buy-in agreement. As a substitute, the person must individually apply for premium Part A at SSA using the conditional enrollment process.

Although the conditional enrollment process provides a way for people to enroll within the QMB eligibility group without paying their very own Part A premiums upfront, the method is administratively burdensome for each individuals and the State, and the overwhelming majority of people fail to finish the method unless an eligibility employee or other application assistor provides hands on assistance through every step of the method. /47/ Two other challenges currently make QMB enrollment harder for SSI recipients without premium-free Part A in group payer States. First, group payer States can only enroll individuals in premium Part A through the general Medicare enrollment period that runs from January through March annually. Second, group payer States are required to pay late enrollment penalties, if applicable, for those Medicaid beneficiaries who didn’t timely enroll in Medicare Part A once they first became eligible to achieve this.

   FOOTNOTE 47 Streamlining Medicare and QMB Enrollment for Recent Yorkers: Medicare Part A Buy-In Evaluation and Policy Recommendations, Medicare Rights Center, February 2011. https://www.medicarerights.org/pdf/Part-A-Buy-In-Evaluation.pdf. END FOOTNOTE

To streamline QMB enrollment for SSI recipients without premium-free Part A in group payer States, we propose so as to add a State option for deeming individuals eligible for the QMB group. Specifically, proposed SEC 435.909(b)(2) would allow, but not require, group payer States to directly initiate Medicare Part A enrollment for people who should not entitled to premium-free Part A without first sending them to SSA to use for conditional Part A enrollment. Under this proposed option, once the State has determined the person eligible for the mandatory SSI or 209(b) group and change into responsible for paying their Part B premiums under the buy-in agreement pursuant to SEC 407.42, the State would also deem them eligible for the QMB group.

We’re aware that State-specific variables can impact a State’s decision to either enter right into a Part A buy-in agreement or to stay a bunch payer State. By allowing, but not requiring, group payer States to adopt the identical streamlined QMB enrollment procedures utilized in Part A buy-in States, we preserve the present statutory option for group payer States to operate in a different way than Part A buy-in States while still enabling them to modernize their processes and facilitate enrollment of those very low-income individuals into Medicare Part A and the QMB group. Nevertheless, we seek comments on the executive and monetary impacts of our proposal and of other approaches, resembling requiring group payer States to deem individuals determined eligible for the mandatory SSI or 209(b) groups as eligible for the QMB group once they’ve accomplished the conditional enrollment process at SSA.

4. Clarifying the Qualified Medicare Beneficiary Effective Date for Certain Individuals (SEC 406.21)

Within the above section, we seek to facilitate enrollment for SSI recipients into QMB. Here, we propose to make clear the effective date of coverage under the QMB group for people who must pay a premium to enroll in Part A and reside in a bunch payer State to be able to provide individuals with protection from Medicare premiums and cost-sharing costs on the earliest possible date.

The primary opportunity individuals need to enroll in premium Part A is during their initial enrollment period (IEP). For most people who change into eligible for Medicare on or after 1966, under section 1837(d) of the Act, the IEP begins on the primary day of the third month before the month the person turns 65 and ends 7 months later.

Eligible individuals who don’t enroll in premium Part A during their IEP, or who disenroll from premium Part A and need to re-enroll, must generally achieve this through the general enrollment period (GEP). The GEP is established under section 1837(e) of the Act, and is the period starting on January 1 and ending on March 31 of annually. For people who enroll in Medicare under the GEP in a month before January 1, 2023, Part A entitlement would begin the primary of July following their enrollment, as provided in sections 1838(a)(2)(D)(i) and (ii) and (a)(3)(B)(i) and (ii) of the Act. Section 120 of the Consolidated Appropriations Act, 2021 (CAA) revised the Part A entitlement effective date for people who enroll through the GEP in a month starting on or after January 1, 2023. Specifically, Part A entitlement for people who enroll in premium Part A through the GEP would begin with the primary day of the month following the month through which they enroll.

Within the 2022 Medicare eligibility and enrollment proposed rule at 87 FR 25094, we proposed to revise SEC 406.21(c) to implement the GEP effective dates outlined in section 120 of the CAA. Specifically, SEC 406.21(c)(3)(i) would require that for people who enroll or reenroll during a GEP prior to January 1, 2023, entitlement would begin July 1 following their enrollment, while SEC 406.21(c)(3)(ii) would require that for people who enroll or reenroll during a GEP on or after January 1, 2023, entitlement would begin on the primary day of the month after the month of enrollment, consistent with section 1838(a)(2)(D)(ii) of the Act (incorporated for premium Part A beneficiaries by reference in section 1818(c) of the Act).

To align with that change, we propose to make clear the applicable effective date of QMB coverage for a person who resides in a bunch payer State and enrolls in conditional Part A through the GEP. As discussed above in section II.A.3 of this preamble, in a Part A buy-in State, CMS considers enrollment in Part B sufficient to satisfy the requirement that a person be entitled to Part A for the needs of the QMB eligibility determination. Nevertheless, in a bunch payer State, enrollment in QMB for people who must pay a premium to enroll in Part A is at all times a two-step process. The State cannot determine individuals eligible for QMB and enroll them in Part A buy-in until SSA establishes actual or conditional Part A enrollment. With respect to QMB enrollment under a buy-in agreement under SEC 406.26, Medicare Part A coverage begins the primary month a person is entitled to Part A under SEC 406.20(b) and has QMB status. We consider a conditional Part A filing to be sufficient to meet the requirement for entitlement to Part A as applicable for QMB coverage. /48/

   FOOTNOTE 48 See CMS Manual for the State Payment of Medicare Premiums, chapter 1, section 1.11. END FOOTNOTE

Specifically, on this rule we propose in latest SEC 406.21(c)(5) to codify existing policy for people who enroll in actual or conditional Part A through the GEP. Starting on or after January 1, 2023, the effective date of Medicare coverage for people who enroll in Medicare through the GEP is the month following the month of enrollment under section 1838(a)(2)(D)(1) and (a)(3)(B)(i) of the Act. For such individuals, QMB coverage starts the month premium Part A entitlement begins (if the State determines the person has met the eligibility requirements for QMB coverage in the identical month that Part A enrollment occurs), or a month later than the month of Part A entitlement (if the person is decided eligible for QMB the month Part A entitlement begins or later).

This proposal would make clear that individuals who reside in group payer States and enroll in actual or conditional Part A through the GEP can obtain QMB as early because the month Part A entitlement begins.

5. Facilitate Enrollment by Allowing Medically Needy Individuals To Deduct Prospective Medical Expenses (SEC 435.831)

The present medically needy income eligibility regulation at 42 CFR 435.831 permits institutionalized individuals to deduct their anticipated medical and remedial care expenses from their income. We propose to amend the regulation to permit noninstitutionalized individuals, under certain circumstances, to do the identical for purposes of medically needy eligibility determinations. This proposal is designed to eliminate the institutional bias inherent in just permitting projection of the fee of look after institutionalized individuals.

Section 1902(a)(10)(C) of the Act provides States the choice to increase Medicaid eligibility to “medically needy” individuals. Implementing regulations are codified at 42 CFR part 435, subpart D. The medically needy are individuals who’ve incomes too high to qualify in a categorically needy group described in section 1902(a)(10)(A) of the Act, but who’ve certain significant and dear health needs. Consistent with section 1902(a)(10)(C)(i)(III) of the Act and regulations at SEC 435.811(a), States establish a separate income standard to find out the income eligibility of medically needy individuals (known as the “medically needy income level,” or “MNIL”). As directed by section 1903(f)(2) of the Act and SEC 435.831(d), a State’s determination of a prospective medically needy individual’s income eligibility includes the deduction of the uncovered medical and remedial expenses incurred by the person, the person’s members of the family, or the person’s financially responsible relatives, from the person’s countable income. This technique of deducting incurred medical and remedial expenses from a person’s countable income is known as a “spenddown.”

To find out income eligibility for medically needy coverage, a State first determines a person’s countable income in accordance with SEC 435.831(b), including application of any disregards imposed under the methodology appropriate for the person (for instance, a $20 monthly income disregard for a person whose Medicaid relies on SSI methodologies), or approved under the State’s Medicaid plan under the authority of section 1902(r)(2) of the Act and SEC 435.601(d).

If the person’s remaining countable income is at or below the MNIL, they’re income-eligible for the medically needy group. If the remaining countable income exceeds the MNIL, the person will need to satisfy a spenddown; that’s, the person will need to cut back the quantity of their income above the MNIL by the quantity of their outstanding medical and remedial care expense liability, from bills the person incurs during their current budget period, and, in some circumstances, previous to it (for instance, under 42 CFR 435.831(f), bills incurred in previous budget periods that weren’t used to satisfy a spenddown because the person had other bills that were sufficient to satisfy the spenddown within the previous budget periods could also be utilized in the present budget period). As required by SEC 435.831(a)(1), States must select a budget period of between 1 and 6 months for use for medically needy individuals. The State multiplies the quantity that a person’s countable income exceeds the MNIL for a single month by the variety of months within the budget period. The product is the quantity of medical or remedial care expenses for which the person must document being liable–the spenddown–to establish eligibility through the budget period. Once the person confirms having the mandatory medical expense liability to the State agency, the person is eligible for the rest of the budget period.

For instance, if a person’s countable monthly income is $1,200 in a State through which the MNIL is $700, the person’s spenddown amount, based on monthly income, could be $500 ($1,200 – $700 = $500). If the budget period elected by the State is 3 months, the State multiplies $500 by 3, and the person’s spenddown is $1,500 for the budget period. If the person’s budget period begins on January 1st, and the person incurs unpaid medical expenses which are equal to or greater than $1,500 on February fifteenth, the person shall be eligible for Medicaid from February fifteenth through March thirty first. To reestablish Medicaid eligibility in the subsequent budget period, the person could have to incur separate medical or remedial care expenses for $1,500. The person won’t change into eligible for Medicaid again until the expenses have been incurred. This leads to the person consistently cycling on and off Medicaid, with eligibility starting sooner or later after the brand new budget period begins, causing a niche in coverage for the person and extra administrative work for the State.

Individually, section 1902(f) of the Act and regulations at SEC 435.121 authorize States to use criteria more restrictive than the SSI program criteria in determining eligibility under the mandatory eligibility group for people in search of Medicaid on the idea of being 65 years old or older or having blindness or disabilities, provided that they provide Medicaid to any such individual who would have been eligible under the State’s 1972 Medicaid plan. (States electing this feature are known as “209(b) States,” after the supply within the Social Security Amendments of 1972, Public Law 92-603, that enacted section 1902(f) of the Act). In determining whether any such individual is income-eligible, section 1902(f) of the Act and SEC 435.121(f)(1)(iii) also require that uncovered medical expenses incurred by the person, the person’s family, or individual’s financially responsible relatives, be deducted from countable income, and that a spenddown be calculated for people with income exceeding the income limit for the mandatory 209(b) State group in generally the identical manner it’s calculated for the medically needy.

In 1994, based on the authority granted to the Secretary under sections 1102 and 1902(a)(4) of the Act to create rules mandatory for the efficient operation of the Medicaid program, and under section 1902(a)(17) of the Act to prescribe the extent to which costs of medical care could also be deducted from income, we established, under SEC 435.831(g)(1), that States have the choice to “include medical institutional expenses (apart from expenses in acute care facilities) projected to the top of the budget period on the Medicaid reimbursement rate” in calculations /49/ (59 FR 1659, January 12, 1994 referred to hereafter because the “1994 rulemaking”). We further confirmed within the preamble to the 1994 rulemaking that 209(b) States are authorized to implement the authority established within the rule regarding the projection of medical institutional expenses.

   FOOTNOTE 49 “Medicaid Program; Deduction of Incurred Medical Expenses (Spenddown)” Final Rule with Comment Period; https://www.govinfo.gov/content/pkg/FR-1994-01-12/html/94-547.htm. END FOOTNOTE

“Projecting” expenses signifies that a State includes in incurred medical expenses those costs that it anticipates a person will incur during a budget period, which may make eligibility effective on the primary day of a person’s budget period, if the anticipated expenses equal or exceed the person’s spenddown. In promulgating the 1994 regulation, we reasoned that institutional services are, by their nature, constant and predictable, which supported a simplified approach for States to find out that an institutionalized individual will meet their spenddown amount each budget period. As required by regulations in SEC 435.831(i)(2), States must reconcile the projected amounts with the actual amounts incurred at the top of the budget period to be able to confirm that the person’s incurred expenses were at the least equal to the person’s spenddown.

For instance, consider a person in an establishment on the primary day of a month with a spenddown amount of $3,000 in a State through which the medically needy budget period is 1 month. The Medicaid rate for the power is $4,500 ($150 day by day), the private rate is $6,000 ($200 day by day), and the State doesn’t project institutional expenses. Until eligibility for Medicaid is established, the person shall be charged the private day by day rate, which might mean that, in a month through which the person doesn’t receive any services not included within the day by day rate, the person will incur $3,000 in expenses as of the fifteenth of the month (3,000 / 200 = 15), at which point the person shall be eligible for Medicaid, for the rest of the month. If the person does, nonetheless, receive any uncovered services beyond the fundamental services included within the day by day rate, the person would change into eligible earlier within the month, although again just for the rest of the month. The result’s that the person is consistently cycling on and off Medicaid, with an eligibility start date each budget period that just isn’t predictable to either the institutionalized individual or State agency.

However, if the State elects to project the person’s institutional expenses under the authority of SEC 435.831(g)–that is, determine that the person will incur the Medicaid rate of $4,500 for the month–the State can establish that the person is eligible for Medicaid, and grant eligibility effective the primary day of the month. No further eligibility-related determination is mandatory. Projecting expenses can profit each parties, by reducing administrative costs for the State and providing continuity of coverage for the beneficiary.

We explained that we considered use of the Medicaid reimbursement rate within the projection of expenses mandatory to attain the very best level of certainty that a person will incur the liability that the regulation was permitting States to anticipate prior to the actual receipt of the services (see 59 FR 1661). For instance, if a State projects the private rate for the services for an institutionalized individual, and the private rate for a specific month exceeds the person’s spenddown and the person is consequently deemed Medicaid eligible on the primary day of the month, the person won’t be charged the private rate for any of the services that month, but as an alternative shall be charged the Medicaid rate, because the provider would have to just accept the Medicaid reimbursement rate for the Medicaid-covered services. If, nonetheless, the person’s spenddown amount exceeds the fee of the Medicaid rate, the person possibly won’t find yourself incurring within the month the expenses mandatory to satisfy his or her spenddown. Subsequently, to avoid possible erroneous grants of eligibility, we determined that using the Medicaid reimbursement rate within the projection of expenses was more appropriate.

The projection of expenses can have the effect of accelerating eligibility. Nevertheless, only permitting projection of the fee of look after institutionalized individuals creates an inherent institutional bias. Further, we consider that there are noninstitutional services that could be similarly constant and predictable such that States could project them for people who must meet a spenddown to change into income-eligible. Permitting projection of such noninstitutional services would scale back a few of the complexity that each State agencies and individuals in search of coverage of home and community-based services (HCBS) currently experience and reduce institutional bias. Projecting noninstitutional expenses would scale back administrative costs related to disenrolling and reenrolling individuals, in addition to lead to higher outcomes for people who would now not cycle on and off Medicaid and experience disruptions to their continuity of care.

We propose to amend SEC 435.831(g) to allow States to project certain additional services that the State can determine with reasonable certainty shall be constant and predictable. Just like the reason provided for institutional expenses within the preamble to the 1994 rule, the projection of expenses for noninstitutional services is proscribed to those which are reasonably certain to be received by the person, since only the amounts for which the person is ultimately liable could be used to cut back income. Just like the reconciliation process required for projected institutional expenses, under the proposed revisions to SEC 435.831(g), States could have to reconcile actual noninstitutional services received with those projected at the top of budget periods to deal with erroneous grants of spenddown-related eligibility. Note that this proposal doesn’t change the requirement that a State proceed to use any eligible expenses actually incurred by the person in determining whether individuals have met the spend down amount, no matter whether the expense was projected.

We propose to incorporate within the regulatory language examples of specific varieties of expenses that we consider meet this standard, while providing additional flexibility for States to discover additional expenses that meet the standards of being constant and predictable. Specifically, we propose to permit projection of medical or remedial expenses for the HCBS which are included in a plan of care (care plan) for a person receiving a piece 1915(i), 1915(j), or 1915(k) profit or participating in a piece 1915(c) HCBS waiver. We consider these medical and remedial expenses are generally constant and predictable because States are required to develop a care plan that identifies the services, and the frequency with which they shall be received, for people eligible for section 1915(c), (i), (j), and (k) services, as set forth in section 1915(c)(1), (i)(1)(E) and (G), (j)(1), (5)(C), and (k)(1)(A)(i) of the Act, and [Sec.] SEC 441.301(b)(1)(i), 441.468(a)(1), 441.540(b)(5), 441.720, and 441.725. States could reasonably calculate, and deduct, the anticipated cost, based on the Medicaid reimbursement rate, of the services in a person’s care plan. We consider this proposal would even have the effect of eliminating the institutional bias that’s fostered by the prevailing regulation’s allowance for the projection of only institutional expenses.

The identical could also be true of people who’ve significant expenses related to high-cost drugs that treat a chronic condition. Pharmacies routinely keep a patient medication profile (“pharmacy profile”) for a patient, which might be used to find out which medications are for chronic conditions and that are for acute treatment. A State could, for instance, use a pharmacy profile to review the 3-, 6-, or 12-month history of the prescriptions that a person has been prescribed, and use that information to project expenses which are reasonably expected to be incurred in the present budget period.

We recognize that the projection of institutional expenses is commonly a simple calculation, because it involves just one provider, with a hard and fast and simply identifiable rate. Against this, the feasibility of projecting expenses for people receiving section 1915(c) or (i) services or prescriptions for chronic conditions will rely upon the person’s specific circumstances. For instance, it is feasible that a piece 1915(c) participant won’t receive a service that is an element of their care plan during a month, or that the frequency with which the person receives considered one of the services, or multiple services, within the care plan varies on a periodic basis. For such HCBS beneficiaries who need a spenddown to qualify, it might take time before a State develops an inexpensive degree of certainty regarding the predictable costs the person incurs every month. For HCBS beneficiaries whose use of services of their care plan varies greatly over the course of multiple budget periods, a State could also be unable to reasonably predict the person’s service costs in a forthcoming budget period. Subsequently, we propose to expressly permit States to project the expenses of section 1915(c), (j), (k) and (i) services and prescription drug services, in addition to other expenses in calculating whether a person meets their spenddown, where the State has determined that such services are constant and predictable.

For each the expenses for services expressly permitted under the examples within the proposed regulation text and for some other expenses for services that the agency has determined are reasonably constant and predictable, States would wish to develop processes to judge the likelihood of a person receiving the services in an upcoming budget period and the anticipated cost of the services. Discrepancies between a State’s projections and the fee of services actually received inevitably will exist. Under proposed SEC 435.831(g)(2), States could be required to project expenses to the top of the budget period with reasonable certainty. Consistent with current regulations at SEC 435.831(i)(2), States would wish to reconcile the projected amounts with the actual amounts incurred at the top of the budget period. Individuals who the State determines because of this of reconciliation didn’t actually meet their spenddown through the budget period may not have eligibility terminated retroactively. The State should use the findings made during reconciliation to prospectively determine whether the person could be expected to incur reasonably constant and predictable expenses in the subsequent budget period, and adjust the projection accordingly.

We invite comment to discover some other varieties of services that individuals may receive on a continuing and predictable basis, and for which a State could project, with a level of relative certainty, consistent costs for a person over the course of a prospective budget period. Such services could be considered for inclusion within the regulatory text in the ultimate rule as specific examples of services that a State can determine with reasonable certainty to be constant and predictable.

We propose to amend SEC 435.831 to exchange the present text in paragraph (g)(2) with the proposed State choice to project noninstitutional expenses. Current paragraphs (g)(2) and (3) in SEC 435.831 shall be redesignated at paragraphs (g)(3) and (4). Note that the proposed changes to SEC 435.831(g) that may enable States to project reasonably certain noninstitutional expenses for medically needy individuals would also apply in projecting noninstitutional expenses in 209(b) States.

6. Application of Primacy of Electronic Verification and Reasonable Compatibility Standard for Resource Information ([Sec.] SEC 435.952 and 435.940)

All 50 States and the District of Columbia are required to implement an asset verification system (AVS) under section 1940 of the Act to confirm certain financial resources for all individuals applying for or receiving Medicaid as an aged, blind, or disabled (ABD) individual. An AVS enables States to confirm assets held in virtually any financial institution in the USA through an electronic data matching process, although not all information returned through an AVS occurs in real time; information from smaller financial institutions may take so long as 30 days or more to be returned to the Medicaid agency. In our work with States implementing the AVS requirement, many States have asked whether or not they are permitted to request additional documentation from applicants and beneficiaries related to resources that could be verified through the State’s AVS, or in the event that they can apply an inexpensive compatibility standard for resources when resource information returned from an electronic data source is comparable to the knowledge provided by the applicant or beneficiary.

The present regulation at SEC 435.952(b) provides that, if information provided by or on behalf of a person is “reasonably compatible” with information obtained by the State in accordance with [Sec.] SEC 435.948, 435.949 or 435.956, that the State must determine or renew eligibility based on such information. Current SEC 435.952(c) provides that a person must not be required to supply additional information or documentation unless information needed by the State in accordance with [Sec.] SEC 435.948, 435.949 or 435.956 can’t be obtained electronically or the knowledge obtained electronically just isn’t reasonably compatible with information provided by or on behalf of the person. Section 435.952(c)(1) provides that States must consider income information obtained through an electronic data match to be reasonably compatible with attested income information if either each are above or each are at or below the applicable income standard or other relevant income threshold. Current SEC 435.952(c)(2) requires the agency to hunt additional information, which can include documentation, if attested information just isn’t reasonably compatible with information obtained through an electronic data match. Nevertheless, documentation from the person is permitted only to the extent electronic data should not available and establishing a knowledge match wouldn’t be effective. In determining effectiveness, States must consider such aspects as the executive costs related to establishing and using the info match compared with the executive costs related to counting on paper documentation, and the impact on program integrity when it comes to the potential for ineligible individuals to be approved, in addition to for eligible individuals to be denied coverage. We seek comment from States on potential implementation challenges, including any systems integration considerations or challenges, under this proposal which could impact the effectiveness and usefulness of such a knowledge match.

The language of SEC 435.952 is written broadly to encompass all aspects of eligibility, including income and resource criteria, when applicable. Nevertheless, on the time SEC 435.952 was promulgated within the 2012 eligibility final rule, no State had implemented the AVS requirement and Federal requirements regarding verification of resources weren’t included within the regulations. Because SEC 435.952(b) and (c) apply specifically to information needed by the State to confirm a person’s eligibility in accordance with [Sec.] SEC 435.948 (regarding income), 435.949 (regarding information received through the Federal Data Services Hub), or 435.956 (regarding non-financial eligibility requirements), some have interpreted this requirement not to use to verification of resources. This interpretation just isn’t consistent with our intent. The language in SEC 435.952 just isn’t specific to income. Indeed, the reasonable compatibility policies described in SEC 435.952(b) and (c) also apply to verification of non-financial eligibility criteria, for instance, State residency which will also be verified electronically (for instance, through a knowledge match with the State’s department of motorcars). Applying [Sec.] SEC 435.952(b) and (c) to resources will help streamline enrollment for people applying for Medicaid on a non-MAGI basis, resembling on the idea of age, blindness, or disability, and reduce burden for each States and beneficiaries. If attested resource information is found to be reasonably compatible with the resource information returned from the AVS, then these resources are considered verified and no further actions from the State or from the beneficiary are needed. Subsequently, we propose to revise paragraphs (b) and (c) of SEC 435.952 to make clear that these provisions apply also to verification of resources. Specifically, we propose to clarify that paragraphs (b) and (c) apply to any information obtained by the State–not just information obtained in accordance with SEC 435.948, 435.949 or 435.956. We also propose to insert the words “and resource” after “income” in paragraph (c)(1) and to delete the word “income” where it appears before “standard” and “threshold” to require that States consider resource information obtained through an electronic data match to be reasonably compatible with attested resource information if each are either above or at or below the applicable standard or other relevant threshold.

This proposal is meant to make clear that States should not permitted to request additional resource information from the beneficiary to find out eligibility if the resource information provided by a person is fairly compatible with the knowledge received from an electronic data source, resembling the AVS. If information provided by a person just isn’t reasonably compatible with the knowledge received from the electronic data source, States must resolve any discrepancies per SEC 435.952(c)(2), which just isn’t revised on this rulemaking.

Under the proposed regulations, resource information obtained from an electronic data source, resembling an AVS, have to be considered reasonably compatible with resource information provided by the applicant or beneficiary if each are either above or at or below the applicable resource standard or other applicable resource threshold. Further, while not required, States could establish an inexpensive compatibility threshold, such that electronic data could be considered reasonably compatible with attested resources if the electronic data is not any higher than attested resources plus the State’s elected threshold amount (expressed as either a percentage or dollar amount). Some States, for instance, apply an inexpensive compatibility threshold of 5 or 10 percent of attested income in verifying income eligibility. States wouldn’t be required to ascertain the identical reasonable compatibility threshold for income and resources, and will apply different reasonable compatibility thresholds for various eligibility groups, provided that the State has an inexpensive rationale for doing so.

We also propose a corresponding technical change to amend SEC 435.940 so as to add section 1940 of the Act as a basis for the income and eligibility verification requirements. The proposed changes to SEC 435.952 on this rulemaking include resource information obtained from electronic data sources, resembling an asset verification program described under section 1940 of the Act.

7. Verification of Citizenship and Identity (SEC 435.407)

In 2016, we revised the Medicaid and CHIP regulations governing the verification of citizenship and identity to require States to rely totally on electronic verification to effectuate the streamlined and coordinated approach required by the ACA to cut back burden on individuals and increase administrative efficiency. These regulatory changes were issued by CMS in a November 2016 final rule titled, “Medicaid and Kid’s Health Insurance Programs: Eligibility Notices, Fair Hearing and Appeal Processes for Medicaid and Other Provisions Related to Eligibility and Enrollment for Medicaid and CHIP” (81 FR 86453, November 30, 2016) (referred to hereafter because the “2016 eligibility and enrollment final rule”). Under the regulations, all States must first try to confirm citizenship electronically using data from the SSA, and most States depend on a match through the Federal Data Services Hub (FDSH) for this data. In that final rule, we also streamlined and simplified the list of documents and other acceptable technique of verification that could be used when citizenship can’t be verified electronically with SSA. One such alternative source of citizenship verifications, codified at SEC 435.407(b), is a knowledge match with the State’s (or one other State’s) vital statistics system. We explained within the preamble to the 2016 eligibility and enrollment final rule that if citizenship verification can’t be accomplished through an electronic data match with SSA, the State must try to confirm citizenship through an electronic data match with the State’s (or one other State’s) vital statistics system, before requesting paper documentation from the person, if such match is accessible throughout the meaning at SEC 435.952(c)(2)(ii).

Under current regulation, individuals whose citizenship is verified based on any of the sources identified in SEC 435.407(b)–which includes, under the present regulations, a match with a State’s vital statistics records or with the U.S. Department of Homeland Security (DHS) Systematic Alien Verification for Entitlements (SAVE) Program–must also provide proof of identity. The documentary evidence identified in section 1903(x)(3)(B) of the Act, codified through the 2016 eligibility and enrollment final rule at SEC 435.407(a), in contrast, provides “stand-alone” proof of citizenship; separate proof of identity just isn’t required. Section 1903(x)(3)(B)(vi) of the Act authorizes the Secretary to specify that other documents along with those laid out in the statute, have to be accepted as stand-alone satisfactory documentation of citizenship in the event that they determine that such documents provide each proof of United States citizenship or nationality, in addition to reliable documentation of non-public identity. As explained below, verification with a State’s vital statistics records or SAVE, like the info match with SSA, which provides each proof of U.S. citizenship or nationality and reliable documentation of non-public identity, meets this standard.

On this rule, we’re proposing to further simplify the verification procedures by moving verification of citizenship with a State vital statistics agency or SAVE from paragraph (b) to paragraph (a) of SEC 435.407 for Medicaid, which is incorporated into CHIP regulations through existing cross-references at [Sec.] SEC 457.380(b)(1)(i) and 435.956(a). This alteration would mean that verification of birth with a State vital statistics agency or verification of citizenship with SAVE could be considered stand-alone evidence of citizenship; separate verification of identity wouldn’t be required, just like the treatment afforded to verification of citizenship with SSA. This proposed change would scale back burden on individuals and State Medicaid agencies and increase administrative efficiency.

Turning first to residents whose status could be verified with DHS’ SAVE Program, SAVE can provide electronic verification of U.S. citizenship for people who’ve a DHS record of naturalized or derived citizenship, often documented with a Certificate of Naturalization or Certificate of Citizenship. Any SAVE program requestor (for instance, the Medicaid or CHIP agency or other profit granting or licensing agency) that requests verification of U.S. citizenship or immigration status through the SAVE program must provide the SAVE program with the person’s biographic information (first name, last name, and date of birth) and a personalised numeric identifier (resembling an Alien Number; Form I-94, Arrival/Departure Record Number; Student and Exchange Visitor Information System (SEVIS) ID number; or unexpired foreign passport number) unique to that individual. DHS verifies identity prior to providing a SAVE program response verifying citizenship or immigration status, reviewing multiple records and in some cases requiring additional information from the requestor. If a person’s immigration status is confirmed by SAVE, the State’s verification of immigration status is complete under current regulations, whereas separate proof of identity is required if SAVE confirms the person’s citizenship. Because the method followed by SAVE is an identical, we don’t consider that the additional step required for residents is justified. Subsequently, we propose revisions to SEC 435.407 to supply for comparable processes for people whose status is verified by SAVE, no matter whether or not they are a citizen or non-citizen. Specifically, we propose to remove verification of citizenship with SAVE currently at SEC 435.407(b)(11) (which requires separate proof of discover) and so as to add such verification at proposed SEC 435.407(a)(8) (which might not require separate proof of identity) for Medicaid, which is incorporated into CHIP regulations through existing cross-references at [Sec.] SEC 457.380(b)(1)(i) and 435.956(a).

Verification of U.S. citizenship with a State vital statistics agency provides a similarly robust data matching process because a State Medicaid or CHIP agency must provide the State vital statistics agency with a minimum set of identifiable information including the name, date of birth, and Social Security Number (SSN). Some States also use additional identifiers in the event that they can be found, resembling the person’s birth county, the parents’ names or the mother’s maiden name. Based on State feedback, CMS understands that the method and data fields used to confirm citizenship with a State vital statistics agency are similar across States. Conducting a knowledge match with specific identifiers like date of birth and SSN is similar process that might be used to supply evidence of identity, thereby making a requirement to individually confirm identity redundant. Subsequently, we propose revisions to SEC 435.407 under which verification of citizenship with a State vital statistics agency would function stand-alone proof of U.S. citizenship and no separate proof of discover could be required. Specifically, we propose to remove verification of citizenship with a State vital statistic’s agency currently at SEC 435.407(b)(2) (which requires separate proof of discover) and so as to add such verification at proposed SEC 435.407(a)(7) (which might not require separate proof of identity) for Medicaid, which is incorporated into CHIP regulations through an existing cross-references at [Sec.] SEC 457.380(b)(1)(i) and 435.956(a). Nevertheless, we recognize that different State Medicaid and CHIP agencies and vital statistics agencies may employ different processes and seek comment on what processes Medicaid and CHIP agencies use to confirm citizenship with a State vital statistics agency, including what information and identifiers are used to finish verification, whether the info matching process with all State vital statistics agencies is sufficiently robust to appropriately apply this proposed change in policy to verification of citizenship in all States, or limit this transformation in policy only to States through which the vital statistic agency’s processes are comparable to those of the SAVE program.

We note that, if citizenship can’t be verified through an electronic match with SSA, States are required to confirm citizenship using an electronic match prior to requesting other types of documentation, if such match is accessible and effective in accordance with SEC 435.952(c)(2)(ii). Inasmuch as State vital statistics agencies generally can provide electronic data matching, we’re also proposing to delete the words “at State option,” that are included in existing SEC 435.407(b)(2), from proposed SEC 435.407(a)(7) for Medicaid, which is incorporated into CHIP regulations through an existing cross-reference at SEC 457.380(b)(1)(i) to SEC 435.956(a). Use of such match with a significant statistics agency just isn’t voluntary if it is accessible and effective in accordance with SEC 435.952(c)(2)(ii). This proposed revision doesn’t necessarily require a State to develop a match with its vital statistics agency. Nevertheless, States that don’t currently perform such electronic matches must develop that capability if such match is accessible and could be effective in accordance with the usual set forth in SEC 435.952(c)(2)(ii). If a State already has established a match with a State vital statistics agency or it might be effective to ascertain such capability in accordance with the usual set forth in SEC 435.952(c)(2)(ii), the State must utilize such match before requesting paper documentation.

B. Promoting Enrollment and Retention of Eligible Individuals

1. Aligning Non-MAGI Enrollment and Renewal Requirements With MAGI Policies ([Sec.] SEC 435.907 and 435.916)

The 2012 and 2013 eligibility final rules established numerous eligibility and enrollment simplifications for MAGI-based Medicaid and CHIP beneficiaries. Amongst these were streamlined processes that made it easier for eligible individuals to use and remain enrolled in Medicaid and CHIP. Nevertheless, beneficiary advocates raised concerns that these simplifications haven’t been afforded to Medicaid beneficiaries excepted from use of MAGI-based methodologies, which is especially problematic provided that individuals over age 65 and people who are eligible based on blindness or a disability are more likely to have more stable eligibility. Subsequently, on this proposed rule, we propose changes to each the applying and renewal requirements for MAGI-excepted applicants and beneficiaries to align with the necessities for populations based on MAGI.

Starting with the applying process, individuals have to be permitted to submit the one streamlined application developed by the Secretary, or another single streamlined application described at SEC 435.907(a)(2) of the present regulations, through all modalities specified at SEC 435.907(a) (online, by telephone, by mail, or in person). Although not expressly stated within the regulations, States are also expected to just accept applications and supplemental forms needed for people to use for coverage on a non-MAGI basis via all modalities identified in SEC 435.907(a). As well as, SEC 435.907(d) prohibits States from requiring an in-person interview as a part of the applying process, when determining eligibility based on MAGI, whereas States are still permitted to require an in-person interview for MAGI-excepted applicants.

At renewal, current SEC 435.916(a) requires States to conduct renewals of Medicaid eligibility on an annual basis for people whose financial eligibility is decided using MAGI-based methodologies. Nevertheless, for people excepted from use of the MAGI-based methodologies, SEC 435.916(b) of the present regulations permits States to conduct regularly-scheduled renewals more steadily (for instance, every 6 months). States must renew eligibility for all Medicaid beneficiaries without requiring information from the person if in a position to achieve this consistent with regulations at [Sec.] SEC 435.916(a)(2) and (b). Nevertheless, when a beneficiary’s eligibility can’t be renewed based on available information, States must follow a set of streamlined procedures for MAGI-based beneficiaries, which should not required for those excepted from MAGI. The procedures for requesting information from MAGI-based beneficiaries are described at SEC 435.916(a)(3) of the present regulations and include: (1) using a pre-populated renewal form; (2) providing the person a minimum of 30 calendar days to sign and return the shape together with any requested information; and (3) reconsidering eligibility for a person terminated for failure to return the renewal form or other needed information if the shape or other information is returned inside 90 calendar days after the date of termination. The procedures for requesting information from MAGI-based beneficiaries are described at SEC 435.916(a)(3) of the present regulations and include: (1) using a pre-populated renewal form; (2) providing the person a minimum of 30 calendar days to sign and return the shape together with any requested information; and (3) reconsidering eligibility for a person terminated for failure to return the renewal form or other needed information if the shape or other information is returned inside 90 calendar days after the date of termination. As well as, States may not require a MAGI beneficiary to finish an in-person interview as a part of the renewal process under SEC 435.916(a)(3)(iv) of the present regulations. States may, but should not required to, adopt the procedures at SEC 435.916(a)(3) for people whose eligibility is decided on a basis apart from MAGI, per SEC 435.916(b) of the present regulations.

While just about all States adopt at the least considered one of the optional processes for renewals of non-MAGI beneficiaries, /50/ the differences in renewal requirements for MAGI and non-MAGI beneficiaries end in a less streamlined and more burdensome process for beneficiaries who qualify for Medicaid on a non-MAGI basis, resembling being age 65 or older or having blindness or a disability. Consequently of those differences, individuals who’re Medicaid eligible on considered one of these bases could also be required to spend more time completing renewal paperwork if their renewal form just isn’t prepopulated. They could be provided less time to return their renewal form and requested information, even when the person must provide information related to additional aspects of eligibility related to non-MAGI eligibility groups as in comparison with MAGI eligibility groups, resembling asset information.

   FOOTNOTE 50 Kaiser Family Foundation (2019). Medicaid financial eligibility for seniors and other people with disabilities: Findings from a 50-State survey, p. 19-20. https://www.kff.org/report-section/medicaid-financial-eligibility-for-seniors-and-people-with-disabilities-findings-from-a-50-state-survey-issue-brief/. END FOOTNOTE

CMS finds this to be problematic for several reasons. First, individuals who’re Medicaid eligible based on being age 65 or older or having blindness or a disability usually tend to survive a hard and fast income and, subsequently, usually tend to remain financially eligible for coverage than the non-disabled beneficiaries under age 65 who qualify for Medicaid based on MAGI. /51/ We’re concerned that, despite the commonly greater stability of their income, and subsequently, eligibility, a bigger proportion of non-MAGI beneficiaries who lose coverage achieve this for procedural reasons. Indeed, as noted in section II.A.1. of this proposed rule, dually eligible for Medicaid and Medicare who lose Medicaid coverage throughout the first 12 months of enrollment likely lose such coverage for reasons which are administrative in nature. /52/ Also, individuals who’re Medicaid eligible based on being age 65 or older or having blindness or disability status may experience additional barriers related to document retention, communication (for instance, limited English proficiency and low health literacy), technology (for instance, printing costs, access to a pc or web) and limited access to transportation, amongst others. Processes that provide greater flexibility, resembling reduced documentation requests and more time for returning information, can reduce these barriers. /53/ /54/ Consequently, we consider that when States don’t use available streamlined renewal procedures for this population, there’s a greater risk of terminations for procedural reasons.

   FOOTNOTE 51 Ku, L. & Steinmetz, E. (2013). Bridging the Gap: Continuity and Quality of Coverage in Medicaid. https://ccf.georgetown.edu/wp-content/uploads/2013/09/GW-Continuity-Report-9-10-13.pdf; Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services (2021). Medicaid Churning and Continuity of Care: Evidence and Policy Considerations Before and After the COVID-19 Pandemic. https://aspe.hhs.gov/sites/default/files/private/pdf/265366/medicaid-churning-ib.pdf. END FOOTNOTE

   FOOTNOTE 52 Assistant Secretary for Planning and Evaluation (2019). Lack of Medicare-Medicaid dual eligible status: Frequency, contributing aspects and implications. https://aspe.hhs.gov/system/files/pdf/261716/DualLoss.pdf. CMS also recently accomplished an updated internal evaluation of ASPE’s study using data from 2015-2018 that shows that dually eligible individuals proceed to lose Medicaid at a high rate of their first 12 months resulting from administrative reasons. END FOOTNOTE

   FOOTNOTE 53 CMS Office of Burden Reduction & Health Informatics (April 2022). Navigating the Medicare Savings Program (MSP) Eligibility Experience. https://www.cms.gov/files/document/navigating-medicare-savings-program-msp-eligibility-experience-journey-map.pdf. END FOOTNOTE

   FOOTNOTE 54 CMS Office of Burden Reduction & Health Informatics (April 2022). Navigating the Medicare Savings Program (MSP) Eligibility Experience. https://www.cms.gov/files/document/navigating-medicare-savings-program-msp-eligibility-experience-journey-map.pdf. END FOOTNOTE

Using the authority provided in sections 1902(a)(4)(A) and (a)(19) of the Act to make sure the right and efficient administration of this system and that eligibility is decided in a way consistent with simplicity of administration and best interests of beneficiaries, we propose to revise current renewal regulations at SEC 435.916 to require States to use the identical renewal procedures for MAGI and non-MAGI beneficiaries. Specifically, we propose, by removing the reference in SEC 435.916(a)(1) to MAGI beneficiaries, to require that States conduct regularly-scheduled renewals of eligibility once, and just once, every 12 months for all Medicaid beneficiaries, including non-MAGI beneficiaries with limited exception, discussed below. We consider aligning the frequency of renewals for non-MAGI beneficiaries with the present requirement for MAGI beneficiaries is acceptable provided that circumstances related to eligibility are generally more stable for non-MAGI beneficiaries and can reduce beneficiary burden, consistent with sections 1902(a)(4) and (a)(19) of the Act. As well as, we consider this proposal promotes equity across enrolled populations since non-MAGI beneficiaries, whose income tends to be more stable, would now not be subject to more frequent requests to return renewal forms or provide documentation to confirm continued eligibility than other beneficiaries. We also note that over 40 States currently conduct renewals just once every 12 months for all Medicaid beneficiaries.

We seek comment on this proposal at SEC 435.916(a)(1) to align the frequency of renewals for all beneficiaries, except as noted below. We’re particularly curious about comments from State agencies on the executive impact of conducting eligibility just once every 12 months for non-MAGI beneficiaries and whether or not State agencies that currently conduct renewals just once every 12 months for all Medicaid beneficiaries have experienced more stable coverage amongst non-MAGI beneficiaries or any program integrity concerns after shifting from a shorter renewal cycle to a 12-month renewal cycle. We’re also curious about data regarding coverage losses amongst non-MAGI beneficiaries resulting from procedural reasons, resembling failure to return renewal paperwork timely, versus changes to specific aspects of eligibility, resembling income or disability status. We’re also curious about hearing from stakeholders and beneficiaries on the impact of more frequent renewals on maintaining coverage.

Section 1902(e)(8) of the Act provides an option for States to renew eligibility for QMBs described in section 1905(p)(1) of the Act more steadily than once every 12 months, but no more steadily than once every 6 months. Thus, we cannot, propose to limit renewals for QMBs to once every 12 months, and proposed SEC 435.916(a)(2) continues to permit States to conduct more frequent renewals of Medicaid eligibility for QMBs consistent with section 1902(e)(8) of the Act. Nevertheless, States are permitted under current regulations at SEC 435.916(b) to conduct renewals once every 12 months for QMBs and would remain in a position to achieve this under proposed SEC 435.916(a)(2). We encourage States to exercise their flexibility to schedule renewals just once every 12 months for QMBs to mitigate churn and ease administrative burden on beneficiaries and States that’s related to more frequent renewals of eligibility.

Proposed SEC 435.916(b)(3) also requires States to adopt the renewal processes at SEC 435.916(a)(3) of the regulations, as revised at redesignated SEC 435.916(b)(2), for non-MAGI beneficiaries when a State is unable to renew eligibility for a person based on information available to the agency. Proposed SEC 435.916(b)(2) and (3) would require States to supply all beneficiaries, including non-MAGI beneficiaries, whose eligibility can’t be renewed in accordance with proposed SEC 435.916(b)(1): (1) a renewal form that’s pre-populated with information available to the agency; (2) a minimum of 30 calendar days to return the signed renewal form together with any required information; and (3) a 90-day reconsideration period for people terminated for failure to return their renewal form but who subsequently return their form throughout the reconsideration period. We consider aligning these renewal procedures would promote continuity of coverage and simplify the renewal process for non-MAGI beneficiaries in a way that’s in the most effective interest of beneficiaries, consistent with section 1902(a)(19) of the Act, including those in households with individuals enrolled on each a MAGI and non-MAGI basis who otherwise could also be subject to more burdensome administrative requirements at renewal. As well as, we consider States may also experience reduced administrative burden related to churn if individuals face fewer administrative barriers to maintaining coverage.

We also propose to eliminate the choice States have under current regulations at [Sec.] SEC 435.907(d) and 435.916(b) to require an in-person interview as a part of the applying and renewal process for non-MAGI beneficiaries. Stakeholder feedback on the beneficiary experience navigating State application and renewal processes indicate that it could possibly be difficult for people who’re Medicaid eligible based on being age 65 or older or having blindness or a disability status to coordinate, prepare for, and take part in an interview and missing and/or having to reschedule an interview, particularly when the method just isn’t flexible for the person, may end up in determinations of ineligibility and/or terminations based on procedural reasons. /55/ We consider in-person interview requirements create a barrier for eligible individuals to acquire and maintain coverage without yielding any additional information than could be obtained through other modalities, particularly for people without access to reliable transportation or a consistent schedule.

   FOOTNOTE 55 CMS Office of Burden Reduction & Health Informatics (April 2022). Navigating the Medicare Savings Program (MSP) Eligibility Experience. https://www.cms.gov/files/document/navigating-medicare-savings-program-msp-eligibility-experience-journey-map.pdf. END FOOTNOTE

Along with eliminating the choice to require an in-person interview, we propose to codify longstanding policy to align enrollment requirements in the most effective interest of all applicants. Proposed SEC 435.907(c)(4) codifies longstanding policy that States accept all MAGI-exempt applications and supplemental forms provided by applicants in search of coverage on a non-MAGI basis, through all of the modalities listed in current regulations at SEC 435.907(a). Eliminating the in-person interview requirement and codifying the necessities for accepting MAGI-exempt applications and supplemental forms through all modalities would further align eligibility and enrollment procedures for MAGI and non-MAGI applicants and beneficiaries and reduce applicant and beneficiary burden, consistent with sections 1902(a)(4) and (a)(19) of the Act.

We propose removing the introductory language at the present SEC 435.916(b) related to the frequency of and process for renewals of eligibility for non-MAGI beneficiaries. We propose redesignating current regulations at SEC 435.916(b)(1) and (2) (related to the agency’s option to think about blindness and disability as continuing at renewal) at proposed SEC 435.916(b)(3)(i) and (ii).

Along with the policy changes proposed to align application and renewal processes for MAGI and non-MAGI populations each time possible, we propose several additional changes to current SEC 435.916 to make sure that the renewal requirements are clear and consistent. We propose to redesignate current regulations at SEC 435.916(a)(2) (related to renewals based on information available to the agency) and SEC 435.916(a)(3) (related to renewals that require information from beneficiaries) to SEC 435.916(b)(1) and (b)(2), respectively. States will proceed to be required to try to renew eligibility for all Medicaid beneficiaries (MAGI and non-MAGI) based on available information before requesting information from the person, as required at current SEC 435.916(a)(2) and (b), and to send a renewal form to, and request information from, beneficiaries for whom the State doesn’t have sufficient information to redetermine eligibility, and accept the renewal form through all modalities required at application at SEC 435.907(a). (online, by telephone, by mail, or in person). We propose to change the header in proposed SEC 435.916(b)(2) from “use of a pre-populated renewal form” to “renewals requiring information from the person” for the reason that current regulations describe the steps States must take when conducting renewals that require information from the person, which incorporates, but just isn’t limited to, using pre-populated renewal forms.

At SEC 435.916, we also propose to revise current paragraph (a)(3)(i)(B), redesignated at proposed paragraph (b)(2)(i)(B), to make clear that the 30 calendar days that States must provide beneficiaries to return their pre-populated renewal form begins on the date the State sends the shape. This is able to mean that beneficiaries have 30 calendar days from the date a form is postmarked or, for beneficiaries who elected to receive electronic notices, the date the electronic is distributed. We consider starting the 30-day period from the date the State sends the shape, as an alternative of the date on the shape, will ensure beneficiaries don’t lose time to reply if the shape is postmarked or sent after it’s dated.

We propose clarifying revisions to current SEC 435.916(a)(3)(i)(B) (related to renewal form signatures), redesignated at proposed SEC 435.916(b)(2)(i)(B), by including a technical change to explicitly state that beneficiaries must sign their pre-populated renewal form under penalty of perjury; current regulations at SEC 435.916(a)(3)(i)(B) includes this requirement only by cross reference to SEC 435.907(f).

We propose to revise current SEC 435.916(a)(3)(iii) (related to timely processing of renewal forms and knowledge returned through the reconsideration period), redesignated at proposed SEC 435.916(b)(2)(iii), to specify explicitly in regulation our current policy that the returned renewal form and knowledge received through the reconsideration period function an application and require, via cross reference to SEC 435.912(c)(3) of the present regulation, that States determine eligibility throughout the same timeliness standards applicable to processing applications, that’s, 90 calendar days for renewals based on disability status and 45 calendar days for all other renewals. Treatment of renewal forms returned through the 90-day reconsideration period as an application signifies that the provision of retroactive eligibility at SEC 435.915 can close the gap in coverage that such beneficiaries otherwise would experience. Adherence to the timeliness standards applicable to applications will ensure eligible individuals are furnished coverage with reasonable promptness, consistent with sections 1902(a)(4) and 1902(a)(8) of the Act and can minimize the likelihood that individuals will forgo needed care. As revised, proposed SEC 435.916(a)(3)(iii) can also be consistent with guidance described within the December 4, 2020, CMCS Informational Bulletin “Medicaid and Kid’s Health Insurance Program (CHIP) Renewal Requirements” (2020 Renewal CIB) that a renewal form returned throughout the reconsideration period serves as an application for the needs of adherence to timeliness standards to make determinations of eligibility. /56/ /57/

   FOOTNOTE 57 CMCS Informational Bulletin: Medicaid and Kid’s Health Insurance Program (CHIP) Renewal Requirements (2020). Available at https://www.medicaid.gov/federal-policy-guidance/downloads/cib120420.pdf. END FOOTNOTE

We propose to redesignate and revise current regulations at SEC 435.916(c) and (d), related to redeterminations based on changes in circumstances, at the brand new proposed SEC 435.919. Proposed revisions to those regulations are discussed in section II.B.2. of this proposed rule.

With the redesignation of current SEC 435.916(c) and (d) to proposed SEC 435.919, we also propose to redesignate current SEC 435.916(e) (related to requesting only information from beneficiaries needed to renew eligibility) at proposed SEC 435.916(b)(2)(v). We propose to redesignate current SEC 435.916(f) (related to determining eligibility on all bases and transmission of information pertaining to individuals now not eligible for Medicaid) and SEC 435.916(g) (regarding accessibility of renewal forms and notices) to proposed SEC 435.916(d) and (e), respectively. Moreover, we modify current SEC 435.916(f)(2), redesignated at SEC 435.916(d)(2) on this proposed rule, to make sure that, prior to terminating coverage for a person determined ineligible for Medicaid, States determine eligibility for CHIP and potential eligibility for other insurance affordability programs (that’s, BHP and insurance affordability programs available through the Exchanges) and transfer the person’s account in compliance with the procedures set forth in SEC 435.1200(e), including proposed changes described in section II.B.5. of this proposed rule. We consider requiring that these actions be accomplished prior to termination is mandatory to limit gaps in coverage for people transitioning between Medicaid and other insurance affordability programs, consistent with sections 1902(a)(4) and 1902(a)(19) of the Act. We add a paragraph heading at proposed SEC 435.916(e) to format the supply consistent with other provisions in SEC 435.916.

Finally, as discussed in section II.B.3. of this proposed rule, we propose to ascertain time standards for States to finish renewals of eligibility in proposed SEC 435.912(c)(4) and add a cross reference to those proposed time standards in proposed SEC 435.916(c).

2. Acting on Changes in Circumstances Timeframes and Protections ([Sec.] SEC 435.916, 435.919, and 457.344)

Section 1902(a)(10) of the Act authorizes States to make medical assistance available under the State plan to individuals who meet certain eligibility criteria. Once an applicant has been determined eligible for coverage, Federal regulations include two basic requirements to make sure that individuals receiving medical assistance proceed to be eligible. First, as described in section II.B.1. of this proposed rule, States are required to conduct regular renewals of eligibility per SEC 435.916(a) and (b) of the present regulations. Second, per SEC 435.916(c) and (d) of the present regulations, States will need to have a process to acquire details about changes in circumstances which will impact a beneficiary’s eligibility and redetermine eligibility in between regular renewals when appropriate.

Current regulations at SEC 435.916(c) require that States have procedures designed to make sure that beneficiaries make timely and accurate reports of any changes in circumstances which will affect their eligibility and that such changes could also be reported through any of the modes for submission of applications described in SEC 435.907(a). Current regulations at SEC 435.916(d) specify that the agency must promptly redetermine eligibility between regular renewals of eligibility each time it receives details about a change in beneficiary circumstances which will affect eligibility, resembling a change in income or the death of a beneficiary. The regulation doesn’t define “promptly.”

We’re concerned that numerous States should not taking appropriate steps to follow up on reported or detected changes in beneficiaries’ circumstances inside an inexpensive time frame or in a way that promotes continuity of coverage for eligible beneficiaries. There may be a possible risk to beneficiaries if a State delays processing a change in circumstances which will entitle a beneficiary to additional assistance or lower premiums or cost-sharing, in addition to risk that beneficiaries may lose coverage for procedural reasons if States do follow up with a beneficiary to request additional information but don’t provide sufficient time for the beneficiary to reply. Furthermore, recent U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) reports, in addition to CMS audits and data analyses have cited cases through which States continued to supply coverage for a lot of months after a change impacting eligibility was identified that ought to have prompted a redetermination based on a change in circumstances and other instances through which States continued to make capitated payments to managed care plans for deceased beneficiaries. /58/

   FOOTNOTE 58 https://www.lla.la.gov/PublicReports.nsf/1CDD30D9C8286082862583400065E5F6/$FILE/0001ABC3.pdf and https://oig.hhs.gov/oas/reports/region7/71604228.pdf; https://oig.hhs.gov/oas/reports/region5/51800026.pdf; https://oig.hhs.gov/oas/reports/region4/41806220.pdf; and https://oig.hhs.gov/oas/reports/region5/51700008.pdf. END FOOTNOTE

Consistent with section 1902(a)(4) of the Act, to advertise the right and efficient administration of the Medicaid program, we propose so as to add a latest SEC 435.919 to obviously define the responsibilities States need to act on changes in circumstances. We propose to revise and redesignate SEC 435.916(c) of the present regulations (related to procedures for reporting changes) to latest SEC 435.919(a). We propose to revise and redesignate current SEC 435.916(d) (related to promptly acting on changes in circumstances) to proposed SEC 435.919(b) and (c).

Proposed SEC 435.919(a)(1) would specify that States will need to have procedures for beneficiaries to make timely and accurate reports of changes in circumstances which will affect eligibility. Proposed SEC 435.919(a)(2) specifies that States must accept each reported changes in circumstances which will affect eligibility and some other beneficiary reported information through the identical modes for submission of application at SEC 435.907(a). We consider that is a very important update that may make sure that beneficiaries can easily report information that supports continued enrollment in Medicaid, resembling updating contact information or reporting an in-state address change, even when the knowledge wouldn’t constitute a change in circumstances that affects eligibility.

Proposed SEC 435.919(b)(1) describes the steps that we consider States needs to be required to absorb processing changes in circumstances reported by a beneficiary in between renewals of eligibility. Under the proposed regulation, States must first evaluate whether the reported change may end in ineligibility for Medicaid or a change in the quantity of medical assistance for which the beneficiary is eligible (for instance, a change in advantages or higher or lower premiums or cost sharing charges). If additional information is required to find out whether the beneficiary stays eligible, the agency must redetermine eligibility based on available information, if in a position to achieve this, and if the extra information just isn’t available to the agency, request such information from the beneficiary. When the agency requests information from the beneficiary to find out whether a change in circumstances leads to coverage that’s more useful to the person (for instance, additional advantages or lower premiums or cost sharing charges), the agency may not take antagonistic motion if the beneficiary doesn’t respond. In this example, the agency wouldn’t provide the more useful coverage but would as an alternative proceed to supply the less useful coverage for which eligibility was already established. The agency must send the beneficiary written notice of this decision consistent with 42 CFR 435.917(b)(1), which must include information on the beneficiary’s right to appeal their eligibility status or level of advantages and services approved.

If the reported change adversely impacts the beneficiary’s eligibility for Medicaid such that termination could also be mandatory, the State must consider whether the beneficiary may remain eligible on some other basis, as currently required under current regulations at SEC 435.916(f)(1), which is redesignated at SEC 435.916(d)(1) on this proposed rule. If the beneficiary is decided to be ineligible for Medicaid on any basis, proposed SEC 435.919(b)(1), cross-referencing to proposed SEC 435.919(b)(4), provides that the State must provide advance notice of termination and fair hearing rights, consistent with 42 CFR part 431, subpart E of the regulations. Prior to creating a determination of ineligibility, the State also must determine potential eligibility for other insurance affordability programs and transfer the person’s account, as appropriate, consistent with existing regulations at SEC 435.916(f)(2), redesignated at proposed SEC 435.916(d)(2). If the agency finds that the reported change leads to other antagonistic motion, resembling higher premiums or cost sharing charges or a reduced profit package, the State must provide advance notice of the antagonistic motion and fair hearing rights, consistent with the necessities of 42 CFR part 431, subpart E. We note that, in accordance with 42 CFR 431.230, if the beneficiary requests a good hearing prior to the date of motion provided within the advance notice (for instance, the date the person’s eligibility shall be terminated), the State may not implement the antagonistic motion until a good hearing decision is rendered.

If a beneficiary-reported change may end in a rise in the quantity of assistance a beneficiary is entitled to, for instance, a discount in premiums or cost sharing, or additional profit, the State must confirm the reported information in accordance with [Sec.] SEC 435.940 through 435.960 and the State’s verification plan prior to granting additional coverage or assistance. Such verification may include electronic data or other information available to the agency, attested information, or documentation from the beneficiary. States may not terminate the beneficiary’s coverage or take other antagonistic motion if the person doesn’t reply to requests for extra information to confirm the beneficiary-reported change. If the reported change has no impact on eligibility or coverage, consistent with section 1902(a)(4) and (a)(19) of the Act, we propose at SEC 435.919(b)(1)(iv) that the agency must acknowledge the reported change by providing the beneficiary with notice acknowledging receipt of the knowledge and explaining that there is no such thing as a impact on eligibility or coverage.

The method we’re proposing for States to act on information obtained from a 3rd party, resembling information obtained through an electronic data match or from one other program resembling the Supplemental Nutrition Assistance Program (SNAP), is described at proposed SEC 435.919(b)(2). This process largely mirrors that described in proposed SEC 435.919(b)(1), discussed above. Under proposed SEC 435.919(b)(2), the agency will need to judge the reliability of the knowledge obtained and, if reliable information from a 3rd party may end in an antagonistic motion, the State must give the beneficiary a possibility to supply information disputing the accuracy of the third-party information in accordance with SEC 435.952(d). If the beneficiary doesn’t respond with the requested information or the knowledge provided doesn’t establish the beneficiary’s continued eligibility or entitlement to the identical level of assistance, the State must: (1) provide advance notice of termination or other antagonistic motion and fair hearing rights consistent with part 431, subpart E; and (2) before terminating the beneficiary’s coverage, assess eligibility for other insurance affordability programs in accordance with proposed revisions to current SEC 435.916(f)(2), redesignated at SEC 435.916(d)(2) on this rulemaking, and transfer the person’s account, as appropriate.

If a change identified by reliable third-party data may end in a rise in the quantity of coverage or assistance a beneficiary is entitled to (for instance, additional advantages or lower premiums or cost sharing), States retain flexibility under the proposed rule either to act on the third-party information without additional follow up or to contact the beneficiary to find out whether the knowledge received is accurate. Nevertheless, States that decide to contact the beneficiary to confirm the accuracy of data prior to furnishing additional assistance may not terminate the beneficiary’s coverage or take other antagonistic motion if the person doesn’t reply to the request for information. Moreover, if States decide to contact the beneficiary and the beneficiary doesn’t reply to the request for information, the State may act on the third-party information. If third-party information just isn’t reliable (for instance, information is older than other information available to or obtained by the State or is incomplete) or doesn’t impact the beneficiary’s eligibility, there is no such thing as a requirement for the agency to take further motion or to supply notice to the beneficiary. Moreover, States may not take antagonistic motion based on unreliable information.

At SEC 435.919(c)(1), we propose that States provide a minimum of 30 calendar days from the date a request for information is distributed, which is the date the request is postmarked or the date the notice is distributed electronically if the beneficiary elected to receive electronic notices, for a beneficiary to acquire and submit information needed to ensure that the State to redetermine eligibility based on a change in circumstances. We consider specifying a minimum timeframe will ensure all States provide beneficiaries an inexpensive time to answer requests for information to display ongoing eligibility and mitigate churn that may otherwise occur when beneficiaries do not need sufficient time to answer such requests. We consider the 30-day timeframe also provides beneficiaries consistency across program requirements as this aligns with the minimum timeframe MAGI beneficiaries are provided to return their renewal form in the present regulations SEC 435.916(a)(3)(i)(B) and proposed timeline for all beneficiaries to return their renewal form at SEC 435.916(a)(2)(i)(B) of this proposed rule. As discussed in section II.B.3. of this proposed rule, we propose to ascertain time standards for States to promptly act on changes in circumstances and standards for acting on anticipated changes in circumstances in proposed SEC 435.912(c)(5) and (6), and we cross reference to those proposed time standards in proposed SEC 435.919(c)(2).

At SEC 435.919(d), we propose that States provide beneficiaries whose coverage was terminated resulting from failure to supply information requested in accordance with proposed SEC 435.919(b)(1)(i) and (ii) with a 90-day reconsideration period. Under the proposal, if a beneficiary returns requested information inside 90 calendar days of termination, the State could be required to redetermine the person’s eligibility without requiring a latest application. While States may not require individuals to finish a latest application throughout the reconsideration period, States might have to request additional information from the person who is required at application, resembling additional information needed to find out eligibility or a signature under penalty of perjury that information provided is accurate. Consistent with SEC 435.915(a) of the present regulations, retroactive coverage through the 90-day period generally could be available, including for MSP eligibility groups described in section 1902(a)(10)(ii), (iii) and (iv) /59/ of the Act, to assist fill any gap in coverage for eligible individuals for whom retroactive eligibility may apply. Just like the 90-day reconsideration period provided to individuals terminated for failure to finish a regularly-scheduled renewal under SEC 435.916(a)(3)(iii) of the present regulations, we consider this proposed policy is very important to cut back gaps in coverage in addition to the executive burden related to churn, when beneficiaries terminated from coverage reapply inside just a few months thereafter, particularly beneficiaries enrolled in managed care. We propose that the applying timeliness standards provided under SEC 435.912(c)(3) would apply to redeterminations initiated through the 90-day reconsideration period proposed at SEC 435.919(d). Application of the timeliness standards at SEC 435.912(c)(3) in this example aligns with the proposed revision of current regulations at SEC 435.916(a)(3)(iii), redesignated at proposed SEC 435.916(b)(2)(iii), to use the timeliness standards to redeterminations initiated through the 90-day reconsideration period afforded beneficiaries under current regulations to return renewal forms. Proposed revisions to current SEC 435.916(a)(3)(iii), redesignated at proposed SEC 435.916(b)(2)(iii), are discussed in section II.B.1. of this proposed rule.

   FOOTNOTE 59 Retroactive eligibility just isn’t available to individuals who qualify for coverage under the QMB group described in section 1902(a)(10)(E)(i) of the Act. Per section 1902(e)(8) of the Act, coverage under the QMB group is effective the month following the month through which the QMB eligibility determination is made. END FOOTNOTE

Proposed SEC 435.919(e) includes the necessities in SEC 435.916(d)(1)(i) and (ii) of current regulation (regarding the limitation on requests for information to mandatory information and the circumstances under which States may begin a latest eligibility period, which is the time frame between application and renewal or repeatedly scheduled renewals, following a change in circumstances). We propose revisions to current SEC 435.916(d)(1)(i), redesignated at SEC 435.919(e)(1) on this proposed rule, to remove the reference to MAGI beneficiaries to be able to apply the requirement that States evaluating a change in circumstances must limit requests for extra information to such change in circumstances to each MAGI and non-MAGI beneficiaries. We consider this transformation is mandatory to make sure non-MAGI beneficiaries should not subject to a full renewal of eligibility more steadily than once every 12 months, consistent with proposed SEC 435.916(a). We redesignate current SEC 435.916(d)(1)(ii), which allows States to start a latest 12-month eligibility period if the agency has enough information to renew eligibility with respect to all eligibility criteria when processing a change in circumstances, to proposed SEC 435.919(e)(2). We also make technical changes to current SEC 435.916(d)(1)(ii), redesignated at proposed SEC 435.919(e)(2), to make use of the term “eligibility period” quite than “renewal period” and to remove the reference to the “12-month” eligibility period to align the length of the brand new eligibility period the State may begin for a person consistent with the eligibility periods described in proposed SEC 435.916(a).

Finally, we propose to redesignate and modify SEC 435.916(d)(2), which requires that States act on anticipated changes in circumstances at the suitable time as proposed at SEC 435.919(b)(3), as this provision also pertains to changes in beneficiary circumstances. In proposed SEC 435.919(b)(3), we modify language in the present regulations at SEC 435.916(d)(2) to require that States act on anticipated changes at an appropriate time (as an alternative of the suitable time) and make clear that because of this the State would wish to initiate a redetermination consistent with timeliness standards for processing anticipated changes in circumstances at proposed SEC 435.912(c)(6). While CMS doesn’t define for every State the suitable time to act on an anticipated change in circumstances, we expect States to start the method early enough to be able to reasonably complete the redetermination prior to the anticipated change occurring. As discussed in section II.B.3. of this proposed rule, we propose to ascertain timelines for States to redetermine eligibility based on anticipated changes in circumstances in proposed SEC 435.912(c)(6). In proposed SEC 435.919(c)(2), we require States to redetermine eligibility for a beneficiary with an anticipated change in circumstances throughout the time standards established in proposed SEC 435.912(c)(6). We consider including the cross reference to proposed SEC 435.912(c)(6) will ensure States determine the suitable time to act based on their processes prior to the anticipated change in circumstances occurring such that the State can complete the redetermination in keeping with the time standards in proposed SEC 435.912(c)(6).

With the proposed creation of SEC 435.919 and the proposed re-designation of SEC 435.916(d), with revisions, to latest SEC 435.919(b), we also propose technical changes at [Sec.] SEC 435.911(c) and 435.1200(e)(1). Current SEC 435.911(c) applies to individuals who submit an application described in SEC 435.907 or whose eligibility is being renewed in accordance with SEC 435.916. We propose so as to add a latest clause to increase the applying of this paragraph to individuals whose eligibility is being redetermined in accordance with SEC 435.919. At SEC 435.1200(e)(1), we propose to exchange the reference to SEC 435.916(d) with a reference to proposed SEC 435.919(b). Changes to SEC 435.1200 are discussed in further detail in section II.B.5. of this preamble. Moreover, the applying of the proposed requirements of SEC 435.919 to CHIP is discussed in section II.E.2. of this preamble.

3. Timely Determination and Redetermination of Eligibility ([Sec.] SEC 435.907 and 435.912)

Several regulatory requirements, currently codified in subpart J of part 435, establish parameters to make sure that applications for coverage should not unduly burdensome and that latest applicants receive a timely determination of eligibility. Other provisions protect current beneficiaries from needlessly onerous renewal requirements and make sure that States keep individuals enrolled while they review potential Medicaid eligibility on other bases. Section 435.907 of the present regulations describes the necessities for States to make available an application for Medicaid, the constraints on the knowledge that could be requested at application, and the modalities through which individuals must give you the chance to use. Similarly, SEC 435.916 (discussed in section II.B.1. of this preamble) describes the necessities for States to conduct renewals and limitations on the knowledge that could be requested from beneficiaries at renewal, and proposed SEC 435.919 (discussed in section II.B.2 of this preamble) would redesignate and revise current SEC 435.916(c) and (d) with respect to redeterminations based on changes in circumstances.

The necessities related to the timely determination of eligibility, including the utmost time period through which individuals are entitled to a determination of eligibility, exceptions to timeliness requirements, and considerations for States in establishing performance standards are found at SEC 435.912. As described at current SEC 435.912(c)(3), States are required to find out the eligibility of recent applicants inside 90 calendar days in the event that they apply on the idea of disability and inside 45 calendar days for applicants applying on all other bases. These longstanding timeframes are vital for ensuring eligible applicants receive timely access to coverage. Nevertheless, the present regulations don’t establish standards to make sure that applicants have enough time to collect and supply additional information and documentation requested by a State in adjudicating eligibility. As well as, the timeframes provided in current SEC 435.912(c) expressly apply only to latest applications; they don’t expressly apply to redeterminations either at renewal or based on changes in circumstances.

Current regulations at SEC 435.930(b) require that States proceed furnishing Medicaid advantages to eligible individuals, until they’re found to be ineligible. Under this provision, a beneficiary is probably not disenrolled if the State has not accomplished a redetermination of eligibility, even after the top of a person’s scheduled renewal date. This provision is critical to making sure that eligible beneficiaries should not inappropriately terminated from coverage. Nevertheless, if completing a renewal is delayed, ineligible individuals may remain inappropriately enrolled.

Ensuring the integrity of Medicaid and CHIP–both to stop inappropriate enrollments and to guard the enrollment of eligible individuals–is a very important component of CMS’s work. From a program integrity perspective, each termination of coverage without an accurate determination of ineligibility and the extension of coverage beyond a beneficiary’s period of eligibility would constitute an error. Through PERM, the MEQC program, and other CMS eligibility reviews, we partner with States to review their eligibility and enrollment processes and conduct case reviews to make sure that eligible individuals can enroll and stay enrolled without undue burden and that ineligible individuals are redirected to the suitable coverage programs. Through this work, in addition to our ongoing work with States prior to the COVID-19 PHE, we’ve change into aware that in certain situations, redeterminations can remain incomplete for several months following the top of a beneficiary’s eligibility period. For instance, this may increasingly occur when a beneficiary doesn’t timely return documentation or when a determination on one other basis is required. While we recognize the challenges States may face in completing redeterminations by the top of a beneficiary’s eligibility period or as quickly as possible once they change into aware of a possible change in circumstances, it will be important that States act promptly once all information and other documentation requested from the person is received.

Consistent with sections 1902(a)(4) and (19) of the Act to make sure the right and efficient administration of this system and that eligibility is decided in a way consistent with simplicity of administration and best interests of beneficiaries, we propose changes to SEC 435.907 and SEC 435.912 to make sure that applicants and beneficiaries have adequate time to furnish all requested information and that States complete initial determinations and redeterminations of eligibility inside an inexpensive timeframe at application, at regular renewals, and following changes in circumstances.

With respect to latest applicants, we propose to revise SEC 435.907 first to redesignate SEC 435.907(d) (regarding a prohibition on requiring in-person interviews) as SEC 435.907(d)(2). As discussed in section II.B.1 of this preamble, we also propose to revise newly redesignated paragraph (d)(2) of SEC 435.907 to remove the clause that states, “for a determination of eligibility using MAGI-based income” such that the prohibition on requiring in-person interviews applies to each the MAGI-based and non-MAGI application processes. Then we propose to ascertain a latest paragraph (d)(1) at SEC 435.907, which might require that, if the State agency is unable to find out an applicant’s eligibility based on the knowledge provided on the applying and verified through electronic data sources, and it must obtain additional information from the applicant, specified requirements would should be met. This may occasionally occur, for instance, if an applicant fails to finish a piece of the applying before signing and submitting it, or if an applicant provides information on the applying that just isn’t reasonably compatible with the knowledge available through electronic data sources.

Proposed SEC 435.907(d)(1)(i)(B) would require the agency to supply most applicants with at the least 15 calendar days, from the date the request is postmarked or the electronic request is distributed, to reply with the extra information. For applicants whose Medicaid eligibility is being considered on the idea of a disability, resembling individuals under age 65 who could also be eligible for the age and disability-related poverty level group described at section 1902(a)(10)(A)(ii)(X) of the Act, proposed SEC 435.907(d)(1)(i)(A) would require the agency to supply the applicant with at the least 30 calendar days, from the date the request is postmarked or the electronic request is distributed, to reply. Moreover, as described at proposed SEC 435.907(d)(1)(ii), applicants have to be permitted to supply additional information through any of the modes by which an application could also be submitted at current SEC 435.907(a). That is current policy that we’re proposing to codify through this proposed rule.

As discussed in sections II.B.1 and II.B.2 of this preamble, current SEC 435.916(a)(3)(i)(B), redesignated at proposed SEC 435.916(b)(2)(i)(B), and proposed SEC 435.919(c)(3) would require the agency to supply current beneficiaries with at the least 30 calendar days from the date the request is postmarked or the electronic request is distributed to submit requested information, starting on the date the State sends the request for extra information, which is the date the request is postmarked or the date the electronic request is distributed. That is longer than the minimum timeframe of 15 calendar days that we propose for many applicants to furnish additional information or documentation. We considered establishing a 30-day requirement for all applicants, consistent with the timeframe proposed at redetermination, but we consider that a 15-day response period for many applicants is acceptable for several reasons. First, in determining eligibility for an applicant, the agency could have recently received information from the applicant (or an individual acting responsibly on their behalf) who’s newly in search of coverage, and we consider the applicant (or such other person) will typically expect a communication from the agency. Against this, at renewal and when the agency is acting on information it has received from other sources, a beneficiary could also be less more likely to expect any communication from the State, and subsequently, could also be less prepared to reply. Second, while States are required to make eligibility effective on the date of application, or as much as 3 months prior if the person would have been eligible retroactively, applicants could also be reluctant to access covered services before the eligibility determination is accomplished. Requiring the agency to make a final determination on applications throughout the maximum 45 calendar days permitted for people applying on a basis apart from disability status while also providing the person with at the least 30 calendar days to answer a request for extra information is unreasonable. Nevertheless, to allow States greater than 45 calendar days to finish applications when additional information is required also could end in eligible individuals delaying needed care. We consider that a minimum 15 calendar days strikes an appropriate balance for many applicants and we seek comment on whether States, beneficiaries, and other interested parties agree that this timeframe is acceptable.

As noted above, we’re proposing that States must provide applicants applying on the idea of disability with at the least 30 calendar days, from the date the request is postmarked or the electronic request is distributed, to return additional information or documentation required by the agency. We consider the longer timeframe is acceptable because some individuals with disabilities might have more time to collect documentation related to their disability determination and since States have as much as 90 calendar days to make a final determination of eligibility on disability-based applications, the extra time won’t undermine States’ ability to make a timely determination.

We’re considering aligning the minimum time that States must provide all applicants to submit additional information or documentation requested by the State, in addition to finalizing an extended timeframe for all applicants. Timeframes into consideration include 15 calendar days, 20 calendar days, 25 calendar days, and 30 calendar days. We’re also considering a minimum requirement of 30 calendar days for all applicants, accompanied by a change to the timeliness requirements for application processing, which might establish an exception to the 45-day requirement at current SEC 435.912(c)(3)(ii) and supply an extra 15 calendar days for a State to finish application processing when additional information is required. We seek comment on the suitable minimum timeframe for applicants to submit requested information at proposed SEC 435.907(d) that can provide the best balance between ensuring that a State determines eligibility as quickly as possible and that applicants have adequate time to collect any information or documentation needed by the State to finish the determination. We also seek comment on whether the ultimate rule should align the timeframe for all applicants or provide an extended period for people applying on the idea of disability, and whether a corresponding exception to the 45-day timeliness requirement at SEC 435.912(c)(3)(ii) should accompany an extended timeframe. As well as, we request comment on whether calendar days or business days would offer a more appropriate measure of timeliness here.

Finally, when the State agency cannot determine an applicant’s eligibility for Medicaid without additional information and the agency denies eligibility since the applicant doesn’t timely reply to a request for extra information, per current regulations at SEC 435.917, the State must provide the person with notice of the agency’s decision. We propose at SEC 435.907(d)(1)(iiii)(A) that, if the person subsequently submits the requested information inside 30 calendar days of the date the notice of ineligibility is distributed (or an extended period established by the State), the State must reconsider the person’s eligibility without requiring the person to finish and submit a latest, full application. This is analogous to the reconsideration periods provided at current SEC 435.916(a)(3)(iii) (redesignated at proposed SEC 435.916(b)(2)(iii) on this proposed rule) for people whose eligibility is terminated at their regularly-scheduled renewal and proposed SEC 435.919(d) for people whose eligibility is terminated following a change in circumstances resulting from failure to supply additional information requested by the agency.

To make sure that a State has adequate time to finish the determination of eligibility when requested information is submitted through the reconsideration period, we propose at SEC 435.907(d)(1)(iii)(B) to start a latest clock for determining timeliness. This is able to provide the State with an extra 45 calendar days (or 90 calendar days for disability-related determinations) to finish the eligibility determination in accordance with proposed SEC 435.912(c)(3), starting on the date that the requested information is submitted. As well as, to guard the needs of applicants, the effective date of coverage would proceed to be determined in accordance with the date upon which the applying was submitted as described at proposed SEC 435.907(d)(1)(iii)(C). We consider this could provide the most effective balance for each the applicant and the State agency, by protecting the applicant’s access to coverage while providing additional time for the State to finish a timely determination. We seek comment on whether the effective date of coverage needs to be determined in accordance with the applying date or whether, consistent with the reconsideration period at renewal and the proposed reconsideration period following a change in circumstances (described in section II.B.2. of this preamble), the return of additional information would effectively constitute a latest application with a latest effective date of coverage.

We’re proposing a 30-day reconsideration period at application, quite than a 90-day reconsideration period just like the 90-day period proposed at redetermination, because we consider applicants will generally expect a communication from the State regarding the status of the submitted application and shall be less likely than current beneficiaries to miss requests for extra information. We are also concerned that an extended reconsideration period for applicants would mean that an extended time frame could have elapsed between the date the applicant has attested to information provided on the applying and the date a determination is ultimately made. Nevertheless, recognizing that a consistent 90-day period for all reconsiderations–at application, at renewal, and following a change in circumstances–may be clearer, we seek comment on whether the length of reconsideration period at application should align with the 90-day reconsideration period currently provided at renewal and proposed for redeterminations based on changes in circumstances on this rulemaking, or whether the reconsideration period for applicants needs to be somewhat longer than 30 calendar days (for instance, 45 calendar days or 60 calendar days) but still lower than 90 calendar days.

With respect to redeterminations, we propose revisions to SEC 435.912 to obviously specify expectations for the utmost time States have to finish redeterminations at regular renewals, in addition to when the State learns of a change in circumstances which will impact a person’s eligibility. Current SEC 435.912 requires States to ascertain timeliness and performance standards. Paragraph (a) of SEC 435.912 of the present regulations defines “timeliness standards” as the utmost time frame through which a person is entitled to a determination of eligibility and “performance standards” as the general standards for timely determinations of eligibility. Current SEC 435.912(b) lists the varieties of eligibility determinations for which States must establish standards, while SEC 435.912(c) sets forth criteria which the agency must account for in establishing these standards. Paragraphs (d) through (g) of current SEC 435.912 require the agency to tell individuals of the timeliness standards, to supply for exceptions to the timeliness standards for determining eligibility, and to document any delays in completing the required actions, in addition to prohibiting the agency from using the applying time standards either as a waiting period or as a reason to disclaim eligibility.

We propose first to revise the definition of “timeliness standards” in SEC 435.912(a) to specify that these standards must include not only the utmost time period through which every applicant is entitled to a determination of eligibility at application in accordance with SEC 435.907, but in addition the utmost time frame through which the agency must redetermine eligibility at renewal in accordance with SEC 435.916 and when an anticipated or known change in circumstances occurs in accordance with proposed SEC 435.919(b)(3). The “performance standards” defined in current SEC 435.912(a) would even be revised to obviously include standards for renewing and redetermining eligibility in a timely and efficient manner across a pool of beneficiaries. Section 435.911(c) of the regulations currently requires, in pertinent part, that agency must, promptly and without undue delay consistent with timeliness standards established under SEC 435.912, provide coverage to individuals who’ve submitted an application described in SEC 435.907 or whose eligibility is being renewed in accordance with SEC 435.916. We propose a conforming amendment to the introductory language in SEC 435.911(c) to incorporate a cross reference to proposed SEC 435.919 to clarify that the terms of SEC 435.911(c) apply also to individuals whose eligibility is being redetermined following a change in circumstances.

Second, we propose so as to add a paragraph heading for SEC 435.912(b) that states, “State plan requirements” and expand upon the activities described in SEC 435.912(b) for which States could be required to ascertain timeliness and performance standards of their State plan. Specifically, we propose to expand the requirement in current SEC 435.912(b)(2) to ascertain timeliness and performance standards to incorporate not only determinations of eligibility for Medicaid and assessments of potential eligibility for other insurance affordability programs, as currently required, but in addition final determinations of eligibility for CHIP consistent with changes proposed at SEC 435.1200(e) and described in section II.B.5. of this preamble. We also propose to include current paragraph (b)(2) of SEC 435.912, which requires States to ascertain timeliness and performance standards for determining potential eligibility for and transferring a person’s electronic account to a different insurance affordability program, into current paragraph (b)(1), such that proposed SEC 435.912(b)(1) would require the agency to ascertain performance and timeliness standards for determining Medicaid eligibility for people who submit an application to the Medicaid agency, in addition to determining eligibility for CHIP when a person is decided ineligible for Medicaid (in accordance with proposed changes discussed in section II.B.5. of this preamble) and determining potential eligibility for insurance affordability programs available through the Exchanges as described at proposed SEC 435.1200(e).

We propose to redesignate current SEC 435.912(b)(3) (regarding determining Medicaid eligibility for people transferred from other insurance affordability programs) as proposed SEC 435.912(b)(2) and so as to add latest paragraphs (b)(3), (4), and (5) to SEC 435.912 as follows:

    * Proposed SEC 435.912(b)(3) would require States to ascertain specific standards for redetermining eligibility at renewal in accordance with SEC 435.916;

    * Proposed SEC 435.912(b)(4) would require the establishment of specific standards for redeterminations of eligibility related to changes in circumstances reported by a beneficiary or received from a 3rd party as described at proposed SEC 435.919(b)(1) and (b)(2) respectively; and

    * Proposed SEC 435.912(b)(5) would require the establishment of specific standards for redeterminations of eligibility on the time of an anticipated change in circumstances in accordance with proposed SEC 435.919(b)(3).

Third, current SEC 435.912(c)(1) provides that the timeliness and performance standards adopted by the agency must cover the period from the date of application, or transfer from one other insurance affordability program, to the date the agency notifies the applicant of its decision or the date the agency transfers the person to a different insurance affordability program. We might revise this to specify that in addition they include the periods of time covered by the timeliness and performance standard adopted by the agency for renewals and redeterminations of eligibility.

Preliminarily, we propose to redesignate the requirement at current SEC 435.912(c)(1) (providing that the standards for these activities cover the period from the date of application or transfer to the Medicaid agency through the date that the agency notifies the applicant of its decision or transfers the account to a different insurance affordability program) as proposed SEC 435.912(c)(1)(i). Proposed SEC 435.912(c)(1)(ii) would offer that timeliness and performance standards adopted by the agency for conducting regularly-scheduled renewals must cover the period from the date that the agency initiates the steps required to renew eligibility on the idea of data available to the agency, as required under SEC 435.916(a)(2) (redesignated as SEC 435.916(b)(1) on this proposed rule), to the date that the agency sends the beneficiary notice regarding their continued eligibility for coverage, or as applicable, terminates eligibility and transfers the person to a different insurance affordability program in accordance with SEC 435.1200(e).

Proposed SEC 435.912(c)(1)(iii) would offer that timeliness and performance standards adopted by the agency for conducting redeterminations of eligibility based on a change in a beneficiary’s circumstances must cover the period from the date that the agency receives information indicating a possible change in circumstances which will affect eligibility to the date that the agency sends the person a notice regarding their continued eligibility for coverage, or as applicable, terminates eligibility and transfers the person’s electronic account to a different insurance affordability program in accordance with SEC 435.1200(e).

Finally, proposed SEC 435.912(c)(1)(iv) would offer that timeliness and performance standards adopted by the agency for conducting redeterminations of eligibility based on an anticipated change in a beneficiary’s circumstances must cover the period from the date the agency begins the redetermination of eligibility based on an anticipated change, as described at SEC 435.919(b)(3) of this subpart, to the date the agency notifies the person of its decision or, as applicable the date the agency terminates eligibility and transfers the person’s electronic account to a different insurance affordability program in accordance with SEC 435.1200(e). We also propose so as to add a heading to paragraph (c) that reads, “Timeliness and performance standard requirements.”

Current SEC 435.912(c)(1) also requires States to comply with the necessities of paragraph (c)(2) (regarding criteria that States must consider in establishing their timeliness and performance standards) in order “to advertise accountability and consistency of high-quality consumer experience amongst States and between insurance affordability programs.” We propose to include this requirement into proposed SEC 435.912(c)(2) and to expand the standards that States must have in mind to reflect the broader scope of activities for which States must account for in establishing their timeliness and performance standards.

Current SEC 435.912(c)(2) requires that, in establishing their timeliness and performance standards, States must account for the capabilities and value of obtainable systems and technology, the final availability of electronic data matching and ease of connections to authoritative sources of data to find out and confirm eligibility, the demonstrated performance and timeliness experience of other State Medicaid, CHIP and other insurance affordability programs, and the needs of people, including their preferred mode of application submission and the relative complexity of adjudicating their eligibility. Proposed revisions to SEC 435.912(c)(2) would add to those criteria the time needed by the agency to judge information obtained from electronic data sources and the time needed to supply advance notice to beneficiaries when the agency makes a determination that may end in the denial or termination of eligibility or one other antagonistic motion, since an antagonistic motion can’t be effective until the top of the advance notice period (generally advance notice have to be sent 10 days prior to the date of the motion, in accordance with [Sec.] SEC 431.211, 431.213 and 431.214). Proposed SEC 435.912(c)(2) also would offer that States account for the needs of beneficiaries, in addition to applicants and the complexity of their cases in establishing their timeliness and performance standards.

Paragraph (c)(3) of SEC 435.912 provides parameters for States in setting a typical for the timely determination of Medicaid eligibility at application and when an account transfer is received from one other insurance affordability program. The parameters in current SEC 435.912(c)(3), of not more than 90 calendar days for determining eligibility on the idea of disability and not more than 45 calendar days for determining eligibility on all other bases, remain unchanged on this proposed rule. Nevertheless, we propose several technical changes to SEC 435.912(c)(3), including the addition of a paragraph heading and extra references to the applying and account transfer activities described in proposed paragraphs (b)(1) and (2) of this section.

We also propose so as to add latest paragraphs (c)(4), (5), and (6) to SEC 435.912 to ascertain separate parameters inside which States must establish timeliness standards for the completion of repeatedly scheduled renewals, redeterminations based on changes in circumstances, and redeterminations based on anticipated changes. In establishing the utmost timeframes in proposed SEC 435.912(c)(4) inside which the agency must complete a repeatedly scheduled renewal, we have in mind the extra time that States might have to finish a redetermination of eligibility when beneficiaries return needed information near the top of their eligibility period, in addition to when the State might have to make a determination of eligibility on one other basis, as required under SEC 435.916(f)(1) of the present regulations, redesignated at SEC 435.916(d)(1) on this proposed rule.

Based on our experience in working with States, we consider that after the agency has received all information needed to finish a redetermination of eligibility, 25 calendar days is ample time for the agency to process the redetermination and supply the minimum 10 days of advance notice of termination or other antagonistic motion, if needed. Subsequently, within the case of a person whose eligibility could be renewed based on available information or who returns all needed information at the least 25 calendar days or more prior to the top of the eligibility period, we propose at SEC 435.912(c)(4)(i) that the agency be required to finish a redetermination by the top of the eligibility period.

Recognizing that in certain cases, a State won’t receive all of the knowledge needed to redetermine eligibility until closer to the top of the eligibility period, proposed SEC 435.912(c)(4)(ii) would offer additional time in such cases. If information is returned before the top of the eligibility period, but with lower than 25 calendar days remaining, proposed SEC 435.912(c)(4)(ii) would offer the agency with one additional month to finish a timely redetermination of eligibility. In such cases, the agency could be required to finish the redetermination, on the idea on which the beneficiary was last determined eligible, by no later than the top of the month following the month through which the person’s eligibility period ends.

For instance, suppose a beneficiary’s 12-month eligibility period is scheduled to finish on March thirty first, but the person doesn’t return all information needed to redetermine eligibility until March twentieth. That is lower than 25 days prior to the top of the eligibility period, so in this instance, the State would wish to finish the renewal by no later than April thirtieth (the top of the month following the month through which the person’s eligibility period ends). We seek comment on whether proposed SEC 435.912(c)(4)(i) and (ii) strike the best balance between maximizing completion of timely renewals and providing States with sufficient time to not only complete a renewal but in addition to supply advance notice of termination when mandatory.

Proposed SEC 435.912(c)(4)(iii) addresses timelines for renewals through which eligibility have to be considered on one other basis. Current SEC 435.916(f) (redesignated at proposed SEC 435.916(d)) requires the agency, when it determines that a person is not any longer eligible on the idea upon which she or he has been receiving coverage, to think about eligibility on all bases prior to completing a determination of ineligibility for Medicaid. When information in the person’s case record or renewal form indicates that the beneficiary could also be eligible on one other basis or bases (for instance, a person determined ineligible based on MAGI could also be eligible based on disability), we recognize that additional time could also be required for States to acquire the extra information needed to make a determination on such other basis. Proposed SEC 435.912(c)(4)(iii)(B) provides the agency with 25 days to make a determination of eligibility for many beneficiaries and to send advance notice of termination if the person is ineligible. Nevertheless, if a latest determination based on disability is mandatory, we propose in SEC 435.912(c)(4)(iii)(A) a maximum of 90 days for States to finish a redetermination of eligibility on the idea of disability. The applicable time period (25 or 90 days) is measured in calendar days from the date the agency determines the person not eligible on the idea on which she or he had been receiving coverage. We consider that an extended 90-day period is acceptable when a determination of disability is required due to the additional complexity in making a disability determination. That is consistent with the utmost 90 days provided for States making a determination of eligibility based on disability at initial application as described at current SEC 435.912(c)(3)(i). Regulations governing determinations of disability are found at SEC 435.541.

These timeliness standards for repeatedly scheduled renewals are cross-referenced in proposed SEC 435.916(c), which requires that a renewal be accomplished by the top of the beneficiary’s eligibility period in accordance with proposed SEC 435.912(c)(4)(i). If a person returns the renewal form with lower than 25 calendar days remaining before the top of their eligibility period, proposed SEC 435.912(c)(4)(ii) would permit the State to finish the renewal by the top of the month following the month through which the person’s eligibility period ends. This is able to be compliant with each the renewal requirement at proposed SEC 435.916(c) and the timeliness requirement at proposed SEC 435.912(c)(4)(ii). As noted previously, when a determination of eligibility is accomplished after the top date of a beneficiary’s eligibility period, current SEC 435.930(b) requires the agency to proceed furnishing Medicaid to the person while the determination of eligibility is pending. This allows the State to proceed providing medical assistance to the person until the renewal is accomplished, and if the person is not any longer eligible for Medicaid, it provides the State with adequate time to supply advance notice and fair hearing rights in accordance with part 431 subpart E of the regulations.

Under proposed SEC 435.912(c)(5), States must complete redeterminations based on changes in beneficiary circumstances reported by a person or third party no later than the top of the month that happens 30 calendar days from the date the State receives information indicating a possible change in circumstances, if the State has sufficient information to judge any potential impact and to redetermine eligibility without requesting additional information from the person. Because most States proceed coverage through the top of the month, we propose to increase the requirement to the top of the month through which the thirtieth day occurs. If additional information from the beneficiary is required, we propose at SEC 435.912(c)(5)(ii) that States have through the top of the month that happens 60 calendar days from the date the State receives information indicating a change in circumstances which will impact eligibility to make a redetermination of eligibility. We note that proposed SEC 435.919(c)(3) would require States to supply beneficiaries with at the least 30 calendar days from the date the request is postmarked or the electronic request is distributed to supply the knowledge and that the State enable beneficiaries to achieve this through any of the modes of submission laid out in SEC 435.907(a). This aligns with the 30 calendar days which States must provide beneficiaries to return a pre-populated renewal form and any needed documentation at renewal under current regulation at SEC 435.916(a)(3)(i)(B), redesignated at proposed SEC 435.916(b)(2)(i)(B).

Proposed SEC 435.912(c)(6) establishes requirements for redeterminations of eligibility based on anticipated changes in circumstances. As described in SEC 435.916(d)(2) (redesignated as proposed SEC 435.919(b)(3)), anticipated changes are events that the agency knows about prematurely, like a beneficiary’s birthday, and States must act on such changes at an appropriate time such that the State completes the redetermination prior to the anticipated change occurring. Thus, while CMS doesn’t specify when a State must begin the redetermination process for an anticipated change in circumstances, under our proposal, the agency must determine the period of time it must act on such changes and to start the redetermination process with sufficient time to finish processing the redetermination prior to the change occurring. As such, we propose to use the identical basic requirements at proposed SEC 435.912(c)(6) for States establishing standards for redeterminations based on anticipated changes in circumstances as those described at proposed SEC 435.912(c)(4) for repeatedly scheduled renewals. At proposed SEC 435.912(c)(6)(i), the agency could be required to finish a redetermination of eligibility based on an anticipated change in circumstances on or before the date of the anticipated change or the last day of the month through which the anticipated change occurs.

When a person is decided ineligible for Medicaid, States have flexibility to terminate coverage either on the date on which the person becomes ineligible (provided that advance notice has been provided and other bases of eligibility have been considered) or at the top of the month. In States which have elected the choice to proceed coverage through the top of the month, the redeterminations described at proposed SEC 435.912(c)(4), (c)(5), and (c)(6) have to be accomplished prior to the top of the month. In all other States, the redetermination have to be accomplished prior to the date specified.

For instance, suppose a State has the next income standard for younger children within the eligibility group for kids under age 19, and a beneficiary whose household income exceeds the usual for kids aged 6 through 18 shall be turning 6 years old on October third in the midst of their eligibility period. This beneficiary lives in a State that continues coverage through the top of the month through which a person becomes ineligible. If the State receives all information needed to find out the person’s continued eligibility (in either the eligibility group for kids under age 19 or one other eligibility group) on or before October sixth (25 days before the top of the month through which the change occurs), then the agency could be required to finish a timely redetermination of eligibility by no later than October thirty first.

If the State receives the knowledge needed to finish a redetermination, but doesn’t have at the least 25 calendar days to process the knowledge, then as described at proposed SEC 435.912(c)(6)(ii), the State would have 1 additional month to finish a timely redetermination of eligibility. Using the instance above, suppose the State receives all information needed to find out the person’s eligibility on or after October seventh, then the agency could be required to finish a timely redetermination of eligibility by no later than November thirtieth. Proposed SEC 435.912(c)(6)(iii) establishes the identical standards for completing a determination of one other basis as that proposed at SEC 435.912(c)(4)(iii) for repeatedly scheduled renewals.

We seek comment on the period of time provided for States to finish a redetermination of eligibility at a regularly-scheduled renewal or based on changes in circumstances at proposed SEC 435.912(c)(4), (c)(5), and (c)(6), whether the regulations should allow for an extended or shorter time frame, and whether using business days quite than calendar days could be more appropriate.

Each of the standards proposed in paragraphs (c)(3) through (6) provides for an exception to the timeliness standards, which is described in current SEC 435.912(e), when the agency cannot comply with the regulatory timelines resulting from an administrative or other emergency beyond the agency’s control. States that use the timeliness exception SEC 435.912(e) must document the rationale for delay within the case record in accordance with SEC 435.912(f). Additionally it is vital to notice that, while the proposed timeliness standards provide maximum timeframes for completion of redeterminations at renewal or based on changes in circumstances, they don’t constitute additional grace periods for States or beneficiaries to delay completion of redeterminations. States are, and can proceed to be, expected to process redeterminations as expeditiously as possible, and extra time is simply authorized beyond the prescribed eligibility period if a beneficiary responds to a request for information after the date required by the agency but prior to the date of termination or other antagonistic motion identified within the beneficiary’s advanced notice of termination or other antagonistic motion.

Finally, we propose numerous technical amendments to paragraphs (d), (e), (f), and (g) of this section to obviously specify that these provisions apply to applicants and applications in addition to beneficiaries and redeterminations of eligibility. Because we’re specifying that the timeliness standards in section SEC 435.912 include each applications and redeterminations, we also propose a related change to current SEC 435.912(g). The present provision prohibits States from using the timeliness standards as a waiting period for brand spanking new applicants or as a reason for denying eligibility since it just isn’t determined throughout the required timeframe. We propose so as to add a latest paragraph (g)(3) to SEC 435.912 that may prohibit States from using the timeliness standards as a reason for delaying termination of a person’s coverage or delaying an antagonistic motion.

We propose to use the identical requirements to separate CHIPs through an existing reference to SEC 435.912 of the Medicaid regulations in SEC 457.340(d)(1). Changes to [Sec.] SEC 457.340(d) are discussed in further detail in section II.E.1. of this preamble.

4. Agency Motion on Returned Mail ([Sec.] SEC 435.919 and 457.344)

Section 1902(a)(10) of the Act requires States to make medical assistance available under the State plan to individuals who meet certain eligibility criteria and provides States with the choice to supply medical assistance to certain other individuals. To make sure that individuals receiving such assistance proceed to satisfy applicable eligibility requirements, States will need to have a process to acquire details about changes in circumstances and redetermine eligibility when appropriate, including at annual renewal. On this rulemaking, we propose at SEC 435.919(f) certain actions that States must take when mail sent to a beneficiary is returned to the agency, no matter whether the returned mail signals potential ineligibility.

The US Postal Service (USPS) returns mail sent to beneficiary when the address used is inaccurate, or the person has moved and USPS has no record of a forwarding address, or the time-limited mail forwarding service has expired. That a beneficiary has moved doesn’t necessarily mean the person is not any longer a State resident or ineligible on that basis. Nevertheless, we’re concerned that when a beneficiary’s mail is returned to the agency, some States depend on that information to conclude that the person can’t be situated and terminate coverage without taking reasonable steps to establish the accuracy of the knowledge received or attempting to locate the beneficiary and update their address. Moreover, if a State attempts to contact the beneficiary to confirm a latest in-state address received from USPS and the person doesn’t respond, many States proceed to make use of the unique address within the beneficiary’s case record. If the brand new address from USPS is correct, the beneficiary has not elected to receive electronic notices, and an ex parte renewal based on information available to the agency just isn’t successful, this can end in termination at the person’s regular renewal because such beneficiaries won’t receive a mailed notice or renewal form and shall be unable to reply as required.

We consider that returned mail may end in a big variety of beneficiaries who proceed to satisfy all eligibility requirements being terminated from coverage, and that it’s critical for States to take reasonable steps to locate beneficiaries who can have moved and to update their address prior to taking any antagonistic motion. Subsequently, consistent with section 1902(a)(4) of the Act, to advertise the right and efficient administration of the Medicaid program, and section 1902(a)(19) of the Act, to supply such safeguards as could also be mandatory to guarantee simplicity of administration and the most effective interests of beneficiaries, we propose adding latest paragraph (f) at proposed SEC 435.919 to specify the steps States must take when beneficiary mail is returned to the agency.

States rely heavily on communicating with beneficiaries by mail to facilitate essential eligibility and enrollment actions, resembling renewals and requests for extra information. Returned mail with an out-of-state or no forwarding address indicates a possible change in circumstance with respect to State residency, but without additional follow up by the State, the receipt of returned mail alone just isn’t sufficient to make a definitive determination as as to whether beneficiaries now not meet State residency requirements because they’ve moved out of State. Returned mail with an in-state forwarding address just isn’t a sign of a change affecting eligibility, but it surely nonetheless is very important for the State to substantiate the accuracy of the knowledge to make sure future ability to contact the beneficiary, for instance, in order that the person can receive and return a renewal form or other information needed by the State to renew their eligibility or can receive critical program information.

Under proposed SEC 435.919(f), when States receive returned beneficiary mail, they need to take proactive steps to confirm any forwarding address provided or to otherwise locate the person. For all returned beneficiary mail, including returned mail with an in-state, an out-of-state, or no forwarding address, we propose at [Sec.] SEC 435.919(f)(1) through 435.919(f)(3), that States conduct a series of information checks and outreach attempts to locate the beneficiary and confirm their address. If the State is unable to locate or confirm a beneficiary’s address after this series of outreach attempts, proposed SEC 435.919(f)(4) through (f)(6) outlines required and permissible State actions based on the placement of the address, if any, provided on the returned mail (that’s, in-state or out-of-state). The proposed steps which States must or may take each time beneficiary mail is returned are discussed in additional detail, below.

Step 1: Check Available Data Sources for Updated Contact Information

Under proposed SEC 435.919(f)(1), each time beneficiary mail is returned, the State must first check data sources available to the agency to discover any potential updated mailing address information available to the State prior to reaching out to the person. At a minimum, a State must check for updated mailing contact information from the next sources: (1) the agency’s Medicaid Enterprise System (MES); (2) the agency’s contracted managed care plans, if applicable within the State; and (3) a number of other third-party data sources, discussed below.

Updated beneficiary contact information from managed care plans, enrollment brokers, claims data, and within the case of integrated eligibility systems, other State administered public profit systems could also be available within the State’s MES, and because of this we consider it’s critical that States check for potential updated address information that could be in this method, as reflected at proposed SEC 435.919(f)(1)(i). Many States have told CMS that individuals enrolled in a managed care plan usually tend to provide their plan, which generally has more frequent contact with their beneficiaries than the State agency, with updated address information. We subsequently propose at SEC 435.919(f)(1)(ii) that the State must obtain and check the address on file with the plan for any individual enrolled in a managed care plan. Finally, there are other third-party data sources available to State Medicaid agencies, and we propose at SEC 435.919(f)(1)(iii) that the State must obtain and check at the least considered one of the next: the State agency that administers SNAP, the State agency that administers TANF, the Department of Motor Vehicles, the USPS National Change of Address (NCOA) database, and other sources laid out in the State’s verification plan to find out if a unique and newer address is accessible.

Discussed in additional detail below, under proposed SEC 435.919(f)(2) and 435.919(g), when a State receives a forwarding address on a chunk of returned mail, the State must try to contact the person to confirm the forwarding address and supply them with a possibility to substantiate or dispute the knowledge.

Step 2: Conduct Outreach Using at Least Two Different Modalities

In verifying a forwarding address provided by USPS under the proposed rule, States must try to contact the beneficiary by each mail (at proposed SEC 435.919(f)(2)), in addition to a modality apart from mail (at proposed SEC 435.919(f)(3)), resembling by phone, electronic notice, email, or text message. States have flexibility as to the order through which they try to contact the beneficiary through different modalities.

In attempting to contact the beneficiary by U.S. mail, we propose at SEC 435.919(f)(2) that the State must send notices to each the present address on file, the forwarding address (if one is provided by USPS), and any address newer than that within the beneficiary’s case records obtained pursuant to proposed SEC 435.919(f)(1). The notice must request that the person confirm their current address. The State must provide the person with an inexpensive time frame to confirm the accuracy of the brand new contact information. Consistent with proposed SEC 435.919(c)(1), we propose that SEC 435.919(f)(2)(i) define this reasonable time frame as 30 calendar days from the date the notice is distributed to the beneficiary. Sending mail to the present address on file represents a key beneficiary protection to make sure that initial piece of returned mail was not incorrectly returned.

We propose at SEC 435.919(f)(3) that, in attempting to contact the beneficiary using a modality apart from mail, the State must make at the least two attempts with at the least three business days between the primary and last attempt. In implementing this requirement, States have flexibility to make use of any combination of obtainable electronic or telephonic modalities. Such communications, initiated either directly by the State agency or through a State contractor or partner, have to be compliant with Federal communications laws resembling the Telephone Consumer Protection Act (47 U.S.C. 227).

If it just isn’t feasible to conduct outreach via another modality, for instance because there is no such thing as a phone or other electronic contact information within the case record or obtained from third-party sources, the State must note that within the case record. For outreach conducted by electronic or telephonic modalities, States must use the contact information available on file. States also may leverage the electronic or telephonic contact information obtained by the State through data checks pursuant to SEC 435.919(f)(1) and reach out to the beneficiary through other modalities pursuant to SEC 435.919(f)(3).

We note that, under SEC 435.918, beneficiaries have to be provided a selection to receive notices via mail or in an electronic format. If a beneficiary has elected to receive notices and communications electronically, the State must send a notice via the person’s preferred electronic format and such notice must provide at the least 30 calendar days from the date the agency sends the notice to confirm the accuracy of the brand new contact information. Whatever the notice format a beneficiary elects, under the proposed rule States must try to contact individuals for whom they’ve received returned mail via each mail and another electronic modality in an effort to substantiate the beneficiary’s correct current address. For a beneficiary who elected to receive electronic notices and communications in accordance with SEC 435.918, if a previous electronic communication attempt failed, the agency cannot use that very same electronic modality as the choice modality to satisfy the requirement at proposed SEC 435.919(f)(3). States have flexibility under the proposed rule as to the order through which they try to contact the beneficiary through different modalities.

Step 3: State Agency Motion Based on Address or No Forwarding Address if Beneficiary Does Not Respond

If a State agency has exhausted all outreach efforts described in [Sec.] SEC 435.919(f)(1) through (f)(3), then the proposed actions that a State must or may take rely upon whether USPS returns an in-state forwarding address, an out-of-state forwarding address or no forwarding address.

Returned mail with an in-state forwarding address reflects a possible change in circumstances that doesn’t affect eligibility. Accordingly, if the beneficiary doesn’t reply to the State’s request to substantiate their current address in an inexpensive period after the State has taken the steps required under proposed [Sec.] SEC 435.919(f)(1) through (f)(3), we propose at SEC 435.919(f)(4)(i) that, consistent with current Federal policy, the State may not terminate the beneficiary’s coverage if the State doesn’t receive a response to its requests that the person confirm their correct current address. Nevertheless, while USPS may occasionally return mail sent to a beneficiary with an erroneous forwarding address, we consider that the USPS information generally is accurate, and definitely is accurate way more often than it’s inaccurate. This accuracy is buoyed by controls implemented by USPS, which include charging a fee by bank card to validate online change of address (COA) requests, requiring individuals submitting a hardcopy COA request to confirm that they understand an unauthorized COA order is a Federal offense, and sending two confirmation letters (to the brand new and old address) to authenticate the order. Subsequently, we propose at SEC 435.919(f)(4)(ii) that, if the State doesn’t receive a response from the beneficiary that an in-state forwarding address provided by USPS is inaccurate, the State must accept the brand new in-state address and update the beneficiary’s account accordingly.

Similarly, the USPS NCOA database includes the everlasting change-of-address records maintained by the USPS. Each time a person or family moves and submits a change-of-address form to their local post office, their latest address is recorded within the NCOA database. States can establish agreements with USPS to realize access to the NCOA database to be able to utilize these address changes. Subsequently, we propose at SEC 435.919(f)(4)(iv) that, if the State doesn’t receive a response from the beneficiary that an in-state address provided by NCOA is inaccurate, the State must accept the brand new in-state address and update the beneficiary’s account accordingly. Moreover, we consider that updated in-state address information obtained from managed care plans could also be treated as reliable data, provided that the updated contact information was received by the plan directly from, or was verified with, the beneficiary. Subsequently, we propose at SEC 435.919(f)(4)(iii) that, if the State doesn’t receive a response from the beneficiary that an in-state address obtained from a managed care plan is inaccurate, the State must accept the brand new in-state address and update the beneficiary’s account accordingly. We seek comment on whether States needs to be required to update a beneficiary’s in-state address using newer contact information reflected in a forwarding address from USPS or an address provided by NCOA or a managed care plan in this example, when the beneficiary has not responded to the State’s request to confirm their current address.

We note that CMS provided some States with authority under section 1902(e)(14)(A) of the Act to depend on updated contact information from a reliable third-party source, resembling an MCO, without first attempting to contact the person and providing them with an inexpensive time frame to confirm the accuracy of the brand new contact information, in accordance with the State Health Official Letter, “Promoting Continuity of Coverage and Distributing Eligibility and Enrollment Workload in Medicaid, the Kid’s Health Insurance Program (CHIP), and Basic Health Program (BHP) Upon Conclusion of the COVID-19 Public Health Emergency,” published on March 2, 2022 (SHO letter #22-001). We seek comment on whether States needs to be permitted or needs to be required to update beneficiary contact information based on information obtained from an MCO, from the USPS NCOA, or other reliable data sources without first attempting to contact the beneficiary to supply them with a possibility to confirm or dispute the brand new information, because such third-party data is reliable, and, if that’s the case, which data sources should States be permitted to depend upon without attempting to contact beneficiaries. We’re especially curious about comments from States that received authority under section 1902(e)(14)(A) of the Act to update beneficiary contact information based on information received from a reliable third party without first attempting to contact the person, as described in SHO letter #22-001. We also seek comment on the efficacy of the requirement to send a notice to a beneficiary’s address on file to make sure that initial piece of returned mail was not incorrectly returned.

Returned mail with an out-of-state forwarding address indicates a possible change in circumstances (State residency) which will impact eligibility. Consistent with current requirements under SEC 435.916(d), we propose at SEC 435.919(f)(5) that, if a beneficiary doesn’t reply to the State’s requests per proposed SEC 435.919(f)(1) through (f)(3) for information to confirm their current address, or if information provided doesn’t establish that the beneficiary continues to satisfy the State residency requirement, the State must provide advance notice of termination and fair hearing rights consistent with 42 CFR part 431 subpart E.

Returned mail with no forwarding address. Current regulations at SEC 435.916(d) require termination of the eligibility of a beneficiary for whom an out-of-state forwarding address has been received if the beneficiary doesn’t respond with information establishing continued State residency, current regulations at SEC 431.213(d) provide for an exception to advance notice within the case of a beneficiary whose “whereabouts are unknown and the post office returns agency mail directed to him indicating no forwarding address” and current regulations at SEC 431.231(d) provide for reinstatement of beneficiaries whose advantages were discontinued resulting from whereabouts unknown (“as evidenced by the return of unforwardable agency mail”) if their whereabouts subsequently change into known. Nevertheless, the present regulations are unclear with respect to what actions States must soak up the case of beneficiaries who didn’t reply to the State’s attempts to contact them to substantiate their address and for whom the State has received no forwarding address and was unable to acquire an updated address from a reliable third-party source.

While it will be important that beneficiaries who remain in-state should not inappropriately terminated, continued enrollment of people whose State residency is unknown, particularly those enrolled in a managed care plan for whom the State pays a monthly capitation payment, may end in unnecessary expense to State Medicaid program and Federal government. To balance these two interests and supply clear requirements for such situations, we propose revising and redesignating current regulation at SEC 431.231(d) at proposed SEC 435.919(f)(6) to require that, when a State receives returned beneficiary mail with no forwarding address, the State must first take reasonable steps to locate the beneficiary consistent with proposed [Sec.] SEC 435.919(f)(1) through (f)(3). If, after taking such steps, the State is unable to locate the beneficiary, we propose at SEC 435.919(f)(6)(i) that States must take appropriate steps to terminate coverage, suspend coverage, or move the beneficiary right into a fee-for-service delivery system.

Under SEC 431.231(d) of the present regulations, redesignated at proposed SEC 435.919(f)(6), States should not required to supply advance notice of termination within the case of a beneficiary whose whereabouts remain unknown after the efforts required to locate the person have been taken, but are required to supply notice of fair hearing rights. Nevertheless, consistent with current regulations at SEC 431.231(d), redesignated at proposed at SEC 435.919(f)(6)(ii)(A), if the beneficiary’s whereabouts change into known prior to the beneficiary’s originally-scheduled renewal date, the State must reinstate their coverage. We propose adding a requirement at SEC 435.919(f)(6)(ii)(A) that States must reinstate coverage back to the date of termination if the person’s whereabouts change into known before their next regularly-scheduled renewal, without the necessity to confirm eligibility. For instance, suppose a beneficiary’s eligibility is terminated in April 2023 on the idea of their whereabouts being unknown. In July 2023, the person seeks care, but is told by the provider that their Medicaid coverage was terminated. If the person contacts the agency before their next regularly-scheduled renewal, the agency must immediately reinstate their coverage retroactive to April 2023. Consistent with current SEC 435.916(d)(1)(ii), redesignated at proposed SEC 435.919(e)(2), we’re adding the choice at proposed at SEC 435.919(f)(6)(ii)(B) for States to start a latest eligibility period (defined in current regulations at SEC 435.916(a), redesignated and revised at SEC 435.916(b) on this proposed rule) for a beneficiary whose whereabouts change into known if the agency has enough information available to it to renew eligibility with respect to all eligibility criteria without requiring additional information from the beneficiary.

Proposed SEC 435.919(g), describes the steps a State may take if it obtains updated mailing information from third-party sources apart from returned mail from the USPS. Specifically, we propose at SEC 435.919(g)(1) that States that obtain updated in-state mailing information from NCOA or managed care plans may treat such information as reliable, provided that the State conducts the next outreach. When updated address information is obtained by the State from NCOA or from a managed care plan that has a contract with the State, the State must send a notice to the present address on file with the State and supply the person with an inexpensive time frame to confirm the accuracy of the brand new contact information. Consistent with proposed SEC 435.919(c)(1), we propose that SEC 435.919(g)(1)(v) define this reasonable time frame as 30 calendar days from the date the notice is distributed to the beneficiary.

States must also contact the beneficiary through other modalities, resembling via telephone, electronic notice, email, or text message, where feasible, and must send information to the brand new address. We propose at SEC 435.919(g)(1)(iii) that, in attempting to contact the beneficiary using a modality apart from mail, the State must make at the least two attempts with at the least 3 business days between the primary and last attempt. In implementing this requirement, States have flexibility to make use of any combination of obtainable electronic or telephonic modalities. Such communications, initiated either directly by the State agency or through a State contractor or partner, have to be compliant with Federal communications laws resembling the Telephone Consumer Protection Act (47 U.S.C. 227). If it just isn’t feasible to conduct outreach via another modality, for instance because there is no such thing as a phone or other electronic contact information within the case record or obtained from third-party sources, the State must note that within the case record. For outreach conducted by electronic or telephonic modalities, States must use the contact information available on file. If the beneficiary doesn’t respond, the State may update the beneficiary record with the brand new contact information. If the beneficiary responds and confirms the brand new address, the State must update the beneficiary record with the brand new contact information. Critically, States should make sure that managed care plans only provide updated contact information received directly from or verified by the beneficiary, and never from a 3rd party or other source. We remind States that the foundations at [Sec.] SEC 435.919(b) and 435.952(d) apply for out-of-state address information obtained under SEC 435.919(g).

At SEC 435.919(g)(2), we propose that States may treat updated in-state address information from other trusted data sources in accordance with proposed paragraph (g)(1) if the State obtains approval from the Secretary. At SEC 435.919(g)(3), we propose the method that States must follow when obtaining any address information from any sources not listed in paragraph (g)(1) or (2) of this section. Under SEC 435.919(g)(3), the agency must follow the steps outlined in SEC 435.919(f)(2) through (6), related to returned mail to be able to confirm the address change with the beneficiary. We seek comment on whether States either needs to be permitted or needs to be required to update beneficiary contact information based on information obtained from an MCO, from the USPS NCOA, or other reliable data sources, resembling Indian Health Care Providers, Federally Qualified Health Centers, Rural Health Clinics, Program of All-inclusive Look after the Elderly providers, Primary Care Case Managers, Accountable Care Organizations, Patient Centered Medical Homes, Enrollment Brokers, or other State Human Services Agencies (for instance, SNAP), without first attempting to contact the person to supply them with a possibility to confirm or dispute the brand new information, because such third-party data is reliable, and, if that’s the case, which data sources should States be permitted to depend upon without attempting to contact beneficiaries. We’re especially curious about comments from States that received authority under section 1902(e)(14)(A) of the Act to update beneficiary contact information based on information received from a reliable third party without first attempting to contact the beneficiary, as described in SHO letter #22-001. We also seek comment on the efficacy of the requirement to send a notice to a beneficiary’s address on file to make sure that initial piece of returned mail was not incorrectly returned, and on the efficacy of the requirement to conduct at the least two outreach attempts to the beneficiary using a modality apart from mail. We also seek comment on the necessities in proposed SEC 435.919(g)(3) paragraphs (f)(2) through (6), related to processing out-of-state address information or address information from a source not identified in SEC 435.919(g)(1), including whether CMS should consider including a requirement that a State check the available data sources outlined in SEC 435.919(f)(1)(i) and SEC 435.919(f)(1)(ii).

Finally, we make a conforming amendment to SEC 431.213(d), which currently cross references SEC 431.231(d), to as an alternative reference SEC 435.919(f). Proposed changes to SEC 457.344 regarding the responsibilities of States administering a separate CHIP within the event of returned mail and once they receive information from a 3rd party a couple of change in address for people enrolled in a separate CHIP are discussed in further detail in section II.E.3 of this preamble.

5. Transitions Between Medicaid, CHIP and BHP Agencies ([Sec.] SEC 431.10, 435.1200, 600.330)

Section 1943 of the Act requires Medicaid agencies to collaborate with separate CHIP and BHP agencies, if such agencies exist within the State, and with the Exchanges to ascertain a coordinated eligibility and enrollment process. Through this process, most applicants, in addition to beneficiaries whose eligibility is being redetermined, are evaluated for eligibility for every of those insurance affordability programs and will enroll in this system for which they’re eligible without having to finish separate applications. The necessities to coordinate eligibility and enrollment amongst insurance affordability programs were established within the 2012 eligibility final rule at SEC 435.1200. State experience in implementing SEC 435.1200 has revealed some weaknesses in the necessities, which enable eligible individuals to experience unnecessary gaps in coverage and periods of uninsurance. Through this proposed rule, we seek to correct those weaknesses and reduce coverage gaps wherever possible.

One weakness in the present requirements occurs when an agency has information indicating that a beneficiary is not any longer Medicaid eligible and sure eligible for one more insurance affordability program, but the person doesn’t respond to substantiate this information. As discussed in sections II.B.1. and II.B.2. of this preamble, when the agency receives information reported by a beneficiary or from a reliable third-party source which can affect eligibility, the agency must promptly redetermine the person’s eligibility. If the third-party information would end in an antagonistic motion, the agency must contact the beneficiary and request additional information to confirm or dispute the knowledge. Similarly, when a State accesses available information in attempting to renew a person’s eligibility during a regularly-scheduled renewal and obtains information indicating the person may now not be eligible, it must send the beneficiary a renewal form (which have to be prepopulated for MAGI-based beneficiaries under the present regulations) and supply sufficient time for the person to return the shape and some other information or documentation needed to ascertain continued eligibility (at the least 30 calendar days for MAGI-based beneficiaries under the present regulations). When a beneficiary or a beneficiary’s representative doesn’t reply to such requests, the agency must provide the person with advance notice of termination and fair hearing rights, consistent with part 431 subpart E of the regulations.

For most people determined ineligible for Medicaid, current SEC 435.1200(e) requires the agency to find out potential eligibility for other insurance affordability programs and, as appropriate, transfer the person’s electronic account to the suitable program. Nevertheless, because this requirement applies only to a beneficiary who “submits an application or renewal to the agency which incorporates sufficient information to find out Medicaid eligibility,” the agency just isn’t required to transfer a person’s account in all cases. When a beneficiary doesn’t submit a required renewal form or other information needed to redetermine or renew eligibility, the Medicaid agency must send such advance notice of termination but just isn’t required to transfer the person’s account to a different insurance affordability program.

These terminations, and not using a resulting transfer to a different insurance affordability program, can create major disruptions in medical health insurance coverage for otherwise eligible individuals. For instance, a family may receive notification of potential income ineligibility for Medicaid, but may not respond because the knowledge described within the notification is correct, and the family doesn’t understand that they need to substantiate their increased income so their account shall be transitioned to CHIP, BHP, or the Exchange of their State in accordance with current SEC 435.1200(e).

Disenrollment from medical health insurance coverage and not using a corresponding transition to enrollment in one other insurance affordability program is a troubling final result, particularly since regulatory requirements at SEC 435.1200 for Medicaid, [Sec.] SEC 457.348 and 457.350 for CHIP, SEC 600.330 for BHP, and 45 CFR 155.302 for Exchanges were designed to make sure coordination of coverage and smooth transitions between insurance affordability programs. Losses of coverage are much more troubling when different programs share an eligibility system and a determination of eligibility for one program might be accomplished seamlessly as the person is decided ineligible for one more program.

When developing the coordination requirements currently published at [Sec.] SEC 435.1200, 457.348 and 457.350, and 600.330, and 45 CFR 155.302, we beneficial, but didn’t require States to utilize a shared eligibility system or service for all insurance affordability programs. Today, we consider every State with separate programs for Medicaid and CHIP /60/ utilizes a single eligibility system or shared eligibility service for eligibility determinations based on MAGI. As such, when a Medicaid beneficiary is decided ineligible resulting from a rise in household income, and the person is screened for potential CHIP eligibility, the system effectively makes a determination of economic eligibility for CHIP. We consider the Medicaid agency could complete the determination of CHIP eligibility based on available information, so the person doesn’t should be screened after which transferred to the separate CHIP agency before a determination of CHIP eligibility could be accomplished.

   FOOTNOTE 60 As of June 1, 2022, 40 States have a separate CHIP; this includes 2 States with only a separate CHIP and 38 States with each a Medicaid expansion and a separate CHIP. END FOOTNOTE

Moreover, while Medicaid and CHIP are separate programs, each use MAGI-based methodologies described at section 1902(e)(14) of the Act, further detailed at [Sec.] SEC 435.603 for Medicaid and cross-referenced at SEC 457.315 for CHIP, to find out financial eligibility. Further, States can, and infrequently do, utilize the identical policies and procedures to confirm MAGI-based income eligibility for Medicaid and CHIP. The truth is, current SEC 435.1200(d)(4) requires the Medicaid agency to just accept findings related to eligibility criteria made by a separate CHIP agency without further verification if that program applies the identical verification policies as those utilized by the Medicaid agency. The same requirement applies to CHIP at SEC 457.348(c)(4). Because the identical financial methodologies are used for every program, if the identical verification requirements apply, a determination of economic eligibility used to find out CHIP eligibility have to be accepted by the Medicaid agency in determining financial eligibility for Medicaid and vice versa.

Through this rule, we propose changes to SEC 435.1200 to enhance transitions between Medicaid and a separate CHIP; corresponding changes to CHIP are described in section II.E.5 of this preamble. We note that these changes would apply only to transitions between Medicaid and a separate CHIP. They might not apply to transitions between title XIX funding and title XXI funding inside Medicaid in States that implement CHIP through a Medicaid expansion, either in whole or partially.

Current SEC 435.1200 implements the ACA requirements established at section 1943(b) of the Act regarding the coordination of enrollment amongst insurance affordability programs. The final requirements for coordination are described at SEC 435.1200(b). Paragraph (b)(1) requires the Medicaid agency to meet the final responsibilities described in later paragraphs, while paragraph (b)(2) requires the agency to certify, for the opposite insurance affordability programs, the standards for determining Medicaid eligibility. Current SEC 435.1200(b)(3) requires the agency to enter into an agreement with the agency or agencies administering a separate CHIP, BHP, and the Exchange operating within the State; such agreement(s) must include a transparent delineation of the responsibilities of every program with respect to eligibility determinations, notices, and fair hearings. Paragraphs (c) and (d) describe the Medicaid agency’s responsibilities for eligibility and enrollment when a person has been determined Medicaid eligible (paragraph (c)) or assessed as potentially Medicaid eligible (paragraph (d)) by a separate CHIP, BHP, or Exchange. Paragraph (e) of current SEC 435.1200 describes the responsibilities of the Medicaid agency to judge a person’s eligibility for CHIP, BHP, and coverage through the Exchanges when a person is decided not eligible for Medicaid (SEC 435.1200(e)(1)) or is undergoing a Medicaid eligibility determination on a non-MAGI basis (SEC 435.1200(e)(2)). Paragraphs (f) through (i) of current SEC 435.1200 describe the coordination requirements for an enrollment website, appeals, and notices.

Amongst the necessities for enrollment simplification and coordination described in section 1943(b) of the Act, paragraph (b)(1)(F) specifically requires outreach and enrollment of underserved populations eligible for Medicaid. One among the populations called out for focused outreach and enrollment is children, including subsets of particularly underserved children, in addition to racial and ethnic minorities, rural populations, and individuals with mental health and/or substance use disorders. While the rise in uninsurance amongst children known to be eligible for Medicaid or one other insurance affordability program has leveled off since 2020 when the PHE went into effect, likely due in large measure to the continual enrollment condition under the FFCRA discussed within the background section of this preamble, to be able to reduce the likelihood of future increases in uninsurance, we propose a latest approach to implementing the coordination requirements in section 1943(b) of the Act.

Section 1902(a)(19) of the Act requires that the Medicaid State plan include safeguards to make sure that eligibility is decided in a way that’s consistent with the simplicity of administration and the most effective interests of beneficiaries. We consider the language and requirements in SEC 435.1200, which don’t require transition of otherwise eligible individuals from one program to a different when beneficiaries have failed to supply requested information to substantiate or dispute third-party data indicating a change in eligibility, have contributed to a rise in uninsurance amongst individuals losing coverage under Medicaid and CHIP, despite the fact that they meet the eligibility requirements for one more considered one of those programs. This result’s inconsistent with each the simplicity of administration of the Medicaid program and the most effective interest of Medicaid beneficiaries.

Utilizing the authority provided in sections 1902(a)(19) and 1943(b)(1)(F) of the Act, we propose to revise paragraphs (b), (c), (e), and (h) of SEC 435.1200 to enhance enrollment of underserved populations and to cut back unnecessary administrative barriers to coverage by requiring Medicaid agencies, in States with a separate CHIP, to:

    * Provide for an agreement with the separate CHIP agency to seamlessly transition the eligibility of beneficiaries between Medicaid and CHIP when their eligibility status changes;

    * Accept determinations of MAGI-based Medicaid eligibility made by a separate CHIP;

    * Establish procedures to receive determinations of Medicaid eligibility accomplished by a separate CHIP;

    * Complete determinations of eligibility for a separate CHIP for people who’re determined ineligible for Medicaid based on reliable third-party data; and

    * Issue a combined notice indicating ineligibility for Medicaid and eligibility for CHIP when appropriate.

In section II.E.4. of this preamble, we discuss proposed changes to the CHIP regulations that correspond with these proposed requirements for Medicaid agencies. When proposed changes to the Medicaid and CHIP regulations are read together, they might make sure that (1) when a person is decided ineligible for Medicaid, the person would receive a determination of CHIP eligibility (from the Medicaid agency) and, if eligible for CHIP, the person’s electronic account could be transferred from the Medicaid agency to the separate CHIP agency, with the separate CHIP agency completing any enrollment-related activities resembling collection of an applicable enrollment fee or premium and/or plan selection; and (2) when CHIP determines that an enrollee has change into ineligible for CHIP, the person would receive a determination of MAGI-based Medicaid eligibility, and, if eligible for Medicaid, the person’s electronic account could be transferred from the separate CHIP agency to the Medicaid agency, with the Medicaid agency completing any enrollment related activities resembling issuing a Medicaid card.

We consider these changes could address potential declines in enrollment which will result from eligible individuals not being seamlessly transitioned to Medicaid from CHIP and from Medicaid to CHIP when available information indicates eligibility for the opposite program. We propose the next specific revisions to the coordination requirements for States with a separate CHIP.

Preliminarily, we propose so as to add a latest requirement to the list of necessities in current SEC 435.1200(b)(3) that have to be addressed in agreements between the Medicaid agency and other insurance affordability programs. Proposed SEC 435.1200(b)(3)(vi) would require the Medicaid agency to incorporate in its agreement with the State’s separate CHIP agency, procedures for seamlessly transitioning the eligibility of people from Medicaid to CHIP once they are determined ineligible for Medicaid and eligible for CHIP. The agreement would also include procedures for seamlessly transitioning the eligibility of people from CHIP to Medicaid once they are determined ineligible for CHIP by that program and eligible for Medicaid. The agreement required under SEC 435.1200(b)(3) would describe the responsibilities for every State agency administering Medicaid and CHIP to effectuate the required coordination.

We propose so as to add a requirement at SEC 435.1200(b)(4) that the Medicaid agency must accept a determination of MAGI-based Medicaid eligibility made by the State agency administering a separate CHIP (See section II.E.5. of this preamble for a discussion of the proposed requirements for agencies administering a separate CHIP to find out MAGI-based Medicaid eligibility.). There are numerous different options that the Medicaid agency could use to effectuate this requirement in compliance with the one State agency’s responsibility to find out Medicaid eligibility described at SEC 431.10(b)(3).

    * If the separate CHIP is run by the one State agency that administers the Medicaid program, then the one State agency itself can determine Medicaid eligibility concurrently it’s determining CHIP ineligibility.

* If the separate CHIP just isn’t a part of the one State agency, then as described at proposed SEC 435.1200(b)(4)(i), the Medicaid and CHIP agencies could conform to utilize the identical MAGI-based methodologies under [Sec.] SEC 435.603 and 457.315, and verification policies and procedures under [Sec.] SEC 435.940 through 435.956 and 457.380, such that the Medicaid agency would accept any finding regarding a criterion of eligibility made by a separate CHIP agency without further verification in accordance with current regulations at SEC 435.1200(d)(4).

    * As described at proposed SEC 435.1200(b)(4)(ii), the agency may use a shared eligibility service that enables the Medicaid agency to take care of responsibility for the foundations and requirements used to find out Medicaid eligibility, while permitting the separate CHIP agency to find out Medicaid eligibility by running the foundations within the shared eligibility service maintained by the Medicaid agency when ineligibility for CHIP is decided. In such cases, any functions performed by the separate CHIP agency could be solely administrative in nature, and never reflective of a delegation of authority to make Medicaid eligibility determinations.

    * If the separate CHIP agency doesn’t use the identical MAGI-based methodologies and verification procedures as those utilized by Medicaid, and the 2 programs don’t share an eligibility service with the Medicaid agency, we propose at SEC 435.1200(b)(4)(iii) that the Medicaid agency may enter into an agreement in accordance with SEC 431.10(d) of the regulations, as amended on this proposed rule, and SEC 431.10(c) under which the Medicaid agency delegates authority to make final Medicaid eligibility determinations to the entity that makes eligibility determinations for a separate CHIP agency. To effectuate this feature, we propose so as to add the State agencies that administer the separate CHIP and BHP programs to the list of entities in SEC 431.10(c)(1)(i)(A) to which the Medicaid agency may delegate authority to make determinations of Medicaid eligibility. A separate BHP agency is added to the list of entities to which Medicaid may delegate eligibility determinations to accommodate either an option or a requirement for a State’s BHP to finish determinations of Medicaid eligibility.

    * Finally, at proposed SEC 435.1200(b)(4)(iv), we would offer States with the choice to utilize a unique policy or procedure approved by the Secretary.

We request comment on whether there are alternative ways that States with a separate CHIP agency needs to be permitted to effectuate a seamless transition of eligibility into Medicaid for people determined ineligible for CHIP.

We also propose to expand the scope of paragraph (c) of SEC 435.1200, which provides for the supply of Medicaid to individuals determined eligible by one other insurance affordability program. Current SEC 435.1200(c) applies only to States which have entered into an agreement under which the Exchange or one other insurance affordability program makes final determinations of Medicaid eligibility. We propose to amend SEC 435.1200(c) to require Medicaid agencies, which must accept final determinations of Medicaid eligibility accomplished by a separate CHIP agency in accordance with proposed paragraph (b)(4), to achieve this in accordance with the necessities of paragraph (c), as described below.

Current SEC 435.1200(c)(1) through (c)(3) require the Medicaid agency to ascertain procedures to receive electronic accounts from one other insurance affordability program; comply with the necessities of SEC 435.911 (regarding determinations of Medicaid eligibility) to the identical extent as if the Medicaid agency had received the applying in an account transferred to it; and maintain proper oversight of the Medicaid program. We propose to redesignate the responsibilities described at current SEC 435.1200(c)(1) through (c)(3) as paragraphs (c)(1)(i) through (iii), to delete the present introductory language in SEC 435.1200(c), and so as to add a latest paragraph (c)(2) to explain the individuals who could be subject to the necessities set out in proposed paragraph (c)(1).

Specifically, proposed SEC 435.1200(c)(2)(i) describes the individuals currently subject to the necessities in SEC 435.1200(c)–that is, individuals determined Medicaid eligible by the Exchanges or other insurance affordability programs (for instance, a BHP), including because of this of a call made by the appeals entity for such program, if the agency has entered into an agreement under which the Exchange or other insurance affordability program may make final determinations of Medicaid eligibility. Proposed SEC 435.1200(c)(2)(ii) describes individuals who’re determined Medicaid eligible by a separate CHIP agency, including as the results of a call made by a CHIP review entity in accordance with proposed 435.1200(b)(4).

Because we propose to require all States with a separate CHIP to meet the responsibilities of proposed SEC 435.1200(c), not only those States that decide to enter into an agreement with one other insurance affordability program, we also propose to revise the final requirement at SEC 435.1200(b)(1) (which currently provides that the Medicaid agency fulfill the necessities set forth in SEC 435.1200(d) through (h)) to incorporate paragraph (c) within the list of necessities in SEC 435.1200 which the Medicaid agency must fulfill. Similarly, we propose to revise SEC 435.1200(b)(3)(ii), which provides that the agreements established between the Medicaid agency and other insurance affordability programs must ensure compliance with SEC 435.1200(d) through (h), to incorporate paragraph (c) of SEC 435.1200.

We don’t propose to make any changes to SEC 435.1200(d) on this proposed rule. Paragraph (d) requires the Medicaid agency to just accept a determination of potential Medicaid eligibility made by one other insurance affordability program. Because this rule wouldn’t require the Medicaid agency to enter into an agreement to just accept eligibility determinations made by a BHP or Exchange or to make determinations of eligibility for BHP or for insurance affordability programs available through the Exchanges, we consider this paragraph will proceed to be mandatory in these cases. As well as, we recognize that there could also be cases through which a separate CHIP agency doesn’t have access to all information needed to find out eligibility for Medicaid (for instance, on a non-MAGI basis), but may give you the chance to finish a determination of potential eligibility and transfer the person’s electronic account to the Medicaid agency to request the extra information and complete the determination.

The proposed revisions to SEC 435.1200(c) aim to enhance the seamless transition of people from a separate CHIP to Medicaid. We also propose changes to SEC 435.1200(e) to enhance the seamless transitioning of people from Medicaid to a separate CHIP. Current SEC 435.1200(e)(1) describes the necessities that, for people determined ineligible for Medicaid, the Medicaid agency determine potential eligibility for and, as appropriate, transfer via a secure electronic interface the person’s electronic account to a different insurance affordability program (that’s, CHIP, BHP or Exchange).

As mentioned previously, current SEC 435.1200(e)(1) doesn’t require the agency to transfer a person’s account to a different insurance affordability if the person fails to submit a “renewal to the agency which incorporates sufficient information to find out Medicaid eligibility[.]” We propose to remove reference to submission of a renewal form, such that the Medicaid agency could be required to transfer the account of a person who, during a regularly-scheduled renewal or redetermination based on a change in circumstances, has been determined ineligible for Medicaid and determined eligible, or potentially eligible, for one more insurance affordability program based on available information. We note that this doesn’t change the agency’s obligation to supply individuals with a possibility to dispute the knowledge obtained by the agency indicating Medicaid ineligibility before the agency terminates their Medicaid eligibility, as required at current SEC 435.952(d), or to supply advance notice of termination and fair hearing rights in accordance with part 431 subpart E of the regulations.

We also propose to revise SEC 435.1200(e)(1) by breaking it into two paragraphs–paragraphs (e)(1)(i) and (ii)–establishing separate requirements for situations through which the Medicaid agency completes a determination of eligibility for a separate CHIP agency and situations through which the Medicaid agency makes a determination of potential eligibility for BHP or for insurance affordability programs available through the Exchanges.

At proposed SEC 435.1200(e)(1)(i), we might require that in a State that operates a separate CHIP, when the Medicaid agency determines a person to be ineligible for Medicaid, it must also determine whether the person is eligible for CHIP using information available to the agency. Information on the person’s financial eligibility will already be available within the eligibility system, together with certain non-financial eligibility aspects resembling State residency and citizenship or eligible immigration status. Other eligibility criteria which could also be applicable to determining eligibility for CHIP, which should not relevant in a Medicaid determination, include enrollment in other insurance coverage and access to State worker medical health insurance. We consider State Medicaid agencies have access to other reliable data sources from which they will obtain any additional information that could be needed about these criteria. State Medicaid agencies have information on other insurance coverage that a beneficiary can have, which States are required to acquire from insurers for purposes of third-party liability and coordination of advantages per section 1902(a)(25)(I) of the Act. State Medicaid agencies can also access information on the provision of State worker health coverage from the State agency which administers such coverage. We consider it’s consistent with simplicity of administration and the most effective interests of beneficiaries for the agency to be expected to access these data sources to make a determination of eligibility for CHIP.

We recognize that it might be easier for some States to discover access to State worker health coverage than others. For instance, in some States, a single State agency may administer the worker health plan for all State employees, and the plan could also be available only to State employees and their dependents. While in other States, particularly those through which the federal government is more decentralized or through which local government agencies also take part in State worker health coverage, we consider it might be tougher to access such information. We seek comment on State Medicaid agencies’ ability to gather information on access to State worker health coverage, particularly if a baby just isn’t already enrolled in such coverage, without requiring additional information from the family.

Ideally, a person’s enrollment in CHIP could be effectuated at the identical time the State terminates coverage in Medicaid so the person wouldn’t experience a period of uninsurance. Nevertheless, we recognize that the separate CHIP agency may require payment of an enrollment fee or premium or other motion, like plan selection, before enrollment could be accomplished. A combined notice, discussed later on this section, may mitigate some risk of a coverage gap by notifying the person concerning the CHIP enrollment fee or premium requirement at the identical time advance notice of Medicaid termination is issued, providing some additional time for families to make the required CHIP payment before Medicaid coverage ends. We seek comment on challenges States may face in easily transitioning enrollment from Medicaid to CHIP and processes that might be implemented to deal with these challenges. We also seek comment on whether there are situations through which the Medicaid agency would give you the chance to finish only a determination of potential eligibility for CHIP, such that the ultimate regulation would wish to permit for situations through which the Medicaid agency would transfer the person’s electronic account to the agency administering a separate CHIP to finalize the determination for its own program.

Proposed SEC 435.1200(e)(1)(ii) would require that when the Medicaid agency determines a person to be ineligible for each Medicaid and CHIP, the agency must determine potential eligibility for BHP if the State operates a BHP and if ineligible for BHP, the agency must determine potential eligibility for insurance affordability programs available through the Exchanges. That is consistent with the present regulatory requirement at SEC 435.1200(e)(1).

As vital because it is to transition a person from one insurance affordability program to a different when eligibility changes, it’s equally vital to make sure that such individual receives clear and consistent information concerning the transition, each before the change is effectuated and when the transition occurs. It will probably be very confusing for people to receive separate notices from the Medicaid program and CHIP, particularly once they arrive at different times. Accordingly, we propose to require that individuals be supplied with a combined eligibility notice when either the Medicaid agency determines the person ineligible for Medicaid and eligible for CHIP or the separate CHIP agency determines the person eligible for Medicaid and ineligible for CHIP.

A “combined eligibility notice” is defined at current SEC 435.4 as an eligibility notice that informs a person or multiple members of the family of a household of eligibility for every of the insurance affordability programs, for which a determination or denial of eligibility was made, in addition to any right to request a good hearing or appeal related to the determination made for every program. A combined notice must meet the final requirements described at SEC 435.917(a), together with the more specific requirements at [Sec.] SEC 435.917(b) (regarding required content) and 435.917(c) (regarding pursuing eligibility on a non-MAGI basis), except that information described in [Sec.] SEC 435.917(b)(1)(iii) (regarding medically needy coverage) and 435.917(b)(1)(iv) (regarding covered advantages and services) could also be included either in a combined notice issued by one other insurance affordability program or in a supplemental notice provided by the agency. A combined eligibility notice have to be issued in accordance with the agreement(s) between the agency and other insurance affordability program(s) per SEC 435.1200(b)(3).

Current SEC 435.1200(h)(1) requires that, to the utmost extent feasible, individuals and households receive a single notice quite than separate notices from each applicable insurance affordability program, communicating the determination of eligibility as required under [Sec.] SEC 435.917 and 457.340. Within the preamble to the 2016 final rule, we noted concerns from numerous commenters concerning the ability of State systems to issue a combined notice and described several considerations when taking a look at the feasibility of issuing combined notices. These considerations included whether the State uses a shared eligibility service, whether the State relies on a Federally-facilitated Exchange to make determinations of Medicaid eligibility, and the maturity of the State’s systems with greater use of combined eligibility notices expected as systems mature. Within the 2016 final rule, we explained that it needs to be feasible to issue a combined notice when a single eligibility system or shared eligibility service is making determinations for multiple programs. As such, we consider that when the agency is enrolling a person in Medicaid based on a determination of eligibility accomplished by one other program, or vice versa, issuance of a combined eligibility notice should at all times be feasible.

Subsequently, we propose to revise SEC 435.1200(h)(1) to require in all cases that individuals determined ineligible for Medicaid and eligible for CHIP in States with separate CHIP and Medicaid agencies in accordance with proposed SEC 435.1200(e)(1)(i) receive a combined eligibility notice informing them that: (1) they’ve been determined now not eligible for Medicaid; and (2) they’ve been determined eligible for CHIP. Similarly, we propose to require the Medicaid agency to make sure that a person determined eligible for Medicaid by a separate CHIP agency also receives a combined notice. We propose to effectuate this requirement through a latest paragraph (h)(1)(i) at SEC 435.1200, which might require that the Medicaid agency include in its agreement with a separate CHIP agency (as described in SEC 435.1200(b)(3) and revised on this rulemaking), that either the Medicaid agency or the CHIP agency will provide such combined eligibility notice explaining each the termination of eligibility for Medicaid and the determination of eligibility for CHIP or vice versa. States that operate its CHIP and Medicaid programs under the identical agency and eligibility system that already provide a seamless, combined Medicaid and CHIP notice, may not must make any changes. Note that no matter which entity sends the combined notice, per the definition of combined notice in SEC 435.4 of the present regulations, the Medicaid content of the notice must comply with the necessities set forth in SEC 435.917.

Proposed SEC 435.1200(h)(1)(ii) would maintain the requirement in current SEC 435.1200(h)(1) that, to the utmost extent feasible, a combined eligibility notice be issued in all other cases (that’s, situations not described at proposed SEC 435.1200(h)(1)(i)), consistent with current regulations. This provision would apply to situations through which the Medicaid agency has determined a person to be potentially eligible for a BHP or insurance affordability programs available through the Exchanges, and to situations through which an Exchange, CHIP or BHP has made an assessment of potential Medicaid eligibility, including on a non-MAGI basis, but not a final determination. As well as, as currently required, when a couple of individual is included on an application or renewal, Medicaid and the opposite insurance affordability programs could be expected to supply a single combined notice for all household members to the extent possible, even when members are eligible for various programs.

We recognize that State eligibility systems still proceed to mature and lots of States are still working through a backlog of system changes to correct issues arising from changes made in response to earlier rulemaking. We seek comment on the feasibility of implementing a combined notice for Medicaid and CHIP eligibility determinations, as well a combined notice with determinations of BHP and insurance affordability programs available through the Exchanges, each in States using a completely integrated eligibility system or shared system and in States utilizing separate systems. We also seek comment on the time that may be required for States to implement these changes in the event that they should not already issuing combined eligibility notices.

Finally, we propose one overarching policy change and a number of other technical amendments to SEC 435.1200. With respect to the policy change, we propose to make clear that the necessities at proposed SEC 435.1200(e)(1) (related to determining eligibility or potential eligibility for other insurance affordability programs) apply not only to individuals who’ve been determined ineligible for Medicaid on all bases, but in addition to individuals who’ve been determined ineligible for Medicaid coverage that is taken into account minimum essential coverage as defined at SEC 435.4. We might effectuate this requirement through a latest paragraph (e)(4) at SEC 435.1200. Consider for instance, a person covered under the eligibility group for kids under age 19 (described at SEC 435.118), which provides minimum essential coverage. If the agency determines that the person’s MAGI-based household income has increased such that it exceeds the income standard for that eligibility group and the one group for which that individual is eligible is the eligibility group through which coverage is proscribed to family planning and family planning-related services (described at SEC 435.214), which doesn’t provide minimum essential coverage, then in accordance with proposed SEC 435.1200(e)(1), the agency could be required to find out that individual’s eligibility for a separate CHIP. If the State either doesn’t offer a separate CHIP, or the person doesn’t meet the eligibility requirements for that program, then the agency would wish to find out that individual’s potential eligibility for BHP and for insurance affordability programs available through the Exchanges and transfer the person’s account in accordance with proposed SEC 435.1200(e)(1)(iii).

Regarding the technical amendments, first we propose to remove “and definitions” from the title of SEC 435.1200(b), as definitions are currently included in SEC 435.1200(a), and we propose to correct the spelling of “programs” in SEC 435.1200(b)(3)(i). Second, we propose a technical change to 435.1200(e)(1) to exchange the reference to SEC 435.916(d) with a reference to proposed SEC 435.919 to reflect the re-designation of current SEC 435.916(d) at SEC 435.919 on this proposed rule. And third, we propose to correct a numbering error in SEC 435.1200(h). The paragraph following SEC 435.1200(h)(3)(i)(B) was incorrectly numbered as (i), and we propose to renumber this paragraph as SEC 435.1200(h)(3)(ii).

In summary, the proposed changes to SEC 435.1200 would require the Medicaid agency to:

    * Be certain that the agreement between the agency and the separate CHIP agency includes procedures for the seamless transition of eligibility between programs;

    * Accept determinations of Medicaid eligibility made by a separate CHIP agency;

    * Make determinations of CHIP eligibility and transfer eligible individuals to the separate CHIP agency; and

    * Provide for the issuance of a combined notice to a person who is decided ineligible for Medicaid and eligible for CHIP or eligible for Medicaid and ineligible for CHIP.

We considered applying these same changes to BHP agencies. Currently, the BHP regulation at SEC 600.330(a) requires the BHP agency to ascertain eligibility and enrollment mechanisms and procedures to maximise coordination with the Exchange, Medicaid, and CHIP. Moreover, it requires a State BHP agency to meet the necessities of SEC 435.1200(d) and (e), and if applicable, paragraph (c) for BHP eligible individuals. On this proposed rule, we propose to revise SEC 600.330(a) to limit the Medicaid requirements that a BHP agency must fulfill to those in SEC 435.1200(d), (e)(1)(ii) and (e)(3). Paragraph (c) of SEC 435.1200 would still be required when applicable (that’s, when the BHP agency has entered into an agreement with one other insurance affordability program to make final determinations of BHP eligibility).

We seek comment on whether it is acceptable to use the changes designed to create seamless transitions between Medicaid and a separate CHIP to BHP as well. This is able to include maintaining the present language in SEC 600.330(a) and revising paragraphs (b), (c), (e), and (h) of SEC 435.1200 to require the Medicaid agency to amend its agreement with the BHP agency to seamlessly transition eligibility between programs, to just accept determinations of Medicaid eligibility made by the BHP agency, to make determinations of BHP eligibility, and to supply for the issuance of a combined Medicaid and BHP eligibility notice. or to take care of current coordination requirements, such that BHPs are required only to judge potential eligibility for Medicaid and CHIP and to just accept determinations of potential BHP eligibility made by a Medicaid or separate CHIP agency. This is able to not prohibit a BHP from moving into an agreement with Medicaid and/or CHIP through which each agency completes determinations of eligibility for the opposite. These changes would require the State Medicaid agency to make a determination of eligibility for BHP based on information available through electronic or other data sources. We seek comment on whether it is feasible for the Medicaid agency to collect the knowledge mandatory to finish such a determination, specifically, information on other reasonably priced insurance coverage available to a person.

6. Optional Group for Reasonable Classification of Individuals Under 21 Who Meet Criteria for One other Optional Group (SEC 435.223)

Section 1902(a)(10)(A)(ii) of the Act authorizes States to supply Medicaid to 1 or more of the specific populations described in section 1905(a) of the Act who also meet the necessities described in section 1902(a)(10)(A)(ii) of the Act (which lists the optional categorically needy eligibility groups). With specific regard to the specific population described in section 1905(a)(i) of the Act–individuals under age 21 or, at State option, under age 20, 19 or 18–the introductory language in section 1902(a)(10)(A)(ii) of the Act permits States to increase medical assistance to “reasonable categories” of such individuals. Section 435.222 implemented optional coverage of people under the age of 21, 20, 19, or 18, or an inexpensive category of such individuals (known as “reasonable classifications” within the regulations) who meet the AFDC income and resource requirements, as described in section 1902(a)(10)(A)(ii)(I) of the Act. Prior to January 1, 2014, and the implementation of MAGI-based methodologies under the ACA, States also were permitted to boost the effective income standard for eligibility for coverage under this group through adoption of income disregards under section 1902(r)(2) of the Act and SEC 435.601(d) of the regulations. Many States used a mix of those authorities to supply Medicaid to all individuals under age 21, in addition to to varied State-defined reasonable classifications of such individuals as much as various income standards under their State plan.

Revisions finalized within the 2016 eligibility and enrollment final rule reflect the adoption of MAGI-based methodologies in determining financial eligibility for most people under Medicaid, including individuals under age 21 eligible under SEC 435.222. The elimination of income disregards under MAGI-based methodologies (see SEC 435.603(g)) also effectively limits the pliability States previously had to boost the effective income standard for coverage under SEC 435.222 to satisfy the needs of recent reasonable classifications of people under age 21 who should not eligible under the mandatory group for kids at SEC 435.118 or, within the case of 19 and 20-year-olds, under the adult group at SEC 435.119. Other flexibilities, nonetheless, are provided within the statute which States may need to employ to satisfy the coverage needs of reasonable classifications of kids who’re excepted from mandatory application of MAGI-based methods under the statute and regulations or otherwise fall outside the scope of SEC 435.222 (for instance, individuals under age 21 in search of coverage on the idea of a disability or blindness or who meet a specified level-of-care need).

As noted above, States have the pliability to supply coverage to individuals under age 21 (or, at State option, under age 20, 19 or 18) or to reasonable classifications of such individuals who meet the necessities of any subparagraph of section 1902(a)(10)(A)(ii) of the Act, which incorporates, but just isn’t limited to, clause (I) of such section. For instance, a State that has chosen the eligibility category described in section 1902(a)(10)(A)(ii)(I) of the Act for people who meet AFDC requirements could define an inexpensive classification of people under age 21 to incorporate individuals who meet a level-of-care need for HCBS. A State that has not chosen the eligibility category described in section 1902(a)(10)(A)(ii)(I) of the Act but has as an alternative chosen the eligibility category described in section 1902(a)(10)(A)(ii)(X) of the Act, regarding individuals who’ve disabilities or are 65 years old or older, could similarly define an inexpensive classification of people who’re under 21 and meet an HCBS-related level of care.

The terms of the present SEC 435.222, nonetheless, don’t accommodate the adoption of such reasonable classifications, either since the regulation requires application of an income test that relies on “household income,” which generally is defined in SEC 435.4 to mean MAGI-based income, or limits inclusion of “reasonable classifications” to the eligibility categories described in section 1902(a)(10)(A)(ii)(I) and (IV) of the Act (or each).

To reflect the pliability that we consider States are afforded under the statute, we’re proposing so as to add a latest SEC 435.223 under which States may provide coverage to all individuals under age 21, 20, 19, or 18, or to an inexpensive classification of such individuals, who meet the necessities of any clause of section 1902(a)(10)(A)(ii) of the Act (as implemented in subpart C of part 435 of the regulations to the extent to which a given clause is so implemented).

While coverage under proposed SEC 435.223 just isn’t expressly limited to individuals excepted from MAGI under SEC 435.603(j), we consider that, as a practical matter, this can most typically be the case, as coverage for an inexpensive classification of people under age 21 who should not excepted from the mandatory use of MAGI-based methodologies is already permitted by SEC 435.222. Considering this and the necessity to tell apart SEC 435.222 and the proposed SEC 435.223, we propose to vary the heading for SEC 435.222 to read, “Optional eligibility for reasonable classifications of people under 21 with income below a MAGI-equivalent standard.”

For people excepted from the mandatory use of MAGI-based methodologies, SEC 435.601 generally requires that States apply the financial methodologies and requirements of the money assistance program that’s most closely categorically related to the person’s status. Within the case of people who’re under age 21 and who’ve blindness or disabilities, this generally means application of SSI-related financial methodologies. Within the case individuals under age 21 who do not need blindness or disabilities, this implies application of the financial methodologies within the State’s former AFDC program.

Due to elimination of the AFDC program in 1996 and the alternative of AFDC-based methodologies with MAGI-based methodologies for determining financial eligibility for people not excepted from MAGI-based methods under the ACA, within the 2012 eligibility final rule, we provided States with flexibility under SEC 435.831(b)(1)(ii) to use either AFDC-based methodologies or MAGI-like methodologies, with limited exception, in determining eligibility for medically needy individuals under age 21, pregnant individuals, and fogeys and other caretaker relatives. Without this flexibility, States could be required to use AFDC-based methodologies to those medically needy populations, despite the fact that the AFDC program ceased to exist over 25 years ago and people methodologies don’t have any other applicability. Proposed SEC 435.601(f)(1)(i) and (ii) similarly provides States with flexibility to use, at State option, either AFDC-based methods or MAGI-like methods in determining income eligibility for people under age 21, for whom probably the most closely categorically related money assistance program is AFDC.

The limited exception to application of “true” MAGI-based methodologies described in SEC 435.603 of the regulations to medically needy individuals under SEC 435.831(b)(1)(ii) stems from section 1902(a)(17)(D) of the Act. This statutory provision, implemented at SEC 435.602 of the regulations, prohibits States from bearing in mind the financial responsibility of any individual in determining eligibility for any applicant or beneficiary under the State plan unless such applicant or recipient is the person’s spouse or the person’s child who’s under age 21, or with blindness or disability. This limitation continues to use to all individuals excepted from mandatory application of MAGI-based methods under section 1902(e)(14)(D) of the Act, implemented at SEC 435.603(j). Subsequently, just like the limitation on the pliability afforded States under SEC 435.831(b)(1)(ii) to use MAGI-based methodologies for otherwise AFDC-related medically needy individuals, proposed SEC 435.601(f)(1)(ii)(B) requires that, in applying MAGI-based methodologies, States must make sure that there is no such thing as a deeming of income or attribution of economic responsibility that may conflict with the necessities of section 1902(a)(17)(D) of the Act; that’s, in determining eligibility under proposed SEC 435.223 for a person under age 21 who’s described in SEC 435.603(j) as exempt from the MAGI methodologies set forth in SEC 435.603, no income apart from the income of the person or his or her parent(s) and/or spouse, could be counted, even when the income of another person could be counted under the MAGI-based methods defined in SEC 435.603.

We also propose two technical changes related to the amendment of SEC 435.601(f). In paragraphs (b)(2) and (d)(1) of SEC 435.601, we replace the cross reference to SEC 435.831(b)(1) (which provides an exception to the final rule to make use of the methods of probably the most closely categorically related money assistance program) with a reference to the brand new subparagraph (f)(1)(ii)(B), which provides for a similar exception. Note that, under section 1902(r)(2) of the Act and SEC 435.601(d), a State also could apply less restrictive methodologies than either AFDC or the MAGI-like methodologies adopted in accordance with the choice at proposed SEC 435.601(e), including application of income disregards. By disregarding all resources, States, at their option, also could effectively eliminate application of an asset test for people excepted from MAGI-based methods in accordance with SEC 435.603(j) who’re in search of coverage under an optional coverage group adopted in accordance with proposed SEC 435.223.

C. Eliminating Barriers to Access in Medicaid

1. Remove Optional Limitation on the Variety of Reasonable Opportunity Periods ([Sec.] SEC 435.956 and 457.380)

Sections 1902(a)(46)(B), 1902(ee)(1)(B)(ii), 1903(x)(4), and 1137(d)(4)(A) of the Act, implemented at SEC 435.956(b) for Medicaid and thru a cross-reference at SEC 457.380(b)(1)(ii) for CHIP, set forth the requirement for States to supply an inexpensive opportunity period (ROP) for people who’ve attested to citizenship or satisfactory immigration status, and for whom the State is unable to confirm citizenship or satisfactory immigration status when the person meets all other eligibility requirements, in accordance with SEC 435.956(a).

In the course of the ROP, the State agency must proceed efforts to finish verification of the person’s citizenship or satisfactory immigration status, or request documentation, if mandatory. In accordance with SEC 435.956(b)(2), through the ROP, the State agency must furnish Medicaid advantages to individuals who meet all other eligibility requirements, and will elect to achieve this effective as of the date of application or the primary day of the month of application, consistent with SEC 435.915(b).

Within the November 30, 2016 Federal Register, we issued the “Medicaid and Kid’s Health Insurance Programs: Eligibility Notices, Fair Hearing and Appeal Processes for Medicaid and Other Provisions Related to Eligibility and Enrollment for Medicaid and CHIP” Final Rule /61/ (81 FR 86382) (referred to hereafter because the “2016 eligibility and enrollment final rule”), which set forth regulations governing the ROP at SEC 435.956. At SEC 435.956(b)(4), we provided an option for States to limit the variety of ROPs that a given individual may receive, if the State demonstrates that the dearth of limits jeopardizes program integrity and receives approval of a State plan amendment (SPA) prior to implementing such limits. This selection to limit a person’s variety of ROPs applies to individuals who re-apply for coverage after they’ve been determined to be ineligible for Medicaid resulting from failure to confirm citizenship, U.S. national status, or satisfactory immigration status through the ROP provided in reference to a previous application.

   FOOTNOTE 61 Accessed from: https://www.federalregister.gov/documents/2016/11/30/2016-27848/medicaid-and-childrens-health-insurance-programs-eligibility-notices-fair-hearing-and-appeal. END FOOTNOTE

We finalized this State option within the 2016 eligibility and enrollment final rule in response to public comments that we received on the “Medicaid, Kid’s Health Insurance Programs, and Exchanges: Essential Health Advantages in Alternative Profit Plans, Eligibility Notices, Fair Hearing and Appeal Processes for Medicaid and Exchange Eligibility Appeals and Other Provisions Related to Eligibility and Enrollment for Exchanges, Medicaid and CHIP, and Medicaid Premiums and Cost Sharing” proposed rule that published within the January 22, 2013, Federal Register (78 FR 4593). /62/ Particularly, one commenter stated that the proposed rule might be interpreted to permit multiple (and unlimited) ROPs through the submission of subsequent applications despite the failure of verification of the person’s citizenship or immigration status. One other commenter questioned whether CMS considered limiting the variety of ROPs that could be provided. In response to those comments, SEC 435.956(b)(4) of the ultimate rule established the State choice to limit the variety of ROPs, provided that before the State implements such a limitation, the State: (1) demonstrates that the dearth of limits jeopardizes program integrity; and (2) receives approval of a SPA electing the choice.

   FOOTNOTE 62 https://www.federalregister.gov/documents/2013/01/22/2013-00659/medicaid-childrens-health-insurance-programs-and-exchanges-essential-health-benefits-in-alternative. END FOOTNOTE

Because the option was finalized, just one State has submitted a SPA requesting to implement this feature, which we approved as a one-year pilot program to supply the State with a possibility to display that not limiting the variety of ROPs jeopardized program integrity within the State. The State’s pilot program limited individuals to 2 ROPs through the 12-month pilot period. In the course of the pilot, the State monitored requests for multiple ROPs, and picked up data on the frequency and characteristics of people who re-applied after failing to finish verification of their status during their first ROP. From its data evaluation of the pilot period, the State observed that the variety of repeat ROPs provided by the State was minimal and concluded that the provision of multiple ROPs posed negligible risk to program integrity. Following the pilot, the State suspended the policy of limiting the ROP period and removed the policy from its State Plan. Apart from the one State, CMS has not received any inquiries about establishing such a limitation or raising program integrity concerns related to ROPs.

Sections 1902(a)(46)(B), 1902(ee)(1)(B)(ii), 1903(x)(4), and 1137(d)(4)(A) of the Act don’t expressly limit the variety of ROPs a person may receive, nor do these provisions expressly provide discretion for States to ascertain such a limit. In light of the absence of any indication that the provision of multiple ROPs poses significant risks to program integrity, we consider that removing the choice for States to impose limits on the variety of ROPs that a person may receive is warranted. Subsequently, we’re interpreting the paradox in 1902(a)(46)(B), 1902(ee)(1)(B)(ii), 1903(x)(4), and 1137(d)(4)(A) of the Act with respect to this query of limiting the variety of ROPs to remove the State choice to limit the variety of ROPs an applicant may receive after re-applying for advantages. We also find this proposal to be consistent with each section 1902(a)(19) of the Act, which requires that States provide safeguards as mandatory to make sure that eligibility for care and services under the State plan are provided in a way consistent with simplicity of administration and the most effective interests of the recipients, and section 1902(a)(8) of the Act, which requires that every one individuals who wish to use for Medicaid have the chance to achieve this. The ROP is integral to the Medicaid application process and ensuring prompt access to services for eligible individuals who’ve attested to U.S. citizenship, national, or satisfactory immigration status, but whose status can’t be promptly verified electronically. We note that a person’s status may change between the filing of applications or latest information or evidence regarding U.S. citizenship/national status or satisfactory immigration status may change into available. This policy revision supports the health and well-being of immigrants and their families in accordance with Executive Order 13993 “Revision of Civil Immigration Enforcement Policies and Priorities” and provides access to health coverage in Medicaid and CHIP for U.S. residents and immigrants who’re eligible to receive such coverage during a Reasonable Opportunity Period in accordance with Executive Order 14070 “Continuing To Strengthen Americans’ Access to Reasonably priced, Quality Health Coverage.”

Subsequently, we propose to revise SEC 435.956(b)(4) to remove the choice for States to ascertain limits on the variety of ROPs. Under proposed SEC 435.956(b)(4) for Medicaid and the prevailing cross-reference at SEC 457.380(b)(1)(ii) for CHIP, States could be prohibited from imposing limitations on the variety of ROPs that a person may receive.

2. Remove or Limit Requirement To Apply for Other Advantages (SEC 435.608)

Under SEC 435.608(a) (regarding “Applications for other advantages”), State Medicaid agencies must require that every one Medicaid applicants and beneficiaries, as a condition of their eligibility, take all mandatory steps to acquire other advantages to which they’re entitled, unless they will show good cause for not doing so. Paragraph (b) of SEC 435.608 describes such advantages to incorporate, but not be limited to, annuities, pensions, retirement, and disability advantages. (Veterans’ compensation and pensions, Social Security disability insurance and retirement advantages, and unemployment compensation are specifically identified as examples). This requirement applies to all Medicaid applicants and beneficiaries, without regard to the idea of their eligibility or the financial eligibility methodology used to find out their eligibility.

This provision was originally promulgated in 1978 (see 43 FR 9810) and codified on the time at 42 CFR 448.3(b)(1)(ii) and 448.21(a)(2)(i)(C). It was redesignated later in 1978 at SEC 435.603 (see 43 FR 45204), and redesignated again in 1993 at SEC 435.608 (see 58 FR 4931). When the rule was established in 1978, we noted that: “Section 1902(a)(17) of the Act requires that available income and resources have to be considered in determining eligibility, apart from amounts that may be disregarded (or put aside for future needs) by the AFDC [Aid to Families with Dependent Children] or SSI programs. Those programs require applicants and recipients to just accept other money advantages which can be found to them; see: section 407(b)(2) of the Act and 45 CFR 233.20(a)(3)(ix) regarding AFDC; and section 1611(e)(2) of the Act and 20 CFR 416.230 and 416.1330 regarding SSI. Thus, this amendment conforms Medicaid requirements to those of the AFDC and SSI programs.” (43 FR 9812).

Section 1902(a)(17)(B) of the Act directs that a State plan “must provide for bearing in mind only such income and resources as are, as determined in accordance with standards prescribed by the Secretary, available to the applicant or recipient and . . . as wouldn’t be disregarded (or put aside for future needs) in determining his eligibility for such aid, assistance or advantages” under various Federal money assistance programs, including the SSI program and the previous AFDC program (emphasis added). This statutory language prohibits State Medicaid agencies from bearing in mind income and resources not counted in determining eligibility for various Federal money assistance programs described in section 1902(a)(17)(B) of the Act. Nevertheless, section 1902(a)(17)(B) of the Act doesn’t mandate that States must have in mind every type or sources of income and resources which are counted within the eligibility determinations for those programs. As a substitute, the language specifically provides discretion to the Secretary to ascertain the standards under which income and resources not disregarded by the varied Federal money assistance programs needs to be considered “available,” that’s, taken into consideration, in determining a person’s Medicaid eligibility.

Thus, while section 1902(a)(17)(B) of the Act authorizes the Secretary to think about as “available” income or resources Medicaid applicants and beneficiaries might receive in the event that they applied for certain advantages, section 1902(a)(17)(B) of the Act doesn’t require the Secretary to achieve this. Nor does section 1902(a)(17)(B) of the Act compel the Secretary to use either the requirement in section 1611(e)(2) of the Act (that individuals in search of SSI apply for other advantages) or the requirement in former section 407(b)(2) of the Act (that individuals in search of AFDC advantages apply for AFDC) to individuals in search of Medicaid.

Adoption of the rule imposed within the SSI and AFDC programs to Medicaid was reasonable in 1978, provided that the first path to Medicaid eligibility on the time was receipt of SSI or AFDC advantages; the Medicaid eligibility pathways available for people not receiving assistance from a Federal money assistance program, or deemed to be receiving assistance from such programs, were very limited.

Nevertheless, Medicaid has significantly modified within the intervening years. For instance, Medicaid eligibility was “de-linked” from money assistance for a good portion of the Medicaid population when the AFDC program was repealed and replaced with the Temporary Assistance for Needy Families (TANF) program in section 103 of the Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA) of 1996 (Pub. L. 104-193). Unlike AFDC, eligibility for TANF doesn’t confer automatic eligibility for Medicaid. Moreover, quite a few eligibility groups have since been authorized under the statute, including groups for kids, pregnant individuals, parents and caretaker relatives, and other adults with income higher than the income standard for money assistance programs and eligibility groups that don’t have any income test, resembling the mandatory eligibility group for former foster care children described in section 1902(a)(10)(A)(i)(IX) of the Act (implemented within the regulations at SEC 435.150), and the optional group serving individuals in need of breast or cervical cancer treatment described in section 1902(a)(10)(A)(ii)(XVIII) of the Act (implemented within the regulations at SEC 435.213).

Further, whereas financial eligibility for all eligibility groups previously had been based on the financial methodologies applied by a money assistance program (primarily AFDC or SSI), effective January 1, 2014, the ACA directed States to use a completely different financial methodology in determining eligibility for most people in search of Medicaid coverage, based on Federal income tax rules within the Internal Revenue Code. This technique, based on MAGI as defined under section 36B(d)(2) of the Internal Revenue Code, generally considers only amounts actually received by a person and the person’s household members, and doesn’t consider other amounts or advantages that the person or other household members could receive if proactive steps were taken. Thus, there is no such thing as a statutory mandate for the rule in SEC 435.608(a) that currently requires application for other advantages by Medicaid applicants and beneficiaries.

Now we have received numerous inquiries from States concerning the requirement to use for other advantages. Some States specifically have requested flexibility to avoid applying this requirement to individuals otherwise eligible for the eligibility group for former foster care children which, as noted above, doesn’t have an income test. These States noted that individuals who otherwise meet all requirements to be enrolled or remain enrolled on this group were losing Medicaid coverage resulting from failure to supply information on application for other advantages, resembling unemployment compensation. Some States received beneficiary complaints related to the burden of this requirement and the impact on individuals who’re required to use for Social Security advantages before reaching their full retirement age. These States, in turn, reached out to CMS for guidance.

Provided that the Medicaid program has largely outgrown the muse upon which SEC 435.608 was based–that is, an in depth connection between Medicaid and money assistance programs–and the barrier to coverage the requirement poses for some individuals, we consider it is acceptable to revisit this regulation. Specifically, we propose to reinterpret the meaning of “such income and resources as are, as determined in accordance with standards prescribed by the Secretary, available to the applicant or recipient” in section 1902(a)(17)(B) of the Act to encompass only the actual income and resources throughout the applicant’s or beneficiary’s immediate control, but to not encompass such income and resources that may be available if such individuals applied for, and were found eligible for, other advantages. Which means eligibility for Medicaid would now not require that applicants and beneficiaries apply for advantages for which they might be entitled. We consider this interpretation is consistent with section 1902(a)(19) of the Act, which provides that eligibility be determined in a way consistent with simplicity of administration and the most effective interests of recipients.

In developing our proposal, we’re considering several alternative options to deal with the requirement to use for other advantages. These alternatives should not mutually exclusive and might be used together with each other.

    * We’re considering revising the requirement in SEC 435.608 to incorporate advantages that may count as income under the financial methodology used to find out the applicant or beneficiary’s income. Individuals whose financial eligibility is decided using MAGI-based methodologies wouldn’t be required to use for other advantages that may not count as income. For instance, such an individual wouldn’t be required to use for advantages resembling TANF or veterans’ advantages as a condition of Medicaid eligibility because those advantages should not counted as income under MAGI-based methodologies. Moreover, individuals who’re eligible for, or applying for coverage under, a Medicaid eligibility group that doesn’t include an income test, wouldn’t be required to use for other advantages, as receipt of other advantages wouldn’t impact a person’s income for purposes of Medicaid eligibility because it might not impact their eligibility. This is able to be true of, for instance, individuals who’re eligible for the previous foster care children eligibility group and the eligibility group serving individuals in need of breast or cervical cancer treatment. This is able to even be true of people who’re eligible for Medicaid on the idea of their receipt of assistance under title IV-E of the Act (see SEC 435.145). Under this feature, nonetheless, individuals in search of coverage under an eligibility group applying the financial methodologies of the SSI program could be required, as a condition of eligibility, to use for advantages that count as income in determining eligibility for SSI. For some individuals, in the middle of processing an application, States must apply each the MAGI and non-MAGI methodologies before probably the most appropriate final result is decided (see SEC 435.911(c)); eliminating the requirement to use for other advantages for MAGI-based individuals but maintaining the requirement for non-MAGI individuals might be administratively burdensome for States. Subsequently, we consider a proposal to eliminate the requirement for all Medicaid applicants and beneficiaries to be the higher approach.

* We are also considering exempting SSI beneficiaries from the requirement to use for other advantages, including SSI beneficiaries in States which have elected their option under section 1902(f) of the Act to use eligibility criteria more restrictive than the SSI program for people who seek eligibility on the idea of being 65 years old or older or who’ve blindness or disabilities (that’s, 209(b) States), but not other applicants and beneficiaries whose financial eligibility relies on SSI financial methodologies. As mentioned above, Federal law requires SSI applicants and beneficiaries to use for other advantages for which they might be eligible. Which means an SSI beneficiary who applies for Medicaid could have already applied for other advantages for which the person could also be eligible, except where the SSA itself has determined: (a) that it doesn’t consider that there are other advantages for which the person could also be eligible; or (b) that, even when there are potentially other such advantages, receipt of such advantages wouldn’t affect the person’s underlying SSI eligibility or payment amount (see 20 CFR 416.210 and SI 00510.001 (“Overview of the Filing for Other Program Advantages Requirement”) within the SSA POMS). With this in mind, we consider that imposing the requirement in SEC 435.608(a) on SSI recipients could be duplicative. We acknowledge that it might be theoretically possible that, in non-1634 States (that’s, criteria States and 209(b) States, as described above), there might be an SSI beneficiary who could also be eligible for a profit for which the SSA ultimately didn’t require the person to use but which could potentially affect the person’s Medicaid eligibility. Nevertheless, we consider that such circumstances could be rare and don’t outweigh the interests of the overwhelming majority of people in 209(b) and criteria States, or simplicity of administration, consistent with section 1902(a)(19) of the Act, or efficiency of administration, consistent with section 1902(a)(19) of the Act. Even so, if the requirement were eliminated for all SSI beneficiaries, along with MAGI-based individuals, but preserved for non-SSI beneficiaries whose eligibility relies on either SSI methodologies or a 209(b) State’s more restrictive methodologies, this approach could similarly create administrative burden for States. Subsequently, we consider that a proposal to eliminate the requirement for all Medicaid populations is superior to this feature as well.

We invite comment on these possible alternatives. If CMS were to adopt a substitute for the proposal to eliminate the requirement to use for other advantages in its entirety, we might consider making several modifications to such requirement, as follows:

For those for whom we might maintain the requirement to use for other advantages as a condition of eligibility, we’re considering making the operation of the requirement a post-enrollment activity. Such a policy could be just like, for instance, the requirement that applicants attest that they’ll cooperate, while beneficiaries must cooperate, with identifying liable third parties under section 1902(a)(25) of the Act, as implemented at SEC 435.610(a)(2). Thus, applicants would wish to attest to their agreement to use for other advantages for which they might be eligible at application unless, consistent with the present regulation at SEC 435.608(a), they will show good cause for not doing so. States would follow up with the person on compliance with the requirement post-enrollment, and non-cooperation by a beneficiary without good cause could be grounds for termination (subject to requirements for advance notice and fair hearing rights in 42 CFR part 431, subpart E).

We’re considering revising the “good cause” exception at SEC 435.608(a) to include language included within the “good reason” exception within the SSI regulations at 20 CFR 416.210(e)(2). Specifically, we’re considering including two examples of situations satisfying the nice cause exemption which are within the SSI provision: (a) where a person is incapacitated; or (b) where it “could be useless” for a person to use for other advantages because the person has previously applied for the opposite advantages and been denied and has not experienced a relevant change in circumstances since that point. Moreover, the SSI policy also excuses compliance with the requirement to use for other advantages where a person won’t receive a profit that can affect eligibility. Subsequently, we’re considering adding these specific examples within the reference within the “good cause” exception in SEC 435.608.

We’re considering requiring States to supply written notice to every individual who’s subject to the requirement in SEC 435.608 of the advantages for which the State believes the person could also be eligible and that the person’s Medicaid eligibility could also be affected by the person’s failure to use for such advantages. That is the SSA’s approach in requiring that SSI applicants and beneficiaries file for other advantages, as described in 20 CFR 416.210(c), and we’d consider this to be an inexpensive condition precedent to imposing the requirement.

We seek comment on this proposal related to SEC 435.608 and the way CMS can update the regulation to cut back unnecessary barriers to enrollment and to cut back burden on individuals and States. We have an interest, for instance, in whether or not it’s the experience of State agencies that imposition of the prevailing rule commonly leads to applicants or beneficiaries receiving additional eligibility-altering income. We’re also curious about the experiences of applicants and beneficiaries of their compliance with this rule, resembling whether it commonly delays favorable eligibility determinations, and, by extension access to care. We’re mindful that the requirement imposed by SEC 435.608(a) just isn’t similarly imposed in eligibility determinations for CHIP, the BHP, or insurance affordability programs available through the Exchanges, and we’re curious about comments on the whether the approach of the latter programs is more practical. We also welcome comments on each of the alternatives we’re considering that may be adopted in a final rule based on comments received.

In consideration of the foregoing evaluation, we propose on this rulemaking to remove the requirement at SEC 435.608 entirely for all Medicaid applicants and beneficiaries to use for other advantages to which they’re entitled.

D. Recordkeeping ([Sec.] SEC 431.17, 435.914, and 457.965)

Comprehensive recordkeeping is crucial to the right and efficient administration of any State Medicaid program, consistent with section 1902(a)(4) of the Act. State Medicaid agencies must maintain records needed to justify and support the selections made regarding all applicants and beneficiaries, defend decisions challenged by an applicant or beneficiary who requests a good hearing, enable State and Federal auditors and reviewers to conduct appropriate oversight, and support the State’s own quality control processes. Applicants and beneficiaries (or their authorized representative) must also give you the chance to review the content of their case record prior to a good hearing difficult an agency’s decision.

Regulations at [Sec.] SEC 431.17 and 435.914 currently require that State Medicaid agencies’ records for applicants and beneficiaries include sufficient content to substantiate the eligibility determination made by the State. Nevertheless, these regulations are largely outdated and unclear. In lots of instances, the necessities lack the specificity reflective of the range of records and knowledge utilized by today’s Medicaid programs. The necessities don’t reflect modern technology, specifically using electronic data, and don’t specify how long applicant and beneficiary case records have to be retained, leading to a spread of retention periods across States. Over time, we’ve received questions from Medicaid agencies requesting clarification on record retention policy, storage modalities, and retention periods.

HHS OIG reports also raise concerns concerning the adequacy of the case records maintained across State Medicaid agencies. /63/ The HHS OIG reports identified case records that lack documentation of income, citizenship, or immigration status verification and located case records through which auditors couldn’t access documents needed to judge the accuracy of a State’s determination of eligibility. Moreover, PERM eligibility reviews within the FYs 2019, 2020, and 2021 cycles found that insufficient documentation was a number one reason for eligibility errors. /64/

   FOOTNOTE 63 California Made Medicaid Payments on Behalf of Non-Newly Eligible Beneficiaries Who Did Not Meet Federal and State Requirements, Office of Inspector General, 2018. Available at https://oig.hhs.gov/oas/reports/region9/91702002.pdf; Recent York Did Not Appropriately Determine Medicaid Eligibility for Some newly Enrolled Beneficiaries, Office of Inspector General, 2018. Available at https://oig.hhs.gov/oas/reports/region2/21501015.pdf; Kentucky Did Not All the time Perform Medicaid Eligibility Determinations for Non-Newly Eligible Beneficiaries in Accordance with Federal and State Requirements, Office of Inspector General, 2017. Available at https://oig.hhs.gov/oas/reports/region4/41608047.pdf; Colorado Did Not Appropriately Determine Medicaid Eligibility for Some Newly Enrolled Beneficiaries, Office of Inspector General, 2019. Available at https://oig.hhs.gov/oas/reports/region7/71604228.pdf. END FOOTNOTE

   FOOTNOTE 64 Fiscal Yr 2019 Agency Financial Report, US Department of Health and Human Services, 2019. Available at https://www.hhs.gov/sites/default/files/fy2019-hhs-agency-financial-report.pdf. END FOOTNOTE

To assist States meet the requirement to take care of appropriate, comprehensive, and accessible records, consistent with section 1902(a)(4) of the Act, we propose to revise SEC 431.17 to more clearly delineate the varieties of information State Medicaid agencies must maintain in case records and to prescribe a minimum retention period. Reflecting modern types of technology, we also propose to revise the regulations to require that States store their case records in an electronic format.

We propose revisions to SEC 431.17(b)(1) to detail the particular records and documentary evidence that have to be retained as a part of each applicant’s and beneficiary’s case record to support the determinations made by State Medicaid agencies. These records, that are critical to demonstrating that States are providing the right amount of medical assistance to eligible individuals, include:

    * All information provided on the initial application submitted by, or on behalf of, an applicant whatever the modality through which an individual applies for Medicaid (for instance, online, by phone, in person or through the Exchange), including the signature and date of application;

    * The electronic account and any information or documentation received from one other insurance affordability program in accordance with SEC 435.1200(c) and (d);

    * Any changes in circumstances reported by the person and any actions taken by the agency in response to such reports;

    * All renewal forms and knowledge returned by or on behalf of the beneficiary to the agency in accordance with SEC 435.916, including the signature on any returned renewal form and the date the shape was received;

    * The date of and basis for any determination, denial, or other antagonistic motion, including decisions made at application, at renewal, and because of this of a change in circumstance, affecting an applicant or beneficiary, in addition to all documents or other evidence to support such motion, including all information provided by, or on behalf of, the applicant or beneficiary and all information obtained electronically or otherwise by the agency or third-party sources. This includes information received from data sources as described within the regulations at [Sec.] SEC 435.940 through 435.960.

    * The supply of, and payment for, services, items and other medical assistance. This includes services or items provided and dates that the services or items were provided; diagnoses related to services or items provided; names of the providers rendering or referring/prescribing the services or items (as applicable), including their National Provider Identifier; the complete amounts billed and paid or reimbursed for the services or items; and any liable third party and the quantity of such liabilities;

    * All notices provided to the applicant or beneficiary under [Sec.] SEC 431.206, 435.917 or 435.918;

    * All records pertaining to any fair hearings requested by, or on behalf of, the applicant or beneficiary, including each request submitted and the date of such request, the whole record of the hearing decision, as described in SEC 431.244(b), and the ultimate administrative motion taken by the agency following the hearing decision and date of such motion; and

    * The disposition of data received by the agency when conducting verifications per regulations at [Sec.] SEC 435.940 through 435.960, including evidence that no information was returned from a given data source. In documenting the disposition of data received through this process, the disposition of data received by the agency includes documentation that the agency determined that information received was not useful to verifying eligibility.

Neither the statute nor current regulations specify how long Medicaid records have to be maintained. We consider that the length of record retention is also a critical factor to effective administration of the State plan and propose to revise SEC 431.17(c) to require that States maintain all records described on this regulation for the period that the applicant or beneficiary’s case is energetic, plus a minimum of three years thereafter. In establishing this minimum time period, we assessed the areas of the Medicaid program for which there are closing dates that may impact record retention, resembling the PERM program, which operates on a 3-year cycle, and Medicaid timely filing, described at section 1132(a)(2) of the Act, which requires that States file any claim for payment no later than 2 years from the calendar quarter of the expenditure. We consider 3 years to be an inexpensive minimum based on these aspects. We consider a case to be energetic starting on the date of application. For applicants determined ineligible (that’s, the applying is denied), the case could be energetic through the date that a determination of ineligibility is made. For applicants determined eligible (that’s, the applying is approved), the case could be energetic until their eligibility is terminated or coverage otherwise ends. A case would also remain energetic for any applicant or beneficiary who has a pending fair hearing or appeal. Within the event that a case becomes energetic again prior to the expiration of the 3-year period, the records retention clock would restart. On this case, under the proposed rule, the State would wish to retain all prior records until 3 years after the person’s eligibility is again terminated or their coverage otherwise ends. For instance, if a beneficiary, who initially applied for coverage in 2020, is terminated in 2022 resulting from a rise in income and in 2024 (2 years later) reapplies and is decided eligible, the case would change into energetic again. The records retention clock would restart, and the entire individual’s records from his or her initial application and enrollment from 2020 to 2022 have to be retained through the latest retention period.

We consider that tying the retention period to the time frame that the case is energetic plus an extra 3 years will make sure that applicant and beneficiary records shall be available for all circumstances through which such records could also be needed, including after a person is not any longer enrolled within the Medicaid program. For instance, if a formerly enrolled applicant reapplies to Medicaid 2 years after they lost coverage, States should depend on previously verified citizenship and immigration status unless the State has reason to consider something has modified. With a view to depend on information previously verified, that information have to be retained within the case record. Moreover, under the estate recovery program authorized by section 1917(b)(1) of the Act, States may get well payments for all Medicaid covered services. Subsequently, States might have to access claims data to be able to tally the fee of covered services for prolonged periods, depending on the length of the applicant’s enrollment. We seek comment on the proposed retention period, in addition to on whether a shorter or longer retention period needs to be required for certain varieties of records, including those pertaining to the supply of, and payment for, services, items and other medical assistance, or whether a shorter or longer period needs to be required for all records–for example, a period of 10 years for all records, just like our policy regarding enrollee records for Medicare, /65/ in addition to the record retention policy applied to managed care organizations under SEC 438.3(u). We also seek comment on whether the retention period needs to be tied to the person or the energetic case.

   FOOTNOTE 65 CMS Records Schedule. Available at https://www.cms.gov/Regulations-and-Guidance/Guidance/CMSRecordsSchedule/index.html. END FOOTNOTE

Current SEC 431.17(d) comprises outdated regulation text that references obsolete or rarely used technology, including microfilm systems. We propose to update this paragraph to require that State Medicaid agencies store records in an electronic format and that the State Medicaid agency make records available to the Secretary or other appropriate parties, resembling State and Federal auditors, inside 30 calendar days of the date records are requested, if not otherwise specified. We seek comment on whether States should retain flexibility to take care of records in paper or other formats that reflect evolving technology. While each of the records and documentary evidence described on this section are considered a part of the case record, we don’t propose that these records have to be stored in a single system.

Finally, we propose conforming revisions to SEC 431.17(a), regarding basis and purpose of SEC 431.17. We also propose revisions to SEC 435.914 of the present regulations, which also pertains to case documentation, to reflect the complete scope of records required under the proposed rule for each applicants and beneficiaries. Section 435.914(a) currently requires that States include in each applicant’s case record facts to support the agency’s decision on the applying. Section 435.914(b) currently requires States to eliminate each application by either: (1) making a finding of eligibility or ineligibility; (2) documenting within the case record that the applicant voluntarily withdrew the applying, and documenting that the agency sent a notice confirming such withdrawal; or (3) including an entry within the case record that the applicant has died or can’t be situated. We propose to revise SEC 435.914(a) to use to each applicant and beneficiary case records and to supply that the records maintained in each individual’s case record include all those described in SEC 431.17(b)(1), as revised on this proposed rule. We propose to revise SEC 435.914(b) to supply that States must eliminate all applications and renewals by a finding of eligibility or ineligibility unless considered one of the three circumstances described above applies. The applicability of those requirements to a separate CHIP, including proposed changes to SEC 457.965, is discussed further in section II.E.5 of this preamble.

E. CHIP Proposed Changes–Streamlining Enrollment and Promoting Retention and Beneficiary Protections in CHIP

Current CHIP regulations adopt most of the Medicaid eligibility regulations, which require that States have methods of creating and continuing eligibility, including coordinated and streamlined eligibility and enrollment processes between CHIP and other insurance affordability programs. With a view to retain the alignment with Medicaid and other insurance affordability programs, we propose to adopt the identical proposed policies for CHIP as are proposed for Medicaid on this proposed rule, except where otherwise noted. We discuss each of those proposed changes as they apply to CHIP below. We seek comment on whether there are any special considerations applicable to CHIP that warrant adoption of a unique policy for CHIP than the proposed alignments with Medicaid requirements, which would come with the varied policies on which we specifically seek comment within the preamble discussing the proposed revisions to the Medicaid regulations.

1. Timely Determination and Redetermination of Eligibility and Related Reviews ([Sec.] SEC 457.340 and 457.1170)

As discussed in section II.B.3 of this proposed rule, we propose changes to [Sec.] SEC 435.907(d) and 435.912 of the Medicaid regulations to make sure applicants are provided a meaningful opportunity to supply additional information needed by the State to make an eligibility determination and to ascertain specific timeliness standards for completion of regularly-scheduled renewals and redeterminations of eligibility resulting from changes in circumstances, including when a State receives information needed to redetermine eligibility too near the top of an enrollee’s eligibility period to finish a redetermination of eligibility prior to the top of the eligibility period.

To make sure continued coordination between Medicaid and CHIP enrollment and renewal processes, as required by section 2102(b)(2)(E) of the Act, we propose to use these changes equally to CHIP, except where otherwise noted. As discussed in section II.B.3 of this proposed rule, we propose revisions at SEC 435.907(d) to require that, if a State cannot determine Medicaid eligibility based on the knowledge provided on the applying and the State needs additional information from the applicant, the State must: (1) give applicants for whom a disability determination just isn’t needed at the least 15 calendar days from the date the request is postmarked or electronic request is distributed to supply the requested information and 30 calendar days from the date the request is postmarked or electronic request is distributed for applicants whose eligibility is being determined on the idea of disability; (2) allow applicants to reply through any of the modes of submission that have to be available for submission of the applying; and (3) reconsider the eligibility of people whose application is denied for failure to supply needed information if the person provides the needed information inside 30 calendar days from the date the denial notice is postmarked or electronic notice is distributed without requiring the person to submit a latest application. The terms of SEC 435.907(d) are applicable to CHIP through an existing reference in SEC 457.330 to SEC 435.907. Subsequently, these proposed changes would apply equally to CHIP, except as noted below with regard to a determination of disability, and no additional revisions to the CHIP regulations are needed.

We note that, unlike Medicaid, there are not any distinct eligibility groups in CHIP for which a determination of disability is required. Some States, nonetheless, have established a separate CHIP for kids with special health care needs (CSHCN). We seek comment on whether the longer time to return additional information requested by the State at application at proposed SEC 435.907(d)(1)(i)(A) for people applying for Medicaid based on disability (a minimum of 30 calendar days), needs to be applied to children applying for a separate CHIP if a determination that the kid qualifies as a CSHNC is required, as these families may similarly need more time to supply additional documentation or other information needed by the State to make a final determination on their application. We also seek comment on whether a minimum of 15 calendar days from the date the State’s request for extra information is postmarked or electronically sent is sufficient for applicants generally (that’s, no matter any need for a determination of CSHCN status) or whether an extended timeframe, resembling 20, 25, or 30 calendar days from the date the request is postmarked or electronically sent, just like the longer time (30 calendar days) proposed for people applying for Medicaid on the idea of disability, is acceptable. As discussed in section II.B.3 of this proposed rule, we’re also considering a minimum requirement of 30 calendar days from the date the request is postmarked or electronically sent for all applicants to supply additional information, together with an exception to the 45-day requirement at current SEC 435.912(c)(3)(ii) to supply States with an extra 15 calendar days to finish application processing if the State requested additional information from the applicant, which might apply to CHIP by existing references at SEC 457.340(d). We also seek comment regarding whether States needs to be afforded additional time to make a determination of eligibility for applicants in search of coverage under a separate CHIP for CSHCN, just like the extra time (maximum of 90 calendar days) provided at SEC 435.912c)(3)(i)) for States to make a final determination of eligibility for people applying for Medicaid coverage based on disability and, if that’s the case, whether an a maximum of 60, 75, or 90 calendar days is acceptable for determining eligibility for a separate CHIP for CSHCN. Moreover, we seek comment on whether calendar or business days could be higher suited as an appropriate timeliness measure. Finally, we also seek comment on whether an extended reconsideration period of 45 calendar days, or 90 calendar days, could be appropriate, just like the proposed 90-day reconsideration period discussed in section II.B.1 and II.B.2 of this preamble if a beneficiary provides the requested information inside 90 calendar days of termination without requiring a latest application.

As also discussed in section II.B.3 of this proposed rule, we propose revisions to SEC 435.912 to specify that States must establish timeliness and performance standards for conducting regularly-scheduled renewals, in addition to redeterminations of eligibility resulting from changes in enrollee circumstances, including maximum timeframes inside which States must complete these actions. Proposed revisions to SEC 435.912 also specify the minimum timeframes that States must provide to enrollees to answer requests for information when completing renewals. Just like Medicaid, we also seek comment on the period of time provided for States to finish a redetermination of eligibility at a regularly-scheduled renewal or based on changes in circumstances at proposed SEC 435.912(c)(4), (c)(5), and (c)(6), whether the regulations should allow for an extended or shorter time frame, and whether using business days quite than calendar days could be more appropriate. Section 435.912 of the Medicaid regulations is applicable to CHIP through an existing reference at SEC 457.340(d). Subsequently, these proposed changes would apply equally to CHIP, except that we propose to revise SEC 457.340(d)(1) to exclude application of certain Medicaid requirements that should not applicable to CHIP. The Medicaid requirements not applicable to CHIP include SEC 435.912(c)(4)(iii) and (c)(6)(iii) (regarding timelines for completing renewals and redeterminations when States must consider other bases of eligibility per SEC 435.916(f)(1), which is redesignated as SEC 435.916(d)(1) on this proposed rule). We also propose to revise the title of SEC 457.340(d) to make clear that the timeliness standards apply each at application and renewal.

Finally, to be able to support effective and efficient eligibility procedures, consistent with sections 2101(a) and 2102(b)(2) of the Act, we propose to change section SEC 457.1170 to require that States ensure the chance for continued enrollment in CHIP during a review of a State’s failure to make a timely determination of eligibility. Currently, States using a program specific review process for separate CHIP must only provide the chance for continued enrollment in CHIP pending the completion of a review for a suspension or termination of CHIP eligibility. We consider this proposed change to SEC 457.1170 will support a CHIP enrollee’s rights during a review if a State fails to satisfy the proposed timeliness standards at each application and renewal consistent with proposed changes in SEC 435.912, as referenced in SEC 457.340(d).

Moreover, we propose to change SEC 457.1170 to make clear that continuation of enrollment includes the continued provision of health advantages through the review period. Currently, SEC 457.1170 provides that States must ensure the chance for continuation of enrollment pending the completion of review of a suspension or termination of enrollment. While we acknowledge that, consistent with our definition of “enrollee” at SEC 457.10, coverage of health advantages is intrinsic to enrollment, we propose so as to add explicit reference to advantages at SEC 457.1170 to emphasise that continued enrollment without provision of advantages pending completion of a review of a termination or suspension of coverage doesn’t satisfy the requirement at SEC 457.1170. Finally, we propose to make explicit references to continuation of advantages in [Sec.] SEC 457.1140 and 457.1180 when describing the method for continuation of enrollment or referencing in notices.

As discussed above in section II.B.3 of the preamble, we seek comment for each Medicaid and CHIP on whether proposed SEC 435.912(c)(4)(ii) (incorporated in CHIP through SEC 457.340(d)) balances maximizing the completion of timely renewals prior to the top of an enrollee’s eligibility period and providing States with sufficient time to finish redeterminations and supply notice for enrollees who return needed documentation or other information prior to the top of their eligibility period, but not by the date requested by the agency to make sure completion of a timely renewal. The notice requirements for CHIP are situated at SEC 457.340(e)(1).

2. Changes in Circumstances ([Sec.] SEC 457.344 and 457.960)

As discussed in sections II.B.2 of this proposed rule, we propose to revise and redesignate paragraphs (c) and (d) of current SEC 435.916, related to changes in circumstances, to a latest SEC 435.919 that’s devoted specifically to State and enrollees’ responsibilities for acting on changes in circumstances. Proposed SEC 435.919 includes procedures for enrollees to report changes to the Medicaid agency and specific steps States must soak up promptly processing such changes.

We propose at SEC 435.919(c)(1) that States must provide a minimum of 30 calendar days for beneficiaries to answer a request for extra information needed to find out eligibility based on a change in circumstances. We also propose at SEC 435.919(d) that State Medicaid agencies provide beneficiaries whose coverage is terminated resulting from failure to supply information needed to redetermine eligibility following a change in circumstances with a 90-day reconsideration period. During this 90-day period, if a beneficiary returns the requested information, the agency could be required to redetermine the person’s eligibility without requiring a latest application.

Consistent with section 2102(b) of the Act related to a State’s eligibility standards and methodologies, we propose to use the changes at proposed SEC 435.919 to CHIP. Regulations governing changes in circumstances for CHIP beneficiaries are currently present in SEC 457.960. For greater transparency, we propose to remove SEC 457.960 in its entirety and incorporate the terms of proposed SEC 435.919 right into a latest SEC 457.344. Among the provisions in current SEC 435.916 (redesignated at proposed SEC 435.919) should not applicable to CHIP and we should not proposing to adopt them through proposed changes to SEC 457.344. Specifically, we propose to not incorporate into SEC 457.344 the requirement proposed at SEC 435.919(b)(4)(i) (currently at SEC 435.916(f)(1)) related to determining eligibility upon all other bases. We don’t consider this requirement is relevant for CHIP since the eligibility of all CHIP beneficiaries relies on MAGI, but we seek comment on whether it needs to be applied to CHIP in cases where a State has a couple of separate CHIP population and an enrollee could transition between populations. For instance, some States have a separate CHIP program specific to CSHCN or elect to supply coverage to other eligibility groups in CHIP, resembling targeted low-income pregnant women.

Currently SEC 457.343 references SEC 435.916, in its entirety as applicable. For instance, the present regulations specify where noted that other CHIP regulations regarding verification and noticing requirements apply rather than Medicaid regulations referenced in SEC 435.916. Outside the redesignation of SEC 435.916 (c) and (d) to SEC 435.919, as discussed above, the remaining changes to the regularly-scheduled renewal requirements at proposed SEC 435.916 may also apply to CHIP through this cross-reference. Nevertheless, there are several proposed revisions to SEC 435.916 that may not be applicable to CHIP populations, resembling proposed [Sec.] SEC 435.916(a)(2) related to Medicare beneficiaries, 435.916(b)(3) related to non-MAGI determinations, and 435.916(d)(1) (a redesignation of current SEC 435.916(f)(1)) related to considering eligibility on all bases prior to terminating a beneficiary.

3. Returned Mail (SEC 457.344)

As discussed in section II.B.4 of the preamble, we propose requirements at SEC 435.919(f) describing the actions that States must take to confirm a person’s address when the State receives returned mail, including the minimum period of time States must provide to individuals to answer such requests. Under this proposed rule, along with sending notices to the present address on file and the brand new address provided by USPS, the State must also try to contact the person using other means, resembling by telephone, email, text, or other electronic notice. Proposed [Sec.] SEC 435.919(f)(1), (2), and (3) specify the actions States must take to confirm a person’s address, and proposed [Sec.] SEC 435.919(f)(4), (5) and (6) describe the actions States must take if a person fails to substantiate their address based on whether the forwarding address is in-state or out-of-state or there is no such thing as a forwarding address. This rule also re-designates existing Medicaid requirements at SEC 431.231(d) as proposed SEC 435.919(f)(6). Under these requirements, States must reinstate coverage if a person’s whereabouts change into known before their next renewal date. Finally, this rule proposes SEC 435.919(g), which describes the actions States may and must take once they receive updated in-state address information from the USPS NCOA database or the State’s contracted managed care entities in addition to requirements once they receive updated address information from other third-party sources, no matter whether those data sources have or haven’t been approved by the Secretary.

Consistent with the section II.E.2 of the preamble, we’re proposing that CHIP adopt the substance of proposed SEC 435.919 as SEC 457.344 with some exceptions. We also propose to use the Medicaid provisions related to receipt of updated address information from returned mail, the USPS NCOA, a State’s contracted managed care plans, and other third-party sources under SEC 435.919(f) and (g) equally to CHIP. Moreover, we make clear at SEC 457.344(f)(5) and (g)(1)(vii) that if any separate CHIP population just isn’t available Statewide and the updated address lies outside of the particular geographic areas through which the State’s separate CHIP provides coverage, the State is required to treat the newly identified address as out-of-state and take the suitable actions when attempting to confirm an enrollee’s address, no matter whether the address is obtained resulting from returned mail or obtained from one other third-party data source.

We seek also comment on several requirements in proposed SEC 457.344(f) and (g). Just like the request for comments on proposed SEC 435.919(f), we seek comment with respect to proposed SEC 457.344(f) on whether States needs to be required to update an enrollee’s in-state address using newer contact information reflected in a forwarding address from USPS or an address provided by NCOA or a managed care plan in this example, when the enrollee has not responded to the State’s request to confirm their current address. Moreover, we seek comment on whether States needs to be permitted or needs to be required to update enrollee contact information based on information obtained from an MCO, from the USPS NCOA, or USPS forwarding without first attempting to contact the enrollee to supply them with a possibility to confirm or dispute the brand new information, because such third-party data is reliable, and, if that’s the case, which data sources should States be permitted to depend upon without attempting to contact enrollees. We’re especially curious about comments from States that received authority under section 1902(e)(14)(A) of the Act (which applies to CHIP through section 2107(e)(1)(I) of the Act) to update enrollee contact information based on information received from a reliable third party (for instance, an MCO, USPS NCOA or USPS forwarding address) without first attempting to contact the person, as described in SHO letter #22-001. States that received such authority were temporarily permitted to just accept updated enrollee contact information from designated reliable sources without first contacting the person in an effort to confirm the accuracy of the brand new contact information. We also seek comment on the efficacy of the requirement to send a notice to an enrollee’s address on file to make sure that initial piece of returned mail was not incorrectly returned.

We also seek comment on whether all States have a Medicaid Enterprise System that encompasses each Medicaid and CHIP, as we’ve assumed under proposed SEC 457.344(f)(1)(i). Finally, inasmuch as proposed SEC 435.919(f)(6) (regarding individuals whose whereabouts change into known) includes regulation text from an existing Medicaid regulation at SEC 431.231(d), we seek comment on whether any provisions of SEC 435.919(f)(6) shouldn’t be applied to CHIP at proposed SEC 457.344(f)(6). We consider there could also be operational challenges States may face when implementing these provisions and we seek further comment on the potential impact of those provisions.

Finally, just like Medicaid, we seek comment on whether under proposed SEC 457.344(g) States either needs to be permitted or needs to be required to update enrollee contact information based on information obtained from an MCO, from the USPS NCOA, or other reliable data sources, resembling Indian Health Care Providers, Federally Qualified Health Centers, Rural Health Clinics, Program of All-inclusive Look after the Elderly providers, Primary Care Case Managers, Accountable Care Organizations, Patient Centered Medical Homes, Enrollment Brokers, or other State Human Services Agencies (for instance, SNAP), without first attempting to contact the person to supply them with a possibility to confirm or dispute the brand new information, because such third-party data is reliable, and, if that’s the case, which data sources should States be permitted to depend upon without attempting to contact enrollees.

We’re especially curious about comments from States that received authority under section 1902(e)(14)(A) of the Act (which applies to CHIP through section 2107(e)(1)(I) of the Act) to update enrollee contact information based on information received from a reliable third party without first attempting to contact the enrollee, as described in SHO letter #22-001. We also seek comment on the efficacy of the requirement to send a notice to an enrollee’s address on file to make sure that initial piece of returned mail was not incorrectly returned, and on the efficacy of the requirement to conduct at the least two outreach attempts to the enrollee using a modality apart from mail. We also seek comment on the necessities in proposed SEC 457.344(g)(3) cross referencing SEC 457.344(f)(2) through (6), related to processing out-of-state address information or address information from a source not identified in SEC 457.344(g)(1) or (2).

4. Transitions Between CHIP and Medicaid ([Sec.] SEC 457.340, 457.348, and 457.350)

As discussed in section II.B.5. of this preamble, every State with separate programs for Medicaid, CHIP, and BHP, and lots of States with a State-based Marketplace utilize a single eligibility system or shared eligibility service. As such, when an enrollee is decided ineligible for one program, and the person is screened for potential eligibility in one other program, the system is effectively making a determination of eligibility for the opposite program. A person who applies on the Medicaid agency doesn’t should be screened after which transferred to the CHIP agency before a determination of CHIP eligibility could be accomplished, even when the CHIP agency operates individually from the Medicaid agency within the State. To enhance transitions between programs and reduce the likelihood of people experiencing gaps in coverage, we proposed changes to the Medicaid transition requirements at SEC 435.1200. As discussed intimately in section II.B.5., these changes would require the Medicaid agency to find out eligibility for CHIP when a person is decided ineligible for Medicaid, and seamlessly transition the person’s electronic account to the separate CHIP agency when determined eligible for CHIP; these changes would also require the Medicaid agency to just accept determinations of MAGI-based Medicaid eligibility made by separate CHIP agencies and enroll those eligible individuals into Medicaid, through considered one of the mechanisms described in SEC 435.1200(b)(4). We also propose changes to the Medicaid regulations at SEC 435.1200(h)(1) to require States to supply a combined eligibility notice to individuals determined ineligible for Medicaid and eligible for separate CHIP. We similarly propose changes to SEC 457.340 to require using a combined notice for transitions between separate CHIP and Medicaid. Moreover, we propose changes to [Sec.] SEC 457.340, 457.348, and 457.350 to enhance transitions between separate CHIP and Medicaid, as described below.

To assist prevent children who’re eligible for CHIP from becoming uninsured when their Medicaid eligibility is terminated, we propose to make several changes to current SEC 457.348, which establishes requirements for the State to coordinate transitions of eligibility between and with other insurance affordability programs. First, we propose so as to add a latest paragraph to SEC 457.348 regarding agency responsibilities for transitioning eligibility. Paragraph (a) of current SEC 457.348 requires the State to enter into agreements with the agencies administering other insurance affordability programs to meet numerous requirements on this section, resembling minimizing burden on individuals through the eligibility process, and ensuring prompt determination of eligibility and enrollment in the suitable program without undue delay. We propose to revise SEC 457.348(a) to require that these agreements provide for not only coordination of notices, but in addition for a combined eligibility notice with other insurance affordability programs. We also propose so as to add a latest paragraph (a)(6) to SEC 457.348, which might require the State to have an agreement with the Medicaid agency which clearly describes the responsibilities of every agency for ensuring a seamless transition between separate CHIP and Medicaid when a person is decided ineligible for one program and eligible for one more program. That is consistent with the proposed Medicaid revision at SEC 435.1200(b)(3)(vi).

Second, we propose to change SEC 457.348(b) to require the CHIP agency to just accept determinations of separate CHIP eligibility made by Medicaid. Current SEC 455.348(b) describes the responsibilities of the CHIP agency for people found CHIP eligible by one other insurance affordability program, if the agency has elected to just accept eligibility determinations made by other programs. We propose to require that the agency accept eligibility determinations made by Medicaid but retain the choice to enter into an agreement with a BHP or Marketplace operating within the State to just accept eligibility determinations made by those entities. To effectuate this transformation in regulation, and to enhance clarity of existing regulations, we propose to delete the introductory language in current paragraph (b) and redesignate the necessities in current SEC 457.348(b)(1) through (3) at proposed SEC 457.348(b)(1)(i) through (iii). We propose so as to add a latest paragraph (b)(2) to explain the individuals who’re subject to the necessities in proposed paragraph (b)(1). Specifically, proposed SEC 457.348(b)(2)(i) describes the individuals who’re subject to the necessities in paragraph (b) in the present regulations–that is, individuals determined eligible for CHIP by the Marketplace or one other insurance affordability program (including because of this of a call made by a Marketplace appeals entity), if the agency has entered into an agreement under which the Exchange makes final determinations of CHIP eligibility. Proposed SEC 457.348(b)(2)(ii) describes individuals who’re determined CHIP eligible by a separate Medicaid (including as the results of a call made by a Medicaid appeals entity). We also propose so as to add latest introductory language at proposed SEC 457.348(b)(1) to clarify that the necessities in proposed paragraph (b)(1) apply to individuals described in proposed paragraph (b)(2).

Paragraph (c) of current SEC 457.348(c) describes the CHIP agency’s responsibilities when individuals are transferred from other insurance affordability programs based on their potential eligibility for CHIP. We should not proposing any revisions to those requirements, since they’ll proceed to use in States that don’t elect to just accept determinations of eligibility made by BHP or the Marketplace. Similarly, we don’t propose any changes to current SEC 457.384(d), which specifies that a State must certify for the Exchange and other insurance affordability programs the standards applied in determining CHIP eligibility.

Third, we propose so as to add a latest paragraph (e) to SEC 457.348 to make clear that the State must accept a determination of CHIP eligibility made by a separate Medicaid program. Just like the proposed changes to the Medicaid regulations discussed in section II.B.5. of this rule, to be able to comply with this requirement, we propose that the agency may: (1) apply the identical MAGI-based methodologies without further verification as Medicaid; (2) enter into an agreement under which the State delegates authority to the Medicaid agency to make final determinations of CHIP eligibility; or (3) adopt other procedures approved by the Secretary. These options are described at proposed SEC 457.348(e)(1), (2), and (3) respectively. We seek comment on whether these options encompass the complete range of processes that a State may establish to just accept determinations of eligibility made by Medicaid.

When accepting a determination of CHIP eligibility made by Medicaid, we expect States to enroll the person in separate CHIP as quickly and seamlessly as possible. Any motion the State requires the person to take prior to enrollment, resembling payment of an enrollment fee or number of a plan, needs to be described within the combined notice provided to the person and the person needs to be given adequate time to answer prevent or minimize a niche in coverage. We request comment on the challenges a State may face in seamlessly transitioning eligibility from one other program, in addition to strategies to mitigate those challenges.

Next, we propose changes to SEC 457.350, which currently focuses on screening individuals for potential eligibility for other insurance affordability programs. We propose to require separate CHIP agencies to finish MAGI-based eligibility determinations for Medicaid and to screen for potential non-MAGI Medicaid, in addition to eligibility for BHP and insurance affordability programs available through the Exchanges. As proposed, when a CHIP enrollee is decided ineligible resulting from a decrease in household income, the separate CHIP agency would also complete a determination of eligibility for Medicaid. The person would now not be screened for potential MAGI Medicaid eligibility, transferred to the Medicaid agency, after which receive a determination of Medicaid eligibility, as required by current SEC 457.350(b). The separate CHIP agency must utilize the choice the Medicaid agency has elected to just accept determinations of MAGI-based Medicaid eligibility made by a separate CHIP. The choices for the Medicaid agency to just accept a CHIP eligibility determination and proceed to comply with Medicaid single State agency responsibilities are discussed in section II.B.5 of the Medicaid preamble. We’re proposing so as to add a latest paragraph (b)(3) at 457.350 to require the State to make sure that Medicaid eligibility determinations are conducted in accordance with the choice elected by the Medicaid agency at proposed SEC 435.1200(b)(4) and that this be reflected within the agreement between the State and the Medicaid agency that’s required at SEC 457.348(a). We seek comment on the feasibility of a contractor for the separate CHIP agency having the power to conduct the Medicaid determination in accordance with the choices specified at SEC 435.1200(b)(4).

These changes correspond with the changes proposed to the Medicaid regulations at SEC 435.1200(e). Along with the changes related to Medicaid eligibility determinations, we also propose to restructure SEC 457.350 to be able to improve the clarity of each existing and proposed requirements for separate CHIP agencies evaluating eligibility for other insurance affordability programs. These proposed changes are effectuated as follows. Specifically, we propose:

    * To amend SEC 457.350(a)(2) to make clear that the State plan must describe how enrollment is facilitated for applicants found either potentially eligible for one more insurance affordability program (that’s, BHP or insurance affordability programs available through the Exchanges) or eligible for Medicaid in accordance with this section.

    * To revise SEC 457.350(b) to require States to find out an applicant’s eligibility for MAGI Medicaid and to find out potential eligibility for non-MAGI Medicaid, BHP, or insurance affordability programs available through the Exchanges for people who should not eligible for MAGI-based Medicaid. Current SEC 457.350(b) requires a State to discover potential eligibility for other insurance affordability programs (specifically MAGI-based Medicaid, non-MAGI Medicaid, and other insurance affordability programs), promptly and without undue delay and consistent with the State’s timeliness standards, when a person is decided ineligible for separate CHIP at application, at renewal, based on a change in circumstances, or following a review. At SEC 457.350(b)(1) we propose to retain the introductory language at current SEC 457.350(b) that a State act promptly and without undue delay, consistent with the timeliness standards established by the State, but we might add a latest paragraph (b)(1)(i) requiring the State to find out eligibility for MAGI-based Medicaid. At proposed SEC 457.350(b)(1)(ii), we might require a State, if unable to make a determination of eligibility for MAGI-based Medicaid to find out potential eligibility for non-MAGI Medicaid, BHP, or insurance affordability programs available through the Exchanges. Proposed SEC 457.350(b)(2) would apply the necessities of proposed paragraphs (b)(1)(i) and (ii) to applicants, enrollees whose eligibility is being redetermined at renewal or based on a change in circumstances, and to individuals determined ineligible for separate CHIP because of this of a review conducted in accordance with subpart K of this part. That is consistent with the applying of current paragraph (b) of SEC 457.350, as described in the present introductory language.

* Technical changes to paragraph (c) of this section. Current SEC 457.350(c) describes the income eligibility test that States must apply when determining a person’s eligibility for MAGI-based Medicaid, or potential eligibility for BHP or insurance affordability programs available through the Exchanges. We propose to revise the references to paragraph (b) to reflect the change at proposed SEC 457.350(b)(1)(i) requiring the State to find out eligibility for MAGI-based Medicaid and the redesignation of the requirement to find out potential eligibility for BHP and insurance affordability programs available through the Exchanges at proposed SEC 457.350(b)(1)(ii).

    * To redesignate current paragraph (f) at proposed SEC 457.350(d), which is currently reserved. Current SEC 457.350(f) applies to individuals determined by the separate CHIP agency to be potentially eligible for Medicaid based on MAGI and requires the State to transfer the person’s account to the Medicaid agency, find the applicant provisionally ineligible for CHIP until the Medicaid determination is accomplished, and redetermine CHIP eligibility if the person is found ineligible when the Medicaid agency completes the determination. Because we propose to require States to finish determinations, quite than potential determinations, of eligibility for Medicaid based on MAGI, we propose several changes to SEC 457.350(f) (redesignated at proposed SEC 457.350(d)). First, we propose to change the title for proposed SEC 457.350(d) to make clear that this provision applies to actions that States must take when determining a person eligible for Medicaid based on MAGI, quite than actions the State must take for people found potentially eligibility for Medicaid. Next, we propose to amend the citation within the introductory language to reflect the changes proposed at paragraph (b)(1) of this section. We propose to revise SEC 457.350(f)(2) (redesignated at SEC 457.350(d)(2)) to require that the State find the applicant ineligible for CHIP (versus provisionally ineligible for CHIP until the Medicaid determination is accomplished). Finally, we propose to delete current paragraph (f)(3), which requires the State to find out or redetermine eligibility when the Medicaid agency returns a determination of ineligibility for a person whom the separate CHIP agency screened as potentially Medicaid eligible, since under proposed SEC 457.350(b) the CHIP agency could have accomplished a determination of eligibility for MAGI-based Medicaid and proposed SEC 435.1200(c) would require the Medicaid agency to just accept the determination of eligibility made by the separate CHIP agency.

    * To redesignate current SEC 457.350(j), describing the necessities for people determined potentially eligible for non-MAGI Medicaid, as proposed SEC 457.350(e). Current SEC 457.350(j) requires the State to transfer the person’s account to the Medicaid agency, complete a determination of CHIP eligibility and evaluate eligibility for other insurance affordability programs if ineligible for CHIP, include coordinated content within the CHIP eligibility notice, and disenroll the person from CHIP in the event that they ultimately are determined eligible for Medicaid. We propose several technical changes to paragraph (j) (redesignated as proposed paragraph (e)). We propose to revise the title to make clear that this paragraph applies not only to applicants but in addition to individuals whose eligibility is being redetermined at renewal or based on a change in circumstances and to individuals who’re determined ineligible for CHIP upon review; we note that this just isn’t a change in policy but simply a correction to the title. Then we propose to revise existing cross-references to align with proposed changes to paragraphs (b), (e), and (g) in SEC 457.350.

    * To redesignate, at SEC 457.350, current paragraph (e) as paragraph (f). Current SEC 457.350(e) applies only to States that use a screening procedure apart from a full Medicaid eligibility determination and requires the State to supply certain information to the family when a baby is found potentially ineligible for Medicaid. We propose to revise the title of SEC 457.350(e) (redesignated at SEC 457.350(f)) to make clear that, in accordance with other changes proposed to this section, this paragraph would apply to individuals who’re determined ineligible for MAGI-based Medicaid and located potentially ineligible for Medicaid on a basis apart from MAGI. We also propose to update the prevailing cross-reference on this paragraph to reflect the redesignation of current paragraph (e) as latest paragraph (f).

    * To delete current paragraph (g) of SEC 457.350 in its entirety and to redesignate current SEC 457.350(i) at proposed SEC 457.350(g). Currently, paragraph (g) describes information States must provide to assist families make informed decisions about applying for Medicaid coverage. We consider that the separate CHIP agency is already required to supply similar information to families of kids which will potentially be eligible for Medicaid on a non-MAGI basis in SEC 457.350(e) (redesignated as proposed SEC 457.350(f)). Subsequently, we propose to eliminate the present requirements at SEC 457.350(g). Current SEC 457.350(i) (which is revised on this rulemaking to remove references to individuals subject to a period of uninsurance, as discussed in section II.F.2 of this proposed rule) sets forth procedures that the State must undertake when a person is found potentially eligible for one more insurance affordability program, including transferring the person’s electronic account to the opposite program. We propose to revise SEC 457.350(i) of the present regulations (redesignated as proposed SEC 457.350(g)) as discussed in section II.F.2. of this preamble.

    * To redesignate requirements at current SEC 457.350(k) and (h) as proposed SEC 457.350(h) and (i) respectively. Current paragraph (k) (redesignated at proposed paragraph (h)) permits the separate CHIP agency to make determinations of eligibility for advance payments of the premium tax credit and value sharing reductions on behalf of the Exchange; we should not proposing any changes to this paragraph. Current SEC 457.350(h) (redesignated at proposed SEC 457.350(i)) describes procedures for waiting lists, enrollment caps, and closed enrollment; we propose only a technical change to this section to update the cross-reference to reflect other changes proposed on this section.

Just like Medicaid, we seek comment on information that the separate CHIP agency wouldn’t give you the chance to access through electronic or other data sources when determining MAGI-based eligibility for Medicaid and for which it might have to contact the person before completing a determination of eligibility. Moreover, we seek comment on whether there are cases through which the separate CHIP agency would give you the chance to finish only a determination of potential MAGI-based eligibility for Medicaid, varieties of situations that may end in only a determination of potential eligibility, and whether the separate CHIP agency might have the choice to transfer the person’s electronic account to the separate Medicaid agency to finalize the determination.

Just like the proposed changes for coordination of notices within the Medicaid regulations at SEC 435.1200(h), discussed in section II.B.5 of this proposed rule, we propose changes to SEC 457.340(f) related to coordination of notices with other programs. These changes correspond with Medicaid changes at SEC 435.1200(h) to make sure that individuals receive a combined notice whatever the agency that completes the eligibility determination or transfers the person’s electronic account to a different insurance affordability program for a final eligibility determination. Providing individuals with a combined notice shall be critical to making sure that they understand the changes in coverage which are occurring and any additional obligations that could be imposed by this system to which their coverage is being transitioned. As previously mentioned above within the section related to transitions from Medicaid to CHIP, States that operate its CHIP and Medicaid programs under the identical agency and eligibility system that already provide a seamless, combined Medicaid and CHIP notice, may not must make any changes.

To effectuate this transformation to the combined notice requirements, we propose changes to SEC 457.340(f)(1). Current SEC 457.340(f)(1) requires States to supply combined notices, to the utmost extent feasible, to individuals and to multiple members of the identical household who’re included on the identical application or renewal form; this paragraph also requires the State to incorporate coordination of notices in its agreement with other insurance affordability programs as described at SEC 457.348(a). We propose to separate current SEC 457.340(f)(1) into three separate requirements–proposed paragraphs (f)(1)(i), (ii) and (iii)–each of which have to be included within the agreement into which the State enters into, in accordance with SEC 457.348(a). Proposed SEC 457.340(f)(1)(i) would establish a latest requirement for the State to make sure that individuals are supplied with a combined notice when their Medicaid eligibility is decided by the separate CHIP agency, or their CHIP eligibility is decided by the agency administering Medicaid. Proposed SEC 457.340(f)(1)(ii) and (iii) would restate the necessities currently described in paragraph (f)(1)–that is, at proposed SEC 457.340(f)(1)(ii) to supply a combined notice to individuals transferred between the State and one other insurance affordability program to the utmost extent feasible; and at proposed SEC 457.340(f)(1)(iii) to require a combined notice for multiple members of the identical household to the utmost extent feasible. We don’t propose to make any changes to SEC 457.340(f)(2). We seek comment on States’ ability to issue a combined notice in accordance with proposed SEC 457.340(f)(1)(i).

Consistent with these changes to SEC 457.350, we propose a conforming change to SEC 457.348(a), which describes the agreements that States must establish with other insurance affordability programs. We propose to revise SEC 457.348(a) to require that these agreements provide for not only coordination of notices, but in addition for a combined eligibility notice with other insurance affordability programs.

5. Recordkeeping (SEC 457.965)

As discussed in section II.D of this preamble, we propose to revise SEC 431.17(b) to obviously detail the particular varieties of information that Medicaid agencies must retain as a part of each applicant and/or enrollee’s case records. We also propose changes to SEC 431.17(c) to specify the minimum duration of time that the knowledge that needs to be retained for each applicant and enrollee files. Finally proposed revisions at SEC 431.17(d) would offer that States must give you the chance to supply stored information inside 30 calendar days after a request has been made if not otherwise specified. Moreover, we clarified in section II.D. of this preamble that we don’t propose that every one of the knowledge that might be considered a part of the case record be stored in a single system.

To make sure effective and efficient administration of the CHIP program, consistent with section 2101(a) of the Act, we propose to change existing CHIP documentation requirements at SEC 457.965 by adopting the identical requirements as we’re proposing for Medicaid at SEC 431.17, except that cross-references to other Medicaid regulations in proposed SEC 431.17 are replaced with corresponding cross-references to existing CHIP regulations. As with Medicaid, we seek comment regarding whether 3 years is an appropriate minimum duration of time for States to retain case records after the case is energetic; moreover, we seek comment whether any longer or shorter duration could be appropriate for certain varieties of information, resembling those related to payment and provision of kid health assistance, to stay within the case records. We’re also particularly curious about comments on whether the retention period needs to be tied to the person or the energetic case. Finally, we seek comment whether States should retain flexibility to take care of records in paper or other formats that reflect evolving technology.

F. Eliminating Access Barriers in CHIP

Following passage of the ACA, CMS focused on aligning methodologies and procedures to be able to create a streamlined, coordinated eligibility and enrollment process across insurance affordability programs. In such rulemaking, we left in place certain flexibilities available to States in administering separate CHIPs which should not permitted in Medicaid, including the choice to specify a time frame that CHIP beneficiaries whose families fail to pay required premiums should not permitted to reenroll in CHIP coverage or “lock out” such beneficiaries; the choice to impose a waiting period prior to enrollment for beneficiaries previously enrolled in other coverage; and the choice to impose annual and lifelong limits on advantages. Each of those policies, if adopted by a State, poses a barrier to obtaining and retaining coverage for CHIP beneficiaries who otherwise meet the eligibility requirements for the State’s program. As discussed further below, we propose to eliminate each of those State options.

1. Prohibit Premium Lock-Out Periods ([Sec.] SEC 457.570 and 600.525(b)(2))

Premium payment policies can directly influence the problem, or ease, eligible children and pregnant individuals face when enrolling in and retaining CHIP coverage. Under section 2103(e)(3)(C) of the Act, States must provide enrollees with a grace period of at the least 30 days from the start of a latest coverage period to make premium payments before the kid or targeted low-income pregnant woman’s coverage is terminated. If the premium stays unpaid at the top of the grace period, States must also offer the family a possibility to point out their income has decreased such that the CHIP enrollee may qualify for a lower premium payment in CHIP or be eligible for Medicaid. States also currently have the choice under SEC 457.570 to impose a premium lock-out period, which is a specified period that a baby or a pregnant individual must wait until being allowed to reenroll within the CHIP program after non-payment of premiums. There isn’t a statutory provision expressly requiring CMS to supply States with the choice to institute a premium lock-out period after non-payment of premiums.

Under Medicaid, premiums are authorized under sections 1902(a)(14), 1916, and 1916A of the Act, and implementing regulations at 42 CFR 447.50 through 447.57. Medicaid permits disenrollment for failure to pay premiums is at 447.55(b)(2), but doesn’t permit premium lock-out periods.

Premium lock-out periods, by design, require children or pregnant individuals to go without coverage for a specified period. While not focused on the CHIP beneficiary populations specifically, a review of the literature on Medicaid lock-out periods previously authorized under section 1115 demonstrations indicates that premium lock-out periods pose a barrier to coverage and hinder access to care. Research on the impact of premium lock-out periods on access to look after Medicaid

beneficiaries authorized under section 1115(a) of the Act also shows that Medicaid beneficiaries who experience lock-outs usually tend to skip or delay provider visits, not fill prescriptions, and report financial barriers to accessing care. /66/ One study found that individuals who experienced interruptions in coverage had higher hospitalization rates for conditions, resembling asthma and diabetes, that would have been managed in outpatient settings with consistent access to treatment. /67/ Gaps in coverage also make it less likely that families establish sustained relationships with health care providers, which can also undermine the standard of care they receive. /68/ The literature also shows that premium lock-out periods disproportionately affect non-White populations in comparison with White populations, which can further exacerbate existing disparities in health outcomes. Moreover, there is no such thing as a evidence to display that lock-out periods incentivize families to comply with requirements.

   FOOTNOTE 66 Ku, L., & Ross, D.C. (2002). Staying covered: the importance of retaining medical health insurance for low-income families. Commonwealth Fund, Task Force on the Way forward for Health Insurance. https://www.commonwealthfund.org/sites/default/files/documents/___media_files_publications_fund_report_2002_dec_staying_covered__the_importance_of_retaining_health_insurance_for_low_income_families_ku_stayingcovered_586_pdf.pdf. END FOOTNOTE

   FOOTNOTE 67 Bindman, A.B., Chattopadhyay, A., & Auerback, G.M. (2008). Interruptions in Medicaid coverage and risk for hospitalization for ambulatory care-sensitive conditions. Annals of internal medicine, 149(12), 854-860. END FOOTNOTE

   FOOTNOTE 68 Ku, L., & Ross, D.C. (2002). Staying covered: the importance of retaining medical health insurance for low-income families. Commonwealth Fund, Task Force on the Way forward for Health Insurance. https://www.commonwealthfund.org/sites/default/files/documents/___media_files_publications_fund_report_2002_dec_staying_covered__the_importance_of_retaining_health_insurance_for_low_income_families_ku_stayingcovered_586_pdf. END FOOTNOTE

With a view to improve continuity of care and align with Medicaid rules on this area, we propose to eliminate premium lock-out periods in CHIP. Section 2101(a) of the Act requires States to supply access to health care in an efficient and efficient manner that’s coordinated with other sources of health advantages coverage. As well as, the April 5, 2022 Executive Order 14070, “Continuing to Strengthen Americans’ Access to Reasonably priced, Quality Health Coverage” requires agencies to discover ways to expand the provision of reasonably priced health coverage, improve quality of coverage, and to strengthen advantages. Specifically, we propose to revise SEC 457.570(c)(1) to ban States from imposing premium lock-out periods; to remove current paragraph (c)(2), and to redesignate and revise paragraph (c)(3) at paragraph (c)(2) to ban States from requiring collection of late premiums or enrollment fees as a condition of eligibility for reenrollment once a lock-out period is over if a person was terminated for failure to pay premiums.

There are a large number of promising practices described within the literature for helping to stop late or missed premium payments, thereby avoiding even short-term disruptions to coverage, /69/ resembling:

   FOOTNOTE 69 Brooks, T. (2013). Handle with Care: How Premiums Are Administered in Medicaid, CHIP and the Marketplace Matters. Georgetown University Center for Children and Families.https://ccf.georgetown.edu/wp-content/uploads/2013/12/Handle-with-Care-How-Premiums-Are-Administered.pdf. END FOOTNOTE

    * Conducting latest member calls to make sure that families understand their payment obligations and options.

    * Ensuring eligibility staff who work directly with families are trained and knowledgeable about payment policies and procedures, and might explain them to people, particularly those experiencing a language or cultural barrier.

    * Generating frequent payment notices and reminders.

    * Providing multiple and convenient options for paying premiums.

    * Providing advance payment incentives (resembling pay for a certain variety of months and permitting 1 free month).

One other possible approach for States to cut back the disruptive effect of non-payment of premiums is to use an inexpensive annual enrollment fee or provide families with the selection between paying monthly premiums or an annual enrollment fee. Just like premiums, States may provide various fees based on family income level to make sure that families at a lower income can afford the enrollment fee. We note that an annual enrollment fee would wish to satisfy the conditions specified at section 2103(e)(3)(A)(i) of the Act regarding limitations on premiums and enrollment fees for kids under 150 percent of the FPL, section 2103(e)(3)(B) of the Act for all other children, and section 2112(b)(6) of the Act for targeted low-income women. To be reasonably priced, an annual fee would likely should be substantially lower than the equivalent of 12 monthly premium payments. /70/ For instance, some States with a separate CHIP charge an annual enrollment fee of $50 for one child or $100 for a family with two or more children. Requiring a single reasonably priced annual payment may improve retention, reduce disenrollment rates, and simplify program administration, for instance, by reducing the fee of billing, collecting and processing premium payments. /71/ We solicit comments on the potential parameters for ensuring that an annual fee is reasonably priced.

   FOOTNOTE 70 Ku, L., & Ross, D.C. (2002). Staying covered: the importance of retaining medical health insurance for low-income families. Commonwealth Fund, Task Force on the Way forward for Health Insurance. https://www.commonwealthfund.org/sites/default/files/documents/___media_files_publications_fund_report_2002_dec_staying_covered__the_importance_of_retaining_health_insurance_for_low_income_families_ku_stayingcovered_586_pdf. END FOOTNOTE

   FOOTNOTE 71 Ibid. END FOOTNOTE

States will proceed to have the choice to disenroll children or targeted low-income pregnant women from coverage resulting from non-payment of premiums, including enrollment fees, so long as the State provides families a minimum 30-day premium grace period, which is required under 2103(e)(3)(C) of the Act. States must inform a person, seven days after the primary day of the grace period, that failure to make a payment throughout the premium grace period will end in termination of coverage, and of the person’s right to challenge the termination. Because States would now not give you the chance to require collection of late premiums or enrollment fees as a condition of eligibility, a family could re-apply for coverage immediately following disenrollment. States retain the pliability to find out whether families shall be required to finish a latest application to be able to reenroll in coverage after disenrollment. Other States allow a time frame after disenrollment for families to make a payment and have coverage reinstated without requiring the submission of a latest application.

We note that, under 42 CFR 600.320(d), States that operate a BHP have the choice to enroll eligible individuals of their BHP during enrollment and special enrollment periods which are no more restrictive than those required for an Exchange at 45 CFR 155.410 and 155.420 or follow the Medicaid and CHIP rules to allow continuous open enrollment all year long. Under SEC 600.525(b)(2), States that elect to permit continuous open enrollment all year long must comply with the reenrollment standards set forth within the CHIP regulations at SEC 457.570(c). Thus, by eliminating the State choice to impose a premium lock-out period in CHIP, we effectively could be eliminating the premium lock-out period for States with a BHP that enables continuous open enrollment all year long.

As such, we propose to remove the requirement at SEC 600.525(b)(2) for a BHP State to define the length of the premium lock-out period in its BHP Blueprint, as premium lock-out periods will now not be permissible. We propose this transformation using our authority in section 1331(c)(4) of the ACA, which requires a State that operates a BHP to coordinate the administration of, and provision of advantages under its BHP with the State Medicaid, CHIP, and other State-administered health programs to maximise the efficiency of such programs and to enhance the continuity of care. We request comment regarding whether BHPs needs to be allowed to proceed operating a premium lock-out period.

We’re also considering the choice of permitting a 30-day lock-out period and invite comments on this feature.

2. Prohibit Waiting Periods ([Sec.] SEC 457.65, 457.340, 457.350, 457.805, and 457.810)

Currently, the CHIP regulations permit States to impose a “period of uninsurance,” or “waiting period,” on individuals who’ve recently disenrolled from a bunch health plan prior to allowing them to enroll in a separate CHIP. Section 457.805 provides some limitations on using waiting periods. Our experience in implementing the ACA provisions designed to extend access for families under Medicaid and CHIP and expand coverage through the Exchanges calls into query whether using waiting periods in CHIP continues to be appropriate. Waiting periods are a State option unique to CHIP programs, as waiting periods should not permitted in Medicaid, BHP, and individual market Exchange plans. /72/ Historically, we’ve interpreted section 2102(b)(3)(C) of the Act, which requires States to make sure that coverage provided under CHIP doesn’t substitute for (or “crowd out”) coverage under group health plans, to allow States to adopt a waiting period. Corresponding regulations at SEC 457.805 specify that State plans must include an outline of “reasonable procedures” to stop substitution.

   FOOTNOTE 72 U.S. Department of Health and Human Services. (2016, May). Ceaselessly Asked Questions on Health Insurance Market Reforms and Marketplace Standards. Retrieved from: https://www.cms.gov/CCIIO/Resources/Fact-Sheets-and-FAQs/Downloads/Waiting-period-FAQ-05262016-Final-.pdf. END FOOTNOTE

Currently, 11 States use a waiting period in CHIP as a mechanism for stopping substitution. Children are denied eligibility under CHIP in the event that they recently had group health coverage, inside a State-prescribed waiting period, and haven’t qualified for a Federal or State-specified exception. Currently, States impose waiting periods that range from one month to 90 days. CHIP regulations at SEC 457.805 provide that a waiting period may not exceed 90 days.

On the inception of CHIP in 1997, employer-sponsored medical health insurance was the predominant alternative source of coverage for kids in families throughout the CHIP income range. With passage of the ACA, coverage in a QHP through the Exchanges became available, and families may now qualify for premium tax credits to buy coverage from the Exchange for his or her children while they wait for CHIP coverage during a waiting period.

Waiting periods, which have historically resulted in a period of uninsurance between the top of personal health coverage and the start of CHIP enrollment, were seen as a deterrent to families dropping private coverage to be able to enroll their children in CHIP. Nevertheless, the provision of coverage through the Exchanges during a waiting period warrants reconsideration of using waiting periods in CHIP. /73/

   FOOTNOTE 73 Under current Treasury regulations, some children may not qualify for Exchange premium tax credits in the event that they are deemed eligible for reasonably priced health coverage through a member of the family’s employer, based on whether the fee of self-only coverage for the member of the family is reasonably priced. The Treasury Department has published a Notice of Proposed Rulemaking that may change this rule. 87 FR 20354 (Apr. 7, 2022). END FOOTNOTE

The supply of Exchange coverage increases the complexity of implementing CHIP waiting periods, as coordinating coverage between the Exchanges and CHIP creates challenges that may result in lack of coverage when affected children must transition from Exchange coverage to CHIP. /74/ As noted, families with children who’re ineligible for CHIP during a waiting period are eligible for advance payments of the premium tax credit to enroll the kid in a QHP through the Exchange, in the event that they meet other applicable requirements. Nevertheless, after a baby is decided eligible for enrollment in a QHP, additional time is required for the family to pick and enroll in a health plan. By the point a baby is enrolled in a health plan through the Exchange, the CHIP waiting period often could have expired, or be near expiring, at which point the kid is eligible for CHIP, and the CHIP agency and family must act to maneuver the kid from Exchange coverage to the State’s CHIP program. Under current regulations at SEC 457.350(i), the CHIP agency is anticipated to notify each the Exchange and family of the kid’s potential eligibility for CHIP at the top of the waiting period. The complexities of tracking waiting periods, sending notices to families, and requiring families to take additional steps to transition coverage likely end in children who’re eligible for CHIP being unenrolled. /75/ /76/ /77/ Moreover, health policy experts in numerous States that proceed to implement waiting periods indicate that the burden imposed on families in some cases prevents them from in search of public coverage again, even once the youngsters are eligible after the waiting period is over. /78/ /79/

   FOOTNOTE 74 Brooks, Tricia. Now could be the time to remove CHIP waiting periods and welcome kids into coverage. April 17, 2020. Retrieved from https://ccf.georgetown.edu/2020/04/17/now-is-the-time-to-remove-chip-waiting-periods-and-welcome-kids-into-coverage/. END FOOTNOTE

   FOOTNOTE 75 Medicaid and CHIP Payment and Access Commission. March 2017. “Chapter 1: The Way forward for CHIP and Kid’s Coverage” in Report back to Congress on Medicaid and CHIP. Retrieved from https://www.macpac.gov/wp-content/uploads/2017/03/The-Future-of-CHIP-and-Childrens-Coverage.pdf. END FOOTNOTE

   FOOTNOTE 76 Foster, Leslie. January 2016. “Research Transient 3: Stakeholder perspectives from Texas” in Health Care Coverage and Access for Children in Low-income Families. Mathematica Policy Research, funded by the David & Lucile Packard Foundation. END FOOTNOTE

   FOOTNOTE 77 Bruce, Giles. February 13, 2020. “Why Do Some States Still Require Long Waits Before Kids Can Get Health Insurance?” in Kid’s Health Matters. University of Southern California, Center for Health Journalism. Retrieved from https://centerforhealthjournalism.org/2020/01/30/why-do-some-states-still-require-long-waits-kids-can-get-health-insurance. END FOOTNOTE

   FOOTNOTE 78 Medicaid and CHIP Payment and Access Commission. March 2017. “Chapter 1: The Way forward for CHIP and Kid’s Coverage” in Report back to Congress on Medicaid and CHIP. Retrieved from https://www.macpac.gov/wp-content/uploads/2017/03/The-Future-of-CHIP-and-Childrens-Coverage.pdf. END FOOTNOTE

   FOOTNOTE 79 Foster, Leslie. January 2016. “Research Transient 3: Stakeholder perspectives from Texas” in Health Care Coverage and Access for Children in Low-income Families. Mathematica Policy Research, funded by the David & Lucile Packard Foundation. END FOOTNOTE

Even for families that successfully navigate the executive hurdles of moving from Exchange to CHIP coverage, coverage transitions create care complexities. A move from the Exchange to CHIP may necessitate a change of providers and/or managed care plans, which interrupt care. These potential changes in coverage may limit a baby’s access to needed services following a waiting period.

The 2013 eligibility final rule amended CHIP regulations at SEC 457.805(b)(1) to impose some limitations on waiting periods, including a 90-day maximum as mentioned above. Subsequent to this rule, the bulk (23 of 36) of States elected to eliminate their CHIP waiting period. No state that has eliminated a waiting period has reported a substitution problem to CMS through their monitoring efforts. Eleven states still implement CHIP waiting periods; nine States have a 90-day waiting period, one State has a 2-month waiting period, and one State has a one month waiting period. Within the 2013 final rule, we also amended SEC 457.805(b)(3) to require that States adopt certain exemptions to any waiting period. Under this regulation, States may not apply a waiting period if:

    * The premium paid by the family for coverage of the kid under the group health plan exceeds 5 percent of household income;

    * The kid’s parent is decided eligible for advance payments of the premium tax credit for enrollment in a QHP through the Exchange since the employer-sponsored insurance through which the family was enrolled is decided unaffordable in accordance with 26 CFR 1.36B-2(c)(3)(v);

    * The associated fee of family coverage that features the kid exceeds 9.5 percent of the household income;

    * The employer stopped offering coverage of dependents (or any coverage) under an employer-sponsored medical health insurance plan;

    * A change in employment, including involuntary separation, resulted within the child’s lack of employer-sponsored insurance (apart from through full payment of the premium by the parent under COBRA);

    * The kid has special health care needs; or

    * The kid lost coverage resulting from the death or divorce of a parent.

Along with the Federally required exemptions to CHIP waiting periods listed above, nearly all of States apply other State-specific exemptions to the waiting period. Requirements at SEC 457.810 apply the identical 90-day maximum and Federal exceptions to waiting periods for CHIP premium assistance programs. Consequently of those exceptions, States have anecdotally reported that few children are subject to waiting periods.

Sections 2102(b)(1)(B)(iii), 2102(b)(1)(B)(iv) and 2112 (b)(5) of the Act reference circumstances through which waiting periods is probably not applied to CHIP populations or coverage. These provisions, included within the statute when it was first enacted in 1997, place certain limitations on using waiting periods, which were implicitly recognized on the time as considered one of the potential strategies states could use to meet the requirement at section 2102(b)(3)(C) of the Act to deal with substitution of coverage. Because the inception of CHIP, the health coverage landscape has significantly modified, including the addition of the Exchange coverage option. Any gap in coverage created by a waiting period or the executive process to transfer children between different coverage options, resembling the Exchange, can compromise child health and development and access to preventive and first health care during childhood and adolescence. As noted above, waiting periods have never been allowed under Medicaid and should not permitted within the Exchanges, either. Nor are waiting periods permitted within the private insurance market, for instance, for people with pre-existing conditions. These changes call into query the appropriateness of waiting periods as a tool to deal with substitution of coverage.

As well as, Executive Order 14070 of April 5, 2022 titled “Continuing to Strengthen Americans’ Access to Reasonably priced, Quality Health Coverage” instructs agencies to discover policy changes to make sure that enrollment and retention in coverage could be more easily navigated by consumers. The navigation of waiting periods for families is difficult, and CHIP is now an outlier amongst insurance providers in comparison with Medicaid and personal insurance coverage providing EHB coverage in allowing waiting periods to be applied before individuals can enroll in coverage. As well as, moving children between CHIP and the Exchange just isn’t an efficient or effective use of State and Federal resources. With a view to align with other programs, and consistent with the requirement in section 2101(a) of the Act to supply access for kids to health care in an efficient and efficient manner that’s coordinated with other sources of health advantages coverage, in addition to Executive Order number 14070 of April 5, 2022, we’re proposing to eliminate all waiting periods in separate CHIPs. States shall be required to proceed monitoring efforts to stop substitution of coverage in accordance with section 2012(b)(3)(c) of the Act.

Specifically, we propose to revise SEC 457.805(b) to supply that States may not impose a waiting period before enrolling eligible individuals in CHIP. We also propose the next conforming changes to other regulatory provisions to remove language referring to waiting periods.

    * Revise SEC 457.65 to remove references to State plan amendments that implement or extend the length of a required period of uninsurance.

    * Remove SEC 457.340(d)(3) (regarding facilitating enrollment in CHIP after a State-required period of uninsurance).

    * Revise SEC 457.350(i) (redesignated at proposed SEC 457.350(g) as discussed in section II.E.4. of this proposed rule) to remove references to individuals subject to a State-required period of uninsurance, and to remove paragraphs (2) and (3) of SEC 457.350(i) (redesignated at proposed SEC 457.350(g)) regarding State notices for people found eligible for other insurance affordability programs through the waiting period).

    * Remove SEC 457.805(b)(2) and (b)(3) (regarding Federal exceptions to waiting periods).

    * Amend SEC 457.810(a) to specify that waiting periods is probably not applied to CHIP premium assistance programs and take away paragraphs (a)(1) and (2) (regarding the 90-day limit for, required exemptions from, waiting periods applied to CHIP premium assistance programs).

Under the proposed rule, States could be required to proceed to watch the prevalence of substitution of coverage, consistent with requirements at SEC 457.805, and to report annually to CMS on the effectiveness of strategies used to stop substitution of coverage pursuant to SEC 457.750(b)(2). Within the preamble of the July 15, 2013 final rule (78 FR 42159), we explained that effective January 1, 2014, monitoring of substitution is a sufficient approach for addressing substitution in any respect income levels. There are numerous ways States monitor substitution of coverage, resembling matching applicants to a database that identifies sources of other coverage, including questions on the one streamlined application about private and group health coverage, and tracking the variety of applicants that reported other coverage and are later enrolled in CHIP. We expect that if this monitoring demonstrates a high rate of substitution, a State will consider strategies resembling offering premium assistance to children enrolled in group health plan coverage, and improving public outreach concerning the range of health coverage options which are available in that State. We can be found to supply technical assistance to develop additional strategies to cut back crowd out if it is decided through monitoring activities that substitution of coverage exceeds a suitable threshold determined by the State.

We invite comments on our proposal to eliminate waiting periods to effectively balance the goal of stopping coverage gaps for kids while ensuring that CHIP coverage doesn’t substitute for coverage available under group health plans. We’re also considering the choice of permitting a 30-day waiting period for States which are in a position to display that top rates of substitution are an issue, and invite comments on this proposal.

3. Prohibit Annual and Lifetime Limits on Advantages (SEC 457.480)

Section 1001 of the ACA added section 2711 to the Public Health Service Act (PHS Act), which prohibits annual and lifelong limits on the supply of essential health advantages (EHBs), as defined in section 1302(b) of the ACA, by group health plans and medical health insurance issuer. As such, annual and lifelong limits should not permitted for people enrolled in QHPs through the Exchanges. Medicaid also doesn’t permit annual or lifetime limits. Nevertheless, the CHIP regulations don’t prohibit annual or lifetime limits, and numerous States have implemented annual and lifelong limits on CHIP advantages. Specifically, 12 States place an annual dollar limit on at the least one CHIP profit, and 6 States place a lifetime dollar limit on at the least one profit. Mostly, annual and lifelong advantages are placed on dental, or specifically orthodontia, coverage. Ten States limit dental coverage to $500-$2,000 annually, and 4 States limit lifetime orthodontia coverage to $725-$1,250. These limits may present barriers to children receiving mandatory dental and orthodontia care. Research on childhood oral health care indicates that dental care is probably the most common unmet treatment need in children. /80/ Many low-income families face barriers resembling accessibility and costs that deter them from in search of oral care services, resulting in increased risk of dental diseases or dental emergencies. /81/ Children in low-income families, including those covered by Medicaid and CHIP, are twice as more likely to have untreated tooth decay in comparison with children with higher incomes. /82/ Thus, annual and lifelong limits further exacerbate unmet treatment needs for CHIP children by placing a financial burden on low-income families.

   FOOTNOTE 80 Newacheck, P. W., Hughes, D. C., Hung, Y. Y., Wong, S., & Stoddard, J. J. (2000). The unmet health needs of America’s children. Pediatrics, 105(4 Pt 2), 989-997. END FOOTNOTE

   FOOTNOTE 81 U.S. Department of Health and Human Services.(2004,October). Guide to kid’s dental care in Medicaid. Centers for Medicare and Medicaid Services. Retrieved from: https://www.medicaid.gov/sites/default/files/2019-12/child-dental-guide.pdf. END FOOTNOTE

   FOOTNOTE 82 Dye, B. A., Mitnik, G. L., Iafolla, T. J., & Vargas, C. M. (2017). Trends in dental caries in children and adolescents in keeping with poverty status in the USA from 1999 through 2004 and from 2011 through 2014. Journal of the American Dental Association (1939), 148(8), 550-565.e7. Retrieved from: https://doi.org/10.1016/j.adaj.2017.04.013. END FOOTNOTE

While many States limit specific advantages to an annual or lifetime dollar amount, currently, no State imposes an aggregate annual or lifetime limit on all CHIP advantages. Nevertheless, some States did impose such limits in previous years. Section 2103(f)(2) of the Act requires that coverage offered under a separate CHIP comply with the necessities of subpart 2 of part A of Title XXVII of the PHS Act insofar as such requirements apply with respect to a medical health insurance issuer that provides group medical health insurance coverage. Because section 2711 of the PHS Act is in subpart 2 of part A of Title XXVII of the PHS Act, which applies to separate CHIPs (by cross-reference in section 2103(f)(2) of the Act), States cannot impose annual or lifetime limits in the supply of any EHBs covered under a separate CHIP.

Under section 2103(a) of the Act, States may elect to supply benchmark coverage, benchmark-equivalent coverage, existing comprehensive State-based coverage, or Secretary-approved coverage to their separate population (where applicable). Whatever the variety of coverage provided, there are several required profit categories that States must offer, including well-baby and well-child visits; dental advantages; mental health and substance use disorder services; testing, treatment, and vaccination for COVID-19; and age-appropriate immunizations.

In accordance with section 2101(a) of the Act, which calls for the supply of CHIP in a way that’s effective and efficient and coordinated with other sources of health advantages coverage for kids, and section 2103(f)(2) of the Act which generally prohibits annual and lifelong limits on EHBs, we’re proposing to revise the regulations at SEC 457.480 to ban all annual and lifelong dollar limits on all advantages in CHIP. Although title XXI of the Act doesn’t apply EHB rules under a separate CHIP, the services which have to be covered under title XXI are also EHBs. Specifically, pediatric services (including dental and vision services) and maternity and newborn care are EHBs. Because we consider that every one of the advantages provided to children or targeted low-income pregnant women under a CHIP State plan are inherently pediatric, maternity, or newborn care services, we consider it’s appropriate–indeed, the higher application of the incorporated requirements in section 2711 of the PHS Act to separate CHIPs–to prohibit annual and lifelong limits on all covered CHIP advantages.

We propose that this prohibition be applied each to aggregate annual and lifelong limits on all advantages, in addition to annual and lifelong limits on specific advantages (for instance, dental services). Such limits construct barriers for families to access health coverage and end in an absence of coverage for kids with the best medical needs. Moreover, these limits create a financial hardship on low-income families and/or a rise in uncompensated care that would raise costs for all health coverage payers. We note that the proposed prohibition on annual and lifelong dollar limits wouldn’t apply to non-monetary annual or lifetime limits on specific advantages. For instance, a State could still implement a limitation on the variety of physical therapy visits or eyeglasses that shall be covered annually, provided such limitations are in compliance with all other Federal requirements. We encourage States to take care of processes that allow beneficiaries to exceed these non-financial limitations when medically mandatory.

We propose to redesignate current paragraphs (a) and (b) of SEC 457.480, as paragraphs (b) and (c) respectively, and so as to add a latest paragraph (a) to ban annual and lifelong dollar limits in the supply of all CHIP medical and dental advantages.

III. Collection of Information Requirements

Under the Paperwork Reduction Act of 1995 (PRA) (44 U.S.C. 3501 et seq.) we’re required to supply 60-day notice within the Federal Register and solicit public comment before a “collection of data” requirement is submitted to the Office of Management and Budget (OMB) for review and approval. For the needs of the PRA and this section of the preamble, collection of data is defined under 5 CFR 1320.3(c) of the PRA’s implementing regulations.

With a view to fairly evaluate whether an information collection needs to be approved by OMB, section 3506(c)(2)(A) of the PRA requires that we solicit comment on the next issues:

    * The necessity for the knowledge collection and its usefulness in carrying out the right functions of our agency.

    * The accuracy of our estimate of the knowledge collection burden.

    * The standard, utility, and clarity of the knowledge to be collected.

    * Recommendations to attenuate the knowledge collection burden on the affected public, including automated collection techniques.

We’re soliciting public comment on each of those issues for the next sections of this rule that contain information collection requirements. Comments, if received, shall be responded to inside the next final rule.

A. Wage Estimates

To derive average costs, we used data from the U.S. Bureau of Labor Statistics’ May 2021 National Occupational Employment and Wage Estimates for all salary estimates (http://www.bls.gov/oes/current/oes_nat.htm). On this regard, the next table presents the BLS’ mean hourly wage, our estimated cost of fringe advantages and overhead (calculated at 100% of salary), and our adjusted hourly wage.

See illustration in Original Document.

Wages for State Governments. As indicated, we’re adjusting our worker hourly wage estimates by an element of 100%. That is necessarily a rough adjustment, each because fringe advantages and overhead costs vary significantly from employer to employer, and since methods of estimating these costs vary widely from study to review. Nonetheless, we consider that doubling the hourly wage to estimate total cost is a fairly accurate estimation method.

Cost to State Governments. To estimate State costs, it was vital to have in mind the Federal government’s contribution to the fee of administering the Medicaid, CHIP, and BHP programs. The Federal government provides funding based on a Federal Medical Assistance Percentage (FMAP) that’s established for every State, based on the per capita income within the State as in comparison with the national average. FMAPs range from a minimum of fifty percent in States with higher per capita incomes to a maximum of 76.25 percent in States with lower per capita incomes. States receive an “enhanced” FMAP for administering their CHIP programs, starting from 65 to 83 percent. For Medicaid, all States receive a 50 percent FMAP for administration. As noted previously, States also receive higher Federal matching rates for certain services and now for systems improvements or redesign, so the extent of Federal funding provided to a State could be significantly higher. As such, in bearing in mind the Federal contribution to the prices of administering the Medicaid, CHIP, and BHP programs for purposes of estimating State burden with respect to collection of data, we elected to make use of the upper end estimate that the States would contribute 50 percent of the prices, despite the fact that the burden will likely be much smaller.

Wages for Individuals. For enrollees, we consider that the burden shall be addressed under All Occupations (at $28.01/hr) for the reason that group of individual respondents varies widely from working and nonworking individuals and by respondent age, location, years of employment, and academic attainment, etc. Unlike our State adjustment to the respondent hourly wage, we didn’t adjust this figure for fringe advantages and overhead for the reason that individuals’ activities will occur outside the scope of their employment.

B. Proposed Information Collection Requirements (ICRs)

1. ICRs Regarding Facilitating Enrollment Through Medicare Part D Low-Income Subsidy “Leads” ([Sec.] SEC 435.601, 435.911, and 435.952)

Except for the proposed changes under SEC 435.952(e)(4), the next changes shall be submitted to OMB for review under control number 0938-1147 (CMS-10410), regarding the gathering of eligibility data from State Medicaid and CHIP agencies. The proposed SEC 435.952(e)(4) changes shall be submitted to OMB under control number 0938-0467 (CMS-R-74), regarding the gathering of data for income verification.

OMB Control Number 0938-1147 (CMS-10410)

Proposed SEC 435.911(e) focuses on using the SSA data from processing LIS applications “leads data” to streamline MSP eligibility determinations. Section 435.911(e)(1) would require States to just accept, via secure electronic interface, the SSA LIS leads data, while SEC 435.911(e)(2) would require that States treat receipt of the leads data as an application for Medicaid and promptly and without undue delay determine MSP eligibility without requiring submission of a separate application. Section 435.911(e)(4) would require States to refrain from requesting information from individuals already provided through leads data unless information available to the agency just isn’t reasonably compatible with information provided by or on behalf of the person, while SEC 435.911(e)(5) requires States to just accept information provided through the leads data regarding a criterion of eligibility without further verification.

We estimate that States would give you the chance to adjudicate over 90 percent of MSP applications for LIS enrollees without gathering additional documentation from the applicants. Subsequently, if there are about 400,000 latest LIS applicants approved annually in 51 States, /83/ we estimate that 90 percent of those applicants or 360,000 (400,000 x 0.9) would give you the chance to enroll in an MSP without providing additional income and resource related documentation, and without the State receiving and adjudicating such data.

   FOOTNOTE 83 Over the past 5 years (2017-2021), SSA approved a mean of 394,025 LIS applications annually. https://www.ssa.gov/open/data/Data-about-Extra-Help-with-Medicare-Prescription-Drug-Plan-Cost.html. END FOOTNOTE

The provisions in SEC 435.911(e) are related to a discount in burden for States and beneficiaries related to application completion and eligibility determinations or redeterminations on the State Medicaid agency, including: reduced verification work for States that don’t must adjudicate the leads data for about 360,000 latest LIS applicants; reduced paperwork to submit for the LIS enrollees applying to MSPs in 51 States; reduced time and costs for enrollees who were previously expended to acquire, print, copy, mail and fax documents to the State to support the State’s verification of income and resources; and reduced enrollee burden related to the necessity for public transportation and cellular phone usage in relation to said document activities (obtaining, printing, copying, mailing and faxing).

We estimate that the provisions in SEC 435.911(e) would save an Eligibility Interviewer 25 minutes (0.42 hr = 25 min/60 min) per eligibility determination at $46.14/hr for the 360,000 latest LIS applicants from reduced paperwork to review due to the proposed self-attestation requirements and reduced verification work resulting from considering the leads data as verified. In aggregate, we estimate an annual savings of minus 151,200 hours (360,000 applicants x 0.42 hr) and minus $6,976,368 (151,200 hr x $46.14/hr). Considering the 50 percent Federal contribution to Medicaid and CHIP program administration, the estimated State savings could be minus $3,488,184.

We estimate these provisions would scale back the time needed for LIS enrollees applying to MSPs to submit paperwork from 4 hours to quarter-hour, for a savings of three.75 hours per enrollee per 12 months across all 51 States. In aggregate, we estimate an annual savings of minus 1,350,000 hours (360,000 applicants x 3.75 hr) and minus $37,813,500 (1,350,000 hr x $28.01/hr). We also estimate enrollee non-labor savings from the changes to SEC 435.911(e) from public transportation, printing, copying, postage, and fax expenses to be about $10 [($4.50 postage for small package or $1.75/page for faxing) + $4 roundtrip bus ride (from home to printing/copying place to post office and back home) + $0.13/page for printing/copying)] per LIS enrollee per 12 months for all 51 States. In aggregate, we estimate an annual non-labor savings of minus $3,600,000 (360,000 enrollees x $10/enrollee).

Under proposed SEC 435.952(e)(1) through (e)(4), States could be required to just accept self-attestation of certain income and resources for MSP applicants and beneficiaries, including dividend and interest income, burial funds of spouse and individual, and the face value of life insurance policy. Because 10 States (about 20 percent of all States) do not need asset tests and don’t require documentation to finish an eligibility determination or redetermination on the State Medicaid agency, we expect the savings from the self-attestation proposals would only apply to roughly 8.4 million individuals (80 percent of 11 million applications/renewals /84/ minus 400,000 individuals who applied to LIS counted above) in the opposite 41 States. We estimate that under proposed SEC 435.952(e)(1) through (e)(4), these 8.4 million individuals would see a discount from 4 hours to 2 hours, for a savings of two hours per individual, to finish an application/renewal in all 41 States. In aggregate, we estimate an annual savings of minus 16,800,000 hours (8,400,000 individuals x 2 hr) and minus $470,568,000 (16,800,000 hr x $28.01/hr). We estimate the non-labor savings under proposed SEC 435.952(e)(1) through (e)(4) derived $10 [($4.50 postage for small package or $1.75/page for faxing) + $4 roundtrip bus ride (to/from post office, printing/copying place and home) + $0.13/page for printing/copying)] per MSP applicant/renewal per 12 months for all 51 States. In aggregate, we estimate an annual non-labor savings of minus $84,000,000 (8,400,000 beneficiaries x $10/beneficiary).

   FOOTNOTE 84 Based on States adjudicating 1.5 million latest applications and 10 million for redetermination annually. END FOOTNOTE

We also estimate that the proposal under SEC 435.952(e)(1) through (e)(4) would save an Eligibility Interviewer quarter-hour (0.25 hr) per eligibility determination or renewal for these 8,400,000 applicants/beneficiaries. In aggregate, we estimate an annual labor savings for States of minus 2,100,000 hours (8,400,000 applicants x 0.25 hr) and minus $96,894,000 (2,100,000 hr x $46.14/hr). Considering the 50 percent Federal contribution to Medicaid and CHIP program administration, the estimated State savings could be minus $48,447,000.

OMB Control Number 0938-0467 (CMS-R-74)

We’re also proposing to revise SEC 435.952(e)(4) to require States to develop a verification process to find out the money give up value of life insurance policies over $1,500. We anticipate this proposal could be a change for 10 States of their process for verifying the money give up value of life insurance policies over $1,500. We don’t anticipate an impact in the next 16 States because they’re using authority in section 1902(r)(2) of the Act to disregard the money give up value of life insurance in whole or part: Alabama, Arizona, California, Connecticut, Delaware, Louisiana, Mississippi, Nevada, Recent Mexico, Recent York, North Carolina, Oregon, South Carolina, Vermont, Wyoming, and Washington, DC. Seventy percent of the remaining States would select to make use of authority in section 1902(r)(2) of the Act to disregard the money give up value of life insurance quite than opting to confirm the money give up value of life insurance. As such, we expect that this transformation would only impact 20 percent of all 50 States and Washington, DC (or 10 States). /85/ Based on enrollment in past years, we anticipate that every one States would adjudicate 1,000,000 latest MSP applications a 12 months plus 10 million renewals. Nevertheless, we anticipate this policy would only affect 2 percent of applicants and beneficiaries across 10 States due to the small number of people that could each afford this kind of life insurance (which is far more expensive than term life insurance) and in addition more likely to apply for MSPs (which tends to be lower-income individuals) 44,000 individuals [(11,000,000 individuals x 0.02 x 0.2].

   FOOTNOTE 85 We should not including impacts for territories in these estimates because territories do not need any enrollment in MSPs. END FOOTNOTE

The burden related to proposed changes to SEC 435.952(e)(4) would consist of the effort and time for eligibility employees in 10 States to gather information regarding the money give up value of life insurance from 44,000 applicants; eligibility employees in 10 States not having to spend time coaching 44,000 applicants find out how to gather and find information on the money give up value of life insurance; and eligibility employees in 10 States not having to review life insurance documents for people with life insurance lower than $1,500.

We estimate that under proposed SEC 435.952(e)(4) it might take an Eligibility Interviewer about 1 hour at $46.14/hr to confirm the money give up value of every life insurance policy over $1,500. In aggregate, we estimate an annual burden of 44,000 hours (1 hr x 44,000 individuals) at a price of $2,030,160 (44,000 hr x $46.14/hr). Considering the 50 percent Federal contribution to Medicaid and CHIP program administration, the estimated State share could be $1,015,080.

We estimate the proposal under proposed SEC 435.952(e)(4) would save Eligibility Interviewers a mean 45 minutes (0.75 hr) per applicant from not needing to teach applicants on find out how to gather and find information on the money give up value of life insurance. In aggregate, we estimate an annual savings of minus 33,000 hours (44,000 applicants x 0.75 hr) and $1,522,620 (33,000 hr x $46.14/hr). Considering the 50 percent Federal contribution to Medicaid and CHIP program administration, the estimated State savings could be minus $761,310.

We also estimate State savings under proposed SEC 435.952(e)(4) from eligibility employees not having to review life insurance documents for people with life insurance lower than $1,500. We anticipate it might take an eligibility employee about 10 minutes (0.167 hr) to review a life insurance document and that this savings would affect 3 percent of applicants and beneficiaries or individuals (66,000 individuals = 11,000,000 individuals x 0.03 x 0.2) across 10 States. In aggregate, we estimate an annual savings of minus 11,022 hours (66,000 individuals x – 0.167 hr) and minus $508,555 ( – 11,022 hr x $46.14/hr). Considering the 50 percent Federal contribution to Medicaid and CHIP program administration, the estimated State savings could be minus $254,278.

In total, bearing in mind the Federal contribution, we estimate a State annual burden reduction of minus $51,935,692 ( – $3,488,184 + – $48,447,000 + $1,015,080 + – $761,310 + – $254,278).

For people, we estimate an annual burden reduction of minus 18,150,000 hours (-1,350,000 + – 16,800,000 hr) and minus $595,981,500 ( – $37,813,500 + – $3,600,000 + – 470,568,000 + – $84,000,000).

2. ICRs Regarding Defining “Family of the Size Involved” for the Medicare Savings Program Groups using the Definition of “Family Size” within the Medicare Part D Low-Income Subsidy Program (SEC 435.601)

The next proposed changes shall be submitted to OMB for review under control numbers 0938-1188 (CMS-10434 #15) regarding the submission of a State plan amendment (SPA) and 0938-1147 (CMS-10410) regarding Medicaid application changes.

OMB 0938-1188 (CMS-10434 #15)

Proposed SEC 435.601 would align the definition of “family size” for purposes of MSP eligibility with that of the LIS program. Specifically, “family of the scale involved” could be defined to incorporate at the least the individuals included within the definition of “family size” within the LIS program: the applicant, the applicant’s spouse, and all other individuals living in the identical household who’re related to and depending on the applicant or applicant’s spouse. While some States either already define family size to match the LIS definition or use a family size that’s less restrictive than this definition, we estimate that 10 States use SSI methodologies to find out family size, which suggests that these States only use a person or couple and some other deemed individuals as a part of the family size. As such, we estimate that 10 States would wish to submit a SPA to vary their definition of family size for MSP eligibility groups to comply with this regulation.

We estimate that it might take each State 3 hours to submit a SPA to update the definition of “family size” of their Medicaid State plans. Of those 3 hours, we estimate it might take a Business Operations Specialist 2 hours at $77.28/hr and a General Operations Manager 1 hour at $110.82/hr to update and submit each SPA to CMS for review. In aggregate, we estimate a one-time burden of 30 hours (10 States x 3 hr) at a price of $2,654 (10 States x ([2 hr x $77.28/hr] + [1 hr x $110.82/hr]) for completing the mandatory SPA updates. Considering the 50 percent Federal contribution to Medicaid and CHIP program administration, the estimated State cost could be $1,327.

OMB 0938-1147 (CMS-10410)

We estimate that it might take each State 200 hours to develop and code the changes to its Medicaid application so as to add inquiries to discover other third parties in prospective MSP group households. We note that these changes don’t create additional burden on beneficiaries as the brand new questions could be in lieu of prior questions. As such, the changes require the programming change reflected here with a neutral impact on applicants. Of those 200 hours, we estimate it might take a Database and Network Administrator and Architect 50 hours at $98.50/hr and a Computer Programmer 150 hours at $92.92/hr. In aggregate, we estimate a one-time burden of two,000 hours (10 States x 200 hr) at a price of $188,630 (10 States x [(50 hr x $98.50/hr) + (150 hr x $92.92/hr)]) for completing the mandatory updates to the Medicaid application. Considering the 50 percent Federal contribution to Medicaid and CHIP program administration, the estimated State cost could be $94,315.

In total, bearing in mind the Federal contribution, we estimate a one-time State cost of $95,642 ($1,327 + $94,315).

3. ICRs Regarding Robotically Enrolling Certain SSI Recipients Into the Qualified Medicare Beneficiaries Group (SEC 435.909)

The next proposed changes shall be submitted to OMB for review under control number 0938-1147 (CMS-10410).

The proposal under SEC 435.909 would require that States deem certain individuals who’re eligible for Medicare Part A and SSI eligible for QMB without requiring an application. Particularly, we propose that: (1) States with 1634 agreements must deem Supplemental Security Income (SSI) recipients who’re entitled to premium-free Medicare Part A; (2) all other States must deem SSI recipients who’re entitled to premium-free Medicare Part A and have been determined eligible for Medicaid under either SEC 435.120 or SEC 435.121; and (3) Part A buy-in States must deem if the person is decided eligible for Medicaid under either SEC 435.120 or SEC 435.121, entitled to SSI, only qualifies for premium Part A, and is enrolled in Part B. To implement these latest requirements, States would wish to discover Medicare-eligible SSI recipients to be able to enroll them within the MSPs. States would also must trigger deeming of Medicare-eligible SSI recipients to QMB by making eligibility systems changes to trigger QMB enrollment once the SSI-individual is Medicare eligible. Current regulations don’t allow State Medicaid agencies to forgo an eligibility determination for Medicaid beneficiaries who’re eligible for SSI once they change into newly eligible for Medicare Part A and B. Subsequently, this latest requirement would mean system changes for all 50 States and the District of Columbia, (altogether, 51 “States”).

While these deeming provisions are intended to enroll more SSI recipients in QMB, this rulemaking wouldn’t reach all SSI recipients eligible for QMB. We estimate currently 16 percent or 566,556 (3,540,975 x 0.16) SSI recipients are eligible but not enrolled in QMB, and nearly 500,000 latest SSI recipients who’re enrolled in Medicaid under either SEC 435.120 or SEC 435.121 would enroll in QMB because of this of the proposal under SEC 435.909. As discussed in section II.A.3. of this proposed rule, within the 34 States with a 1634 agreement, the Medicaid agency mechanically enrolls the SSI recipients in Medicaid following a knowledge exchange with SSA after which CMS mechanically initiates Part B buy-in for the person through the “buy-in data exchange.” Within the remaining States, individuals must submit a separate application to the State Medicaid agency to be determined eligible for Medicaid. CMS doesn’t mechanically initiate Part B buy-in for SSI individuals who live in SSI criteria and 209(b) States; quite, States must initiate Part B buy-in once the SSI recipient has individually applied for and been determined eligible for the mandatory SSI or 209(b) group. Moreover, SSI recipients who live in group payer States and are eligible for premium Part A are still required to undergo an advanced two-step application process to ascertain QMB eligibility once a person is decided eligible for the mandatory SSI or 209(b) groups and has been enrolled in Part B pursuant to the State’s buy-in agreement. Under the proposed rule, the applying process for SSI recipients who live in criteria and 209(b) States would remain the identical and so would the two-step application process to ascertain QMB eligibility for SSI recipients living in group payer States and having premium part A.

Based on SSA data and internal CMS evaluation of the 566,556 SSI recipients eligible for QMB but not enrolled, we estimate almost 83 percent (469,820) were likely eligible for premium-free Part Some time roughly 17 percent (96,736) were eligible for premium Part A. Of the 469,820 who were eligible for premium-free Part A, we estimate 405,963 reside in States with 1634 agreements, and 63,857 reside in 209(b) or SSI criteria States. Because Medicaid is automatic in States with 1634 agreements, we estimate that 405,963 individuals (the entire above-mentioned SSI recipients in 1634 States) could be mechanically enrolled in QMB under this latest provision.

In contrast, we estimate that only 65 percent of the above-mentioned 63,857 SSI recipients in 209(b) or SSI criteria States, or 41,507 individuals, could be enrolled under the brand new provision. It’s because it’s unlikely that every one SSI recipients who live in SSI or 209(b) States would complete the Medicaid application process of their State. Of the 96,736 eligible for premium Part A, we estimate 33 percent (31,923) are in Part A buy-in States and 67 percent (64,813) of those eligible for premium Part A are in group payer States, where deeming could be optional. We estimate that 95 percent (30,327) of people in Part A buy-in States who’re eligible for premium Part A would enroll because of this of the brand new provision because we estimate that every one of those individuals live in States with 1634 agreements. Nevertheless, for the individuals eligible for premium Part A in group payer States where deeming could be optional, we expect some more populous States to make use of this feature, so we’re estimating 33 percent (21,388 = 64,813 x 0.33) of all individuals with premium Part A living in group payer States would newly enroll.

Subsequently, we estimate a complete of 499,185 individuals (405,963 + 41,507 + 30,327 + 21,388) would newly enroll without the necessity to finish an application. We estimate that those individuals would each save 2 hours from not filling out Medicaid applications and compiling associated documentation (going from 2 to zero hours) at $28.01/hr. We estimate an annual savings of minus 998,370 hours (499,185 individuals x 2 hr) and minus $27,964,344 (998,370 hr x $28.01/hr).

All 51 States would wish to make eligibility systems changes to deem an SSI individual in QMB once they’re eligible for Medicare. We estimate it might take a Computer Programmer a mean of 180 hours per State at $92.92/hr to make systems changes to set their systems to look for Medicare eligibility in Federal systems after which enroll that individual in QMB. In aggregate, we estimate a one-time burden of 9,180 hours (51 States x 180 hr) at a price of $853,006 (9,180 hr x $92.92/hr). Considering the 50 percent Federal contribution to Medicaid and CHIP program administration, the estimated State share could be $426,503.

We also estimate that this provision would end in an annual reduction of burden for the State to now not review and adjudicate QMB applications from SSI recipients. We estimate that this proposal would save an Eligibility Interviewer 1 hour (going from 1 hour to zero) per QMB determination at $46.14/hr. We also estimate that States conduct QMB eligibility determinations for about 250,000 SSI individuals across 51 States, which might now not be mandatory. In aggregate, we estimate an annual burden savings of minus 250,000 hours (250,000 individuals x – 1 hr/response) and minus $11,535,000 ( – 250,000 hr x $46.14/hr). Considering the 50 percent Federal contribution to Medicaid and CHIP program administration, the estimated State savings could be minus $5,767,500.

In total, for the ICRs related to SEC 435.601 under OMB control number 0938-1147 (CMS-10410), bearing in mind the Federal contribution, we estimate an annual State burden reduction of minus $5,340,997 ($426,503 + – $5,767,500).

4. ICRs Regarding Facilitating Enrollment by Allowing Medically Needy Individuals To Deduct Prospective Medical Expenses (SEC 435.831)

The next proposed changes shall be submitted to OMB for review under control 0938-TBD (CMS-10819). Right now, the control number is to be determined (TBD). OMB will assign the control number upon their clearance of the proposed rule’s latest information collection request. The brand new control number shall be set out in the ultimate rule.

The amendments proposed under SEC 435.831(g) would permit States to project certain additional services that the State can determine with reasonable certainty shall be constant to be able to prevent those within the medically needy group from cycling on and off Medicaid, and stopping the occurrence of an eligibility start date each budget period that just isn’t predictable to either the institutionalized individual or State agency. Over time, this could reduce the burden on the State by eliminating the necessity to process a latest application or renewal every month for every individual within the medically needy group. This is able to also reduce the burden on the person who wouldn’t must reapply every month but as an alternative would remain constantly enrolled. Nevertheless, there could be an up-front cost to the States to program their eligibility systems to project the fee of look after the medically needy group and to remove the triggers to renew eligibility every month once the spenddown amount is reached.

We estimate that every one 56 States (50 States, 5 territories, and the District of Columbia; hereinafter “56 States”) would wish to make system changes to program their eligibility systems to project the fee of look after the medically needy group and to remove the triggers to renew eligibility every month once the spenddown amount is reached. We estimate it might take a mean of 200 hours per State to develop and code the changes to every State’s system to reschedule renewals for medically needy beneficiaries no more steadily than once every 12 months. Of those 200 hours, we estimate it might take a Database and Network Administrator and Architect 50 hours at $98.50/hr and a Computer Programmer 150 hours at $92.92/hr. Subsequently, we estimate a one-time burden of 11,200 hours (56 States x 200 hr) at a price of $1,056,328 (56 States x [(50 hr x $98.50/hr) + (150 hr x $92.92/hr)]) for completing the mandatory system changes. Considering the 50 percent Federal contribution to Medicaid and CHIP program administration, the estimated State share could be $528,164.

We estimate that under proposed SEC 435.831(g), each of all 56 States would now not must process a latest application or renewal every month for 25 individuals within the medically needy group annually. We estimate it currently takes an Eligibility Interviewer, Government Programs, 2 hours at $46.14/hr and an Interpreter and Translator 1 hour at $56.16/hr to assist process a latest application or renewal every month for six months per 12 months per beneficiary. Subsequently, each State would save 450 hours (3 hr x 6 months/12 months x 25 beneficiaries) and $22,266 (6 months/12 months x 25 beneficiaries x [(2 hr x $46.14/hr) + (1 hr x $56.16/hr)]) annually by not processing a latest application or renewal every month for every individual within the medically needy group. In aggregate, we estimate this provision would save all States minus 25,200 hours (450 hr x 56 States) and minus $1,246,896 ($22,266 x 56 States). When bearing in mind the 50 percent Federal contribution to Medicaid and CHIP program administration, the estimated State savings could be minus $623,448.

Likewise, we estimate that under proposed SEC 435.831(g), those self same 25 beneficiaries would now not must reapply every month but as an alternative would remain constantly enrolled, thus reducing the burden on the individuals. We estimate that it currently takes a beneficiary 2 hours at $28.01/hr to reapply every month in a mean of 6 months per 12 months. Subsequently, beneficiaries in each State would save a complete of 300 hours (2 hr x 6 months/12 months x 25 beneficiaries/State) and $8,403 (300 hr x $28.01/hr) annually. In aggregate, under this provision, beneficiaries across all 56 States would save 16,800 hours (300 hr x 56 States) and $470,568 ($8,403 x 56 States) annually.

In total, for the ICRs related to SEC 435.831 under OMB control number 0938-TBD (CMS-10819), bearing in mind the Federal contribution, we estimate a one-time State cost of minus $95,284 ($528,164 + – $623,448).

5. ICRs Regarding Application of Primacy of Electronic Verification and Reasonable Compatibility Standard for Resource Information ([Sec.] SEC 435.952 and 435.940)

The next proposed changes shall be submitted to OMB for review under control number 0938-0467 (CMS-R-74).

States have asked whether or not they are permitted to request additional documentation from applicants and beneficiaries related to resources that could be verified through the State’s asset verification system (AVS), or in the event that they can apply an inexpensive compatibility standard for resources when resource information returned from an electronic data source is in comparison with the knowledge provided by the applicant or beneficiary. We consider the necessities at SEC 435.952(b) and (c), which require States to use an inexpensive compatibility test to income determinations, apply to resource determinations as well. We consider that clearly applying the necessities at SEC 435.952(b) and (c) to resources will help streamline enrollment for people applying for Medicaid on a non-MAGI basis, resembling on the idea of age, blindness, or disability, and reduce burden for each States and beneficiaries.

The amendments proposed under [Sec.] SEC 435.952 and 435.940 would make clear that, if information provided by a person is fairly compatible with information returned through an AVS, the State must determine or renew eligibility based on that information. They might also make clear that States must consider asset information obtained through an AVS to be reasonably compatible with attested information if either each are above or each are at or below the applicable resource standard or other relevant resource threshold.

Under the proposed changes to [Sec.] SEC 435.952 and 435.940, we estimate that the States would save an Eligibility Interviewer 1 hour per beneficiary at $46.70/hr to now not reach out to 10,000 individuals per State for extra information to confirm their resources. In aggregate, we estimate a savings for all States of 510,000 hours (51 States x 10,000 individuals/State x 1 hr) and $23,531,400 (510,000 hr x $46.14/hr). When bearing in mind the 50 percent Federal contribution to Medicaid and CHIP program administration, the estimated State savings could be minus $11,765,700 ($23,531,400 x 0.5).

Under the proposed changes to [Sec.] SEC 435.952 and 435.940, we estimate that 10,000 individuals per State would save on average 1 hour each at $28.01/hr to now not must submit additional information to confirm their resources. In aggregate for people in all States, we estimate a savings of minus 510,000 hours (1 hr x 10,000 individuals/State x 51 States) and minus $14,285,100 (510,000 hr x $28.01/hr).

6. ICRs Regarding Verification of Citizenship and Identity (SEC 435.407)

The next proposed changes shall be submitted to OMB for review under control number 0938-0467 (CMS-R-74).

The amendments proposed under SEC 435.407 would simplify eligibility verification procedures by considering verification of birth with a State vital statistics agency or verification of citizenship with SAVE as stand-alone evidence of citizenship. Likewise, under this provision, separate verification of identity wouldn’t be required. This proposed revision just isn’t intended to require a State to develop a match with its vital statistics agency if it doesn’t have already got one in place. Nevertheless, if a State already has established a match with a State vital statistics agency or it might be effective to ascertain such capability in accordance with the usual set forth in SEC 435.952(c)(2)(ii), the State must utilize such match before requesting paper documentation from the applicant. We estimate this provision would apply to the roughly 100,000 applicants per 12 months for whom States cannot confirm U.S. citizenship with SSA.

We estimate that the amendments proposed under SEC 435.407 would take a Management Analyst quarter-hour (0.25 hr) per applicant at $96.66/hr to envision the State’s vital statistics agency for verification of U.S. citizenship of an applicant. In aggregate for all 56 States, this provision would add a burden of 25,000 hours (0.25 hr x 100,000 applicants) and $2,416,500 (25,000 hr x $96.66/hr). Considering the 50 percent Federal contribution to Medicaid and CHIP program administration, the estimated State share could be $1,208,250.

In contrast, we estimate that the amendments proposed under SEC 435.407 would save an Eligibility Interviewer 45 minutes (0.75 hr) at $46.70/hr by now not needing to request and process paper documentation of citizenship. In aggregate, all 56 States would save minus 75,000 hours (0.75 hr x 100,000 applicants) and minus $3,460,500 (75,000 hr x $46.14/hr). Considering the 50 percent Federal contribution to Medicaid and CHIP program administration, the estimated State savings could be minus $1,730,250.

In total for the ICRs related to SEC 435.407 under OMB control number 0938-0467 (CMS-R-74), bearing in mind the Federal contribution, we estimate an annual State savings of minus $522,000 ($1,208,250 + – $1,730,250). For people, we estimate that the amendments proposed under SEC 435.407 would save each applicant 1 hour at $28.01/hr plus a mean of $10 in miscellaneous costs [($4.50 postage for small package or $1.75/page for faxing) + $4 roundtrip bus ride (from home to printing/copying place to post office and back home) + $0.13/page for printing/copying], to now not need to collect and submit paper documentation of citizenship. In aggregate, all 100,000 applicants would save 100,000 hours (1 hr x 100,000 applicants) and $2,801,000 (100,000 hr x $28.01/hr) in labor and + $1,000,000 ($10.00 x 100,000 applicants) in non-labor related costs.

7. ICRs Regarding Aligning Non-MAGI Enrollment and Renewal Requirements With MAGI Policies (SEC 435.916)

The next proposed changes shall be submitted to OMB for review under control number 0938-1147 (CMS-10410).

The amendments proposed under SEC 435.916(a) would align the frequency of renewals for non-MAGI beneficiaries with the present requirement for MAGI beneficiaries, which allows for renewals no more steadily than every 12 months. Proposed SEC 435.916(b) also requires States to adopt the prevailing renewal processes required for MAGI beneficiaries for non-MAGI beneficiaries when a State is unable to renew eligibility for a person based on information available to the agency. Proposed SEC 435.916(b)(2) would require States to supply all beneficiaries, including non-MAGI beneficiaries, whose eligibility can’t be renewed without contacting the person in accordance with proposed SEC 435.916(b)(1), a renewal form that’s pre-populated with information available to the agency, a minimum of 30 calendar days to return the signed renewal form together with any required information, and a 90-day reconsideration period for people terminated for failure to return their renewal form but who subsequently return their form throughout the reconsideration period. Proposed SEC 435.916(b)(2) now not permits States to require an in-person interview for non-MAGI beneficiaries as a part of the renewal process.

We estimate that in 2021, six States–Minnesota, Recent Hampshire, Texas, Utah, Washington, and West Virginia–have policies in place to conduct regularly-scheduled renewals for at the least some non-MAGI beneficiaries more steadily than once every 12 months. One other State conducts more frequent renewals for non-MAGI populations during normal operations, but elected to conduct renewals just once every 12-months for all beneficiaries through the COVID-19 PHE. We excluded the State from these estimates as it might have needed to make changes for the temporary authority in effect as of 2021 through the PHE.

Under proposed SEC 435.916(a), we estimate it might take a mean of 200 hours per State to develop and code the changes to every State’s system to reschedule renewals for non-MAGI beneficiaries no more steadily than once every 12 months. Of those 200 hours, we estimate it might take a Database and Network Administrator and Architect 50 hours at $98.50/hr and a Computer Programmer 150 hours at $92.92/hr. In aggregate, we estimate a one-time burden of 1,200 hours (6 States x 200 hr) at a price of $113,178 (6 States x [(50 hr x $98.50/hr) + (150 hr x $92.92/hr)]) for completing the mandatory system changes. Considering the 50 percent Federal contribution to Medicaid and CHIP program administration, the estimated State share could be $56,589.

We also estimate that 21 States don’t pull available non-MAGI beneficiary information to prepopulate a renewal form. /86/ Under proposed SEC 435.916(b)(2), we estimate it might take a mean of 200 hours per State to develop and code the changes to every State’s system to tug the prevailing non-MAGI beneficiary information to prepopulate a renewal form. Of those 200 hours, we estimate it might take a Business Operations Specialist 50 hours at $77.28/hr and a Management Analyst 150 hours at $96.66/hr. In aggregate, we estimate a one-time burden of 4,200 hours (21 States x 200 hr) at a price of $385,592 (21 States x [(50 hr x $77.25/hr) + (150 hr x $96.66/hr)] for completing the mandatory system changes and designing the shape. Considering the 50 percent Federal contribution to Medicaid and CHIP program administration, the estimated State share could be $192,796.

   FOOTNOTE 86 Kaiser Family Foundation. Medicaid Financial Eligibility for Seniors and Individuals with Disabilities: Findings from a 50-State Survey. Available at: https://files.kff.org/attachment/Issue-Transient-Medicaid-Financial-Eligibility-for-Seniors-and-People-with-Disabilities-Findings-from-a-50-State-Survey. END FOOTNOTE

While we do not need evidence of what number of States currently require an in-person interview, to calculate this burden, we’ll assume all 56 States achieve this, with the understanding that the actual State savings shall be much less. In 2020, there have been about 2,688,386 non-MAGI beneficiaries /87/ for whom States would now not must conduct an in-person interview for non-MAGI beneficiaries as a part of the renewal process. Under proposed SEC 435.916(b)(2), we estimate that an Eligibility Interviewer would save on average 0.5 hours per beneficiary at $46.14/hr. In aggregate, we estimate this could save States minus 1,344,193 hours (0.5 hr x 2,688,386 beneficiaries) and minus $62,021,065 (1,344,193 hr x $46.14/hr). Considering the 50 percent Federal contribution to Medicaid and CHIP program administration, the estimated State savings could be minus $31,010,533.

   FOOTNOTE 87 Major Eligibility Group Information for Medicaid and CHIP Beneficiaries by Yr, accessed from: https://data.medicaid.gov/dataset/267831f3-56d3-4949-8457-f6888d8babdd. END FOOTNOTE

In total for the ICRs related to SEC 435.916 under OMB control number 0938-1147 (CMS-10410), bearing in mind the Federal contribution, we estimate a one-time State savings of minus $30,761,148 ($56,589 + $192,796 – $31,010,533) with an annual savings of minus $31,010,533. We estimate that within the six States–Minnesota, Recent Hampshire, Texas, Utah, Washington, and West Virginia–that currently have policies to conduct regularly-scheduled renewals for non-MAGI beneficiaries more steadily than once every 12 months during normal operations, in 2020, there have been about 2,688,386 non-MAGI beneficiaries /88/ who would now not must submit a renewal under proposed SEC 435.916(a). Assuming impacted beneficiaries are evenly distributed across these six States, and assuming it currently takes each beneficiary 1 hour at $28.01/hr to submit a renewal form, in aggregate, beneficiaries across these six States would save minus 2,688,386 hours (2,688,386 non-MAGI beneficiaries x 1 hr) and minus $75,301,692 ( – 2,688,386 hr x $28.01/hr).

   FOOTNOTE 88 Ibid. END FOOTNOTE

While we do not need evidence of what number of States currently require an in-person interview, to calculate this burden, we’ll assume all 56 States achieve this, with the understanding that the actual individual burden shall be much less. In 2020, there have been about 2,688,386 non-MAGI beneficiaries /89/ who would now not must travel to a Medicaid office to finish an in-person interview to be able to maintain coverage under proposed SEC 435.916(b)(2). Assuming impacted beneficiaries are evenly distributed across these 56 States and assuming it currently takes each beneficiary 1 hour to travel to and take part in an in-person interview, plus on average $10/person in travel expenses, in aggregate, beneficiaries across these 56 States would save minus 2,688,386 hours (2,688,386 beneficiaries x 1 hr) and minus $75,301,692 (2,688,386 hr x $28.01/hr) in labor and minus $26,883,860 (2,688,386 non-MAGI beneficiaries x $10.00) in non-labor related costs.

   FOOTNOTE 89 Ibid. END FOOTNOTE

Under proposed SEC 435.916(b)(2), we estimate 37 States will need to ascertain a reconsideration period for non-MAGI beneficiaries or extend the timeframe of their existing reconsideration period for non-MAGI beneficiaries to 90 calendar days. In 2020, there have been as much as 2,688,386 non-MAGI beneficiaries in 56 States /90/ who would newly not need to finish a latest application to regain coverage after being terminated for coverage for failure to return their renewal form under this provision. Roughly 4.2 percent of beneficiaries are disenrolled from coverage and reenroll inside 90 days. /91/ Subsequently, we estimate 74,603 beneficiaries (2,688,386 beneficiaries/56 States x 0.042 x 37 States) would newly not need to finish a full application to reenroll in coverage because they might be in a 90-day reconsideration period under proposed SEC 435.916(b)(2). Assuming impacted beneficiaries are evenly distributed across the 37 States and assuming it currently takes each beneficiary 1 hour at $28.01/hr to submit a latest full application, this provision would save, in aggregate, beneficiaries across these 37 States a complete of minus 74,603 hours (74,603 beneficiaries x 1 hr) and minus $2,089,630 (74,603 hr x $28.01/hr).

   FOOTNOTE 90 Ibid. END FOOTNOTE

   FOOTNOTE 91 Kaiser Family Foundation (2021). Medicaid Enrollment Churn and Implications for Continuous Coverage Policies. https://www.kff.org/medicaid/issue-brief/medicaid-enrollment-churn-and-implications-for-continuous-coverage-policies/. END FOOTNOTE

For beneficiaries, we estimate a complete burden reduction of minus $179,576,874 ( – $75,301,692 – $102,185,552 – $2,089,630).

8. ICRs Regarding Acting on Changes in Circumstances ([Sec.] SEC 435.916, 435.919, and 457.344)

The next proposed changes shall be submitted to OMB for review under control number 0938-1147 (CMS-10410).

The amendments proposed under SEC 435.919 would, if the State cannot redetermine the person’s eligibility after a change in circumstance using third party data and knowledge available to the agency, allow beneficiaries at the least 30 calendar days from the date the State sends a request for extra information to supply such information. As well as, the amendments would require States to supply beneficiaries terminated resulting from failure to supply information requested after a change in circumstance with a 90-day reconsideration period.

Since the proposed requirements under [Sec.] SEC 435.912, 435.919, and 457.344 would end in more time for beneficiaries to answer the State’s request for extra information, it is probably going that fewer beneficiaries would lose eligibility because of this of this provision. As well, since the proposed amendments would, for the primary time, provide a 90-day reconsideration period after a change in circumstance for all roughly 85,809,179 Medicaid and CHIP beneficiaries (within the 51 States that reported enrollment data for November 2021), /92/ to submit additional information to take care of their eligibility, it is probably going that beneficiaries wouldn’t need to finish and States wouldn’t must process full applications for 4.2 percent of those individuals or 3,603,986 beneficiaries (85,809,179 beneficiaries x 0.042) who lose coverage and later reenroll. /93/

   FOOTNOTE 92 CMS, November 2021 Medicaid & CHIP Enrollment. Available at https://www.medicaid.gov/medicaid/program-information/medicaid-and-chip-enrollment-data/report-highlights/index.html. END FOOTNOTE

   FOOTNOTE 93 Kaiser Family Foundation. (2021). Medicaid Enrollment Churn and Implications for Continuous Coverage Policies. https://www.kff.org/medicaid/issue-brief/medicaid-enrollment-churn-and-implications-for-continuous-coverage-policies/. END FOOTNOTE

Assuming the 40 States with a separate CHIP agency can adapt language from the Medicaid notice for his or her purposes, we estimate it might not take as long for those 40 States to revise the notice requesting additional information from beneficiaries regarding their eligibility after a change in circumstance to incorporate language allowing the beneficiary 30 calendar days to reply. Subsequently, we estimate it might take a mean of 6 hours per State Medicaid agency and three hours per separate CHIP agency to finish this task. Of the 6 Medicaid hours, we estimate it might take a Business Operations Specialist 4 hours (and a pair of hr for CHIP) at $77.28/hr and a Management Analyst 2 hours (and 1 hr for CHIP) at $96.66/hr. We estimate an aggregate, one-time burden of 426 hours [(51 Medicaid States /94/ x 6 hr) + (40 CHIP States x 3 hr)] at a price of $35,673 (51 States x [(4 hr x $77.28/hr) + (2 hr x $96.66/hr)] + (40 States x [(2 hr x $77.28/hr) + (1 hr x $96.66/hr)]) for revising the notice requesting additional information. Considering the 50 percent Federal contribution to Medicaid and CHIP program administration, the estimated State share could be $17,837.

   FOOTNOTE 94 While this provision applies to all States, Washington, DC, and the 5 territories, we’re only estimating the burden for the 51 States for which we’ve current enrollment data, per the November 2021 CMS enrollment snapshot, available at https://www.medicaid.gov/medicaid/national-medicaid-chip-program-information/downloads/october-november-2021-medicaid-chip-enrollment-trend-snapshot.pdf. END FOOTNOTE

We also estimate it might take each State 6 hours to revise the termination notice to beneficiaries who didn’t reply to the State’s request for extra information regarding their eligibility after a change in circumstance to incorporate language allowing the beneficiary a 90-day reconsideration period. Of those 6 hours, we estimate it might take a Business Operations Specialist a mean of 4 hours at $77.28/hr and a Management Analyst 2 hours at $96.66/hr. In aggregate, we estimate a one-time burden of 336 hours (56 States x 6 hr) at a price of $28,137 (56 States x [(4 hr x $77.28/hr) + (2 hr x $96.66/hr)] for revising the termination notice. Considering the 50 percent Federal contribution to Medicaid and CHIP program administration, the estimated State share could be $14,068.

We also estimate that it might save each State 50 hours to process full applications annually for beneficiaries who would now not lose coverage and later reenroll. Specifically, we estimate it might save an Eligibility Interviewer 40 hours at $46.14/hr and an Interpreter and Translator 10 hours at $56.16/hr. In aggregate, we estimate an annual savings of minus 2,800 hours (56 States x 50 hr) and minus $134,803 ([(40 hr x $46.14/hr) + (10 hr x $56.16/hr)] x 56 States) for processing fewer full applications. Considering the 50 percent Federal contribution to Medicaid and CHIP program administration, the estimated State savings could be minus $67,402.

In total, for ICRs related to SEC 435.919 under OMB control number 0938-1147 (CMS-10410), bearing in mind the Federal contribution, we estimate a complete State savings of minus $35,497 ($17,837 + $14,068 – $67,402).

We estimate that it might save each beneficiary who’s disenrolled after a change in circumstance 2 hours at $28.01/hr to now not submit a full application. As stated above, roughly 4.2 percent of beneficiaries are disenrolled from coverage and reenroll inside 90 days. /95/ Because this provision applies to all beneficiaries, which numbered roughly 85,809,179 individuals for Medicaid and CHIP (within the 51 States that reported enrollment data for November 2021), /96/ we estimate roughly 3,603,986 beneficiaries (85,809,179 beneficiaries x 0.042) would save this time not reapplying after a change in circumstance. In aggregate, we estimate that this provision would save beneficiaries minus 7,207,972 hours (3,603,986 beneficiaries x 2 hr) and minus $201,895,296 (7,207,972 hr x $28.01/hr).

   FOOTNOTE 95 Kaiser Family Foundation (2021). Medicaid Enrollment Churn and Implications for Continuous Coverage Policies. https://www.kff.org/medicaid/issue-brief/medicaid-enrollment-churn-and-implications-for-continuous-coverage-policies/. END FOOTNOTE

   FOOTNOTE 96 CMS, November 2021 Medicaid & CHIP Enrollment. Available at https://www.medicaid.gov/medicaid/program-information/medicaid-and-chip-enrollment-data/report-highlights/index.html. END FOOTNOTE

9. ICRs Regarding Timely Determination and Redetermination of Eligibility in Medicaid (SEC 435.912) and CHIP (SEC 457.340)

The next proposed changes shall be submitted to OMB for review under control number 0938-1188 (CMS-10434 #15) for the State plan changes and 0938-1147 (CMS-10410) for the remaining burden related to updating notices and systems.

OMB Control Number 0938-1188 (CMS-10434 #15)

The amendments on this section would establish standards to make sure that applicants have enough time to collect and supply additional information and documentation requested by a State in adjudicating eligibility. As well as, the proposed amendments would apply to redeterminations either at renewal or based on changes in circumstances, the present requirements which apply at application. To deal with the present situation where redeterminations remain unprocessed for several months following the top of a beneficiary’s eligibility period resulting from the beneficiary failing to return needed information to the State, these proposed amendments would require States to ascertain timeliness standards for each beneficiaries to return requested information to the State, in addition to for the State to finish a redetermination of eligibility when the beneficiary returns information too late to process before the top of the eligibility period. As well as, these proposed amendments would require States to ascertain performance and timeliness standards for determining Medicaid eligibility, in addition to determining eligibility for CHIP and BHP when a person is decided ineligible for Medicaid.

Lastly, the amendments proposed under SEC 435.912 would for the primary time establish set timeframes for when States must complete existing requirements related to acting on change in circumstances. The amendments would require States to process a redetermination inside 30 calendar days from the date the State receives information indicating a possible change in a beneficiary’s circumstance if no information is required from the person to redetermine eligibility and inside 60 calendar days if the State must request additional information from the person.

We estimate that it might take each State 3 hours to update their Medicaid State plans via a SPA to ascertain timeliness standards for the State to process redeterminations. Of those 3 hours per SPA, we estimate it might take a Business Operations Specialist 2 hours at $77.28/hr and a General Operations Manager 1 hour at $110.82/hr to update and submit each SPA to CMS for review. In aggregate, we estimate a one-time burden of 168 hours (56 States x 3 hr) at a price of $14,861 (56 responses x ([2 hr x $77.28/hr] + [1 hr x $110.82/hr])) for completing the mandatory SPA updates. Considering the 50 percent Federal contribution to Medicaid and CHIP program administration, the estimated State share could be $7,431.

OMB Control Number 0938-1147 (CMS-10410)

We estimate that it might take each State 6 hours to update their notices to tell beneficiaries of the newly established timeframes inside which they need to return requested additional information to ensure that the State to process their redeterminations. Of those 6 hours, we estimate it might take a Business Operations Specialist 4 hours at $77.28/hr and a Computer Programmer 2 hours at $92.92/hr. In aggregate, we estimate a one-time burden of 336 hours (56 States x 6 hr) and $27,718 (56 States x ([4 hr x $92.92/hr] + [2 hr x $77.28/hr])) for all States to update the notices. Considering the 50 percent Federal contribution to Medicaid and CHIP program administration, the estimated State share could be $13,859.

We also estimate it might take a mean of 200 hours per State to develop and code the changes to every State’s system to remove the edit to disenroll those beneficiaries who fail to return additional information throughout the newly established timeframes. Of those 200 hours, we estimate it might take a Business Operations Specialist 50 hours at $77.28/hr and a Management Analyst 150 hours at $96.66/hr. In aggregate, we estimate a one-time burden for all States of 11,200 hours (56 States x 200 hr) at a price of $1,028,244 ([(50 hr x $77.25/hr) + (150 hr x $96.66/hr)] x 56 States) for completing the mandatory system changes. Considering the 50 percent Federal contribution to Medicaid and CHIP program administration, the estimated State share could be $514,122.

In total for the ICRs related to [Sec.] SEC 435.912 and 457.340 under OMB control number 0938-1188 (CMS-10434 #15) and 0938-1147 (CMS-10410), bearing in mind the Federal contribution, we estimate a complete one-time State cost of $535,412 ($7,431 + $13,859 + $514,122).

10. ICRs Regarding Returned Mail ([Sec.] SEC 435.919 and 457.344)

The next proposed changes shall be submitted to OMB for review under control number 0938-1147 (CMS-10410).

This rule proposes to specify the steps States must take when beneficiary mail is returned to the agency. States could be required to first conduct a series of information checks to discover updated beneficiary contact information, including the State’s Medicaid Enterprise System (MES), managed care plans, enrollment brokers, claims data, and other State administered public profit systems, like TANF, SNAP, the DMV, in addition to the NCOA. If updated contacted information is found, States must send a notice to that latest address. Second, based on this information available to the State agency, the State must try to contact the beneficiaries by each mail, in addition to a modality apart from mail, resembling by phone, electronic notice, email, or text message, as permissible. This provision also requires the State to send notices to each the present address on file and the forwarding address, if one is provided on the returned mail, requesting that the beneficiary confirm the brand new address. Third, only after the above has occurred with no response may the State take motion, including updating the beneficiary’s in-state address, terminating or suspending the beneficiary’s enrollment, or moving the beneficiary from managed care to fee-for-service Medicaid.

We estimate that it might take all 42 Medicaid managed care States (and 34 States with managed care in separate CHIP) 40 hours to update their managed care contracts to enter into regular data-sharing arrangements with their MCOs to acquire up-to-date beneficiary contact information. While a few of these States have each Medicaid and CHIP managed care and will even contract with the identical plans for each programs, we assume there is no such thing as a overlap for purposes of this estimate. Of those 40 hours, we estimate it might take a Procurement Clerk 10 hours at $43.20/hr and a Management Analyst 30 hours at $96.66/hr. In aggregate, we estimate this could create a one-time burden for States of three,040 hours [40 hr x (42 Medicaid States + 34 CHIP States] at a price of $253,217 [(10 hr x $43.20/hr) + (30 hr x $96.66/hr) x 76 State agencies]. Considering the 50 percent Federal contribution to Medicaid and CHIP program administration, the estimated State share could be $126,609.

We estimate, using CMS’ own evaluation, that about half of all States (56 States/2 = 28 States) currently check DMV data for updated beneficiary information, resembling contact information, as a component of their routine verification plans. Using this as a proxy for whether the State has an agreement with third-party sources, for instance, NCOA, DMV, etc., we estimate that it might take 28 States each 40 hours to ascertain these data-sharing agreements. Of those 40 hours, we estimate it might take a Procurement Clerk 10 hours at $43.20/hr and a Management Analyst 30 hours at $96.66/hr. In aggregate, we estimate a one-time burden of 1,120 hours (40 hr x 28 States) at a price of $93,290 ([(10 hr x $43.20/hr) + (30 hr x $96.66/hr)] x 28 States). Considering the 50 percent Federal contribution to Medicaid and CHIP program administration, the estimated State share could be $46,645.

Assuming 15 percent /97/ of all Medicaid beneficiaries (12,871,377 beneficiaries = 85,809,179 beneficiaries x 0.15) /98/ generate returned mail annually, we estimate that it might take 51 States each 30 seconds (roughly 0.0083 hr) per notice to send one additional notice by mail not only to the present address on file, but in addition to the forwarding address, if one is provided. We estimate that it might take a Management Analyst in each State 0.0083 hr/notice at $96.66/hr to program the sending of those extra notices for a complete of 106,832 hours (0.0083 hr x 12,871,377 beneficiaries) at a price of $10,326,381 (106,832 hr x $96.66/hr). We also estimate this amendment would create additional burden in postage costs for all States and all beneficiaries totaling $7,722,826 ($0.60/notice /99/ x 12,871,377 /100/ ). Considering the 50 percent Federal contribution to Medicaid and CHIP program administration, the estimated State share could be $9,024,603.

   FOOTNOTE 97 KHN, November 9, 2019, “Return to Sender: A Single Undeliverable Letter Can Mean Losing Medicaid.” Available at https://khn.org/news/tougher-returned-mail-policies-add-to-medicaid-enrollment-drop/. END FOOTNOTE

   FOOTNOTE 98 Centers for Medicare & Medicaid Services, “October and November 2021 Medicaid and CHIP Enrollment Trends Snapshot,” March 28, 2022. Available at https://www.medicaid.gov/medicaid/national-medicaid-chip-program-information/downloads/october-november-2021-medicaid-chip-enrollment-trend-snapshot.pdf. END FOOTNOTE

   FOOTNOTE 99 This amount relies on the present USPS postage rate for traditional letters. END FOOTNOTE

   FOOTNOTE 100 While this provision applies to all States, Washington, DC, and the 5 territories, we’re only estimating the burden for the 51 States for which we’ve current enrollment data, per the November 2021 CMS enrollment snapshot available at https://www.medicaid.gov/medicaid/national-medicaid-chip-program-information/downloads/october-november-2021-medicaid-chip-enrollment-trend-snapshot.pdf. END FOOTNOTE

We estimate that it might take an Eligibility Interviewer a mean of 5 minutes (5/60 = roughly 0.083 hr) per beneficiary at $46.14/hr to make one additional outreach attempt using a modality apart from mail to the estimated 12,871,377 beneficiaries per 12 months for whom the State receives returned mail. In aggregate, we estimate this could add a burden of 1,068,324 hours (0.083 hr x 12,871,377 beneficiaries) at a price of $49,292,469 (1,068,324 hr x $46.14/hr). Considering the 50 percent Federal contribution to Medicaid and CHIP program administration, the estimated State share could be $24,646,235.

In total for the ICRs related to [Sec.] SEC 435.919 and 457.344 under OMB control number 0938-1147 (CMS-10410), and bearing in mind the 50 percent Federal contribution, we estimate a complete State cost of $33,844,092 ($126,609 + $46,645 + $9,024,603 + $24,646,235).We estimate that current State policies on returned mail can have contributed to roughly 2.125 percent drop in enrollment. /101/ Applying that change, we estimate that 273,517 beneficiaries (12,871,377 beneficiaries x 0.02125) would now not be disenrolled after non-response to a State notice generated by returned mail and would now not must reapply to Medicaid. Subsequently, we estimate that these amendments would result in a discount in burden for 273,517 beneficiaries who would otherwise be disenrolled after generating returned mail. We estimate that these beneficiaries at $28.01/hr would each save 2 hours of time not needed to reapply for Medicaid. In aggregate, we estimate this amendment would save beneficiaries in all States minus 547,034 hours (273,517 beneficiaries x 2 hr) and minus $15,322,422 (547,034 hr x $28.01/hr).

   FOOTNOTE 101 KHN, November 9, 2019, “Return to Sender: A Single Undeliverable Letter Can Mean Losing Medicaid.” Available at https://khn.org/news/tougher-returned-mail-policies-add-to-medicaid-enrollment-drop/. END FOOTNOTE

11. ICRs Regarding Improving Transitions Between Medicaid and CHIP ([Sec.] SEC 435.1200, 457.340, 457.348, 457.350, and 600.330)

The next proposed changes shall be submitted to OMB for review under control number 0938-1147 (CMS-10410).

In States with separate Medicaid and CHIP programs, proposed SEC 435.1200 would require each the Medicaid and CHIP agencies to make system changes to more seamlessly transition the eligibility of people from one program to the opposite. Now we have not included a burden estimate for changes to the BHP regulations, since revisions to the Medicaid cross-references are intended to take care of current BHP policies.

We estimate that proposed SEC 435.1200 would take each of the 40 States with a separate CHIP 40 hours to execute a delegation agreement between the Medicaid and CHIP agencies to implement more seamless coverage transitions. Of those 40 hours, we estimate it might take a Procurement Clerk 10 hours at $43.20/hr and a Management Analyst 30 hours at $96.66/hr. In aggregate, we estimate a one-time burden of 1,600 hours (40 hr x 40 States) at a price of $133,272 [(10 hr x $43.20/hr) + (30 hr x $96.66/hr) x 40 States]. Considering the 50 percent Federal contribution to Medicaid and CHIP program administration, the estimated State share could be $66,636.

We estimate that it might take all 40 States with a separate CHIP a mean of 42 hours each to review any policy differences between their Medicaid and CHIP programs and make any mandatory administrative actions to allow coordination of enrollment, resembling a delegation of eligibility determinations or alignment of economic eligibility requirements between the 2 programs roughly. Of those 42 hours, we estimate it might take a Business Operations Specialist 22 hours at $77.28/hr and a Management Analyst 20 hours at $96.66/hr. In aggregate, we estimate a one-time burden of 1,680 hours (40 States x 42 hr) at a price of $145,334 ([(22 hr x $77.28/hr) + (20 hr x $96.66/hr)] x 40 States) to review and make mandatory policy changes. Considering the 50 percent Federal contribution to Medicaid and CHIP program administration, the estimated State share could be $72,667.

We estimate that it might take all 40 States with a separate CHIP 200 hours to make changes to their shared eligibility system or service to find out, based on available information, whether the person is eligible for Medicaid or CHIP when determined ineligible for the opposite program and before a notice of ineligibility is distributed. Of those 200 hours, we estimate it might take a Business Operations Specialist 50 hours at $77.28/hr and a Management Analyst 150 hours at $96.66/hr. In aggregate, we estimate a one-time burden for all 40 States of 8,000 hours (40 States x 200 hr) at a price of $734,520 ([(50 hr x $77.28/hr) + (150 hr x $96.66/hr)] x 40 States) for completing the mandatory system changes. Considering the 50 percent Federal contribution to Medicaid and CHIP program administration, the estimated State share could be $367,260.

We estimate that 25 percent of States with a separate CHIP (40 States x 0.25 = 10) are already using combined notices and would see no additional burden from this provision. For the 30 of the 40 States with separate CHIPs who don’t currently use a combined notice, we estimate that it might take 6 hours to develop or update a combined eligibility notice for people determined ineligible for Medicaid and eligible for CHIP or vice versa and 40 hours to make the system changes mandatory to implement it. Of those 46 hours, we estimate that it might take a Business Operations Specialist 14 hours at $77.28/hr and a Management Analyst 32 hours at $96.66/hr. In aggregate, we estimate a one-time burden of 1,380 hours (30 States x 46 hr) at a price of $125,251 ([(14 hr x $77.28/hr) + (32 hr x $96.66/hr)] x 30 States) to develop the notice. Considering the 50 percent Federal contribution to Medicaid and CHIP program administration, the estimated State share could be $62,626.

In total for the ICRs related to [Sec.] SEC 435.1200, 457.340, 457.348, 457.350, and 600.330 under OMB control number 0938-1147 (CMS-10410), and bearing in mind the Federal contribution, we estimate a complete cost of $1,138,377.60 ($66,636 + $72,667 + $367,260 + $62,626).We also estimate that this provision would save each beneficiary on average 3 hours to now not submit a renewal form once they’ve been determined ineligible for one program and determined potentially eligible for one more insurance affordability program based on available information. Assuming 1 percent of beneficiaries (85,809,179 beneficiaries x 0.01 = 858,092 beneficiaries) currently submit a Medicaid renewal because of this, in aggregate, we estimate an annual saving for beneficiaries in all States of minus 2,574,276 hours (3 hr x 858,092 individuals) and minus $72,105,471 (2,574,276 hr x $28.01/hr).

We estimate that it might save each beneficiary 4 hours previously spent reapplying for coverageAssuming 0.25 percent of beneficiaries (214,523 beneficiaries = 85,809,179 beneficiaries x 0.0025) currently lose coverage for failure to return a renewal form when now not eligible, as an alternative of being transitioned to this system for which they’re eligible, we estimate an annual saving for beneficiaries in all States of minus 858,092 hours (4 hr x 214,523 individuals) and minus $24,035,157 (858,092 hr x $28.01/hr).

For beneficiaries, we estimate a complete savings of minus $96,140,628 ( – $72,105,471 – $24,035,157).12. ICRs Regarding Eliminating Requirement to Apply for Other Advantages (SEC 435.608)

With regard to the burden related to developing and coding the changes to every State’s application system to eliminate the trigger for the Medicaid applicant to use for other profit programs, the proposed requirement and burden shall be submitted to OMB for review under control number 0938-TBD (CMS-10819). Right now, the control number is to be determined (TBD). OMB will assign the control number upon their clearance of the proposed rule’s latest information collection request. The brand new control number shall be set out in the ultimate rule.

This rule proposes to remove the requirement at SEC 435.608 that State Medicaid agencies must require all Medicaid applicants and beneficiaries, as a condition of their eligibility, to take all mandatory steps to acquire any advantages to which they’re entitled. The requirement applies to adults only, which equates to roughly 46,000,000 Medicaid applicants. /102/ Most people already apply for other advantages resembling Veterans’ compensation and pensions, Social Security disability insurance and retirement advantages, and unemployment compensation, because they wish to receive them. As such, the requirement only impacts those individuals who only applied for a profit because they’d to to be able to get or keep Medicaid.

   FOOTNOTE 102 CMS, November 2021 Medicaid & CHIP Enrollment. Available at https://www.medicaid.gov/medicaid/program-information/medicaid-and-chip-enrollment-data/report-highlights/index.html. END FOOTNOTE

If we estimate that, in a given 12 months, 5 percent of beneficiaries must apply for one more profit, that may be 2,300,000 people to whom the requirement would now not apply by removing this provision. Nevertheless, the burden of this requirement on beneficiaries with respect to the gathering of data pertains to the applying requirements of other agencies, and subsequently an estimate of burden reduction just isn’t reflected on this section.

We estimate it might take a mean of 200 hours per State to develop and code the changes to every State’s application system to eliminate the trigger for the Medicaid applicant to use for other profit programs. Of those 200 hours, we estimate it might take a Database and Network Administrator and Architect 50 hours at $98.50/hr and a Computer Programmer 150 hours at $92.92/hr. For States, we estimate a complete one-time burden of 11,200 hours (56 States x 200 hr) at a price of $1,056,328 ([(50 hr x $98.50/hr) + (150 hr x $92.92/hr)] x 56 States) to finish the mandatory system changes.

Considering the 50 percent Federal contribution to Medicaid and CHIP program administration, the estimated State share could be $528,164.

13. ICRs Regarding Removing Optional Limitation on the Variety of Reasonable Opportunity Periods (SEC 435.956)

This provision doesn’t create any latest or revised reporting, recordkeeping, or third party disclosure requirements or burden. The necessities and burden are addressed as a part of the one streamlined application that’s approved by OMB under control number 0938-1191 (CMS-10440).

We propose to revise SEC 435.956(b)(4) to remove the choice for States to ascertain limits on the variety of ROPs. Under proposed SEC 435.956(b)(4), all 56 States could be prohibited from imposing limitations on the variety of ROPs that a person may receive.

Because the option was finalized, just one State submitted a SPA requesting to implement this feature, and implemented via a 12-month pilot. Following the pilot, the State suspended the policy of limiting the ROP period and removed the choice from its State Plan. Apart from the one State, CMS has not received any inquiries about establishing such a limitation. Subsequently, we estimate that the proposed amendments to SEC 435.956(b)(4) won’t result in any change in burden on States.

14. ICRs Regarding Recordkeeping ([Sec.] SEC 431.17 and 457.965)

The next proposed changes shall be submitted to OMB for review under control number 0938-TBD (CMS-10819). Right now, the control number is to be determined (TBD). OMB will assign the control number upon their clearance of the proposed rule’s latest information collection request. The brand new control number shall be set out in the ultimate rule.

The amendments proposed under [Sec.] SEC 431.17 (Medicaid) and 457.965 (CHIP) would clearly delineate the varieties of information that States must maintain in Medicaid and CHIP case records while the case is energetic along with the minimum retention period of three years. This proposal clearly defines the records, resembling the date and basis of any determination and the notices provided to the applicant/beneficiary. While current regulations don’t include a timeframe for records retention, proposed [Sec.] SEC 431.17(c) and 457.965(c) would establish a minimum retention period of three years, and proposed [Sec.] SEC 431.17(d) and 457.965(d) would require that records be stored in an electronic format and that such records be made available to appropriate parties inside 30 days of a request if not otherwise specified.

We recognize that States are in various stages of electronic recordkeeping today and that a portion of non-MAGI beneficiary case records are currently stored in a paper-based format, together with a small portion of MAGI-based beneficiary case records. Subsequently, under proposed [Sec.] SEC 431.17(c) and 457.965(c), we estimate it might take a mean of 20 hours per State for a Management Analyst at $96.66/hr to update each State’s policies and procedures to retain records electronically for 3 years minimum. In aggregate, we estimate a one-time burden of 1,120 hours (56 States x 20 hr) at a price of $108,259 (1,120 hr x $96.66/hr) for completing the mandatory updates.

Considering the 50 percent Federal contribution to Medicaid and CHIP program administration, the estimated State share could be $54,130 ($108,259 x 0.5).

15. ICRs Regarding Prohibiting Premium Lock-Out Periods and Disenrollment for Failure To Pay Premiums ([Sec.] SEC 457.570 and 600.525(b)(2))

The next proposed CHIP State plan changes shall be submitted to OMB for review under control number 0938-1147 (CMS-10410). The BHP Blueprint changes shall be submitted to OMB for review under control number 0938-1218 (CMS-10510).

OMB Control Number 0938-1147 (CMS-10410)

The amendments proposed to [Sec.] SEC 457.570 and 600.525(b)(2) would eliminate the choice for States to impose premium lock-out periods in CHIP and in States with a BHP that enables continuous open enrollment all year long.

Under proposed SEC 457.570, we estimate it might take a Management Analyst 2 hours at $96.66/hr and a General and Operations Manager 1 hour at $110.82/hr in all 15 States that currently impose lock-out periods to amend their CHIP State plans to remove the lock-out period and submit in MMDL for review. We estimate an aggregate one-time burden of 45 hours (15 States x 3 hr) at a price of $4,562 (([2 hr x $96.66/hr] + [1 hr x $110.82/hr]) x 15 States). Considering the 50 percent Federal contribution to Medicaid and CHIP program administration, the estimated State share could be $2,281.

OMB Control Number 0938-1218 (CMS-10510)

Our proposed amendments would require BHP States to revise their BHP Blueprints to remove the premium lock-out period. Under proposed SEC 600.525(b)(2), within the one BHP State that imposes a lock-out period, we estimate it might take a Management Analyst 2 hours at $96.66/hr and a General and Operations Manager 1 hour at $110.82/hr to revise their BHP Blueprints to remove the premium lock-out period. We estimate an aggregate one-time burden of three hours (1 State x 3 hr) at a price of $304 (([2 hr x $96.66/hr] + [1 hr x $110.82/hr]) x 1 State).

In total for the ICRs related to [Sec.] SEC 457.570 and 600.525(b)(2) under OMB control numbers 0938-1147 (CMS-10410), and OMB Control Number 0938-1218 (CMS-10510), bearing in mind the Federal contribution for the CHIP-related changes, we estimate a complete one-time cost for the State of $2,585 ($2,281+ $304).

16. ICRs Regarding Prohibiting Waiting Periods in CHIP ([Sec.] SEC 457.65, 457.340, 457.350, 457.805, and 457.810)

The next proposed changes shall be submitted to OMB for review under control number 0938-1147 (CMS-10410).

The amendments proposed to [Sec.] SEC 457.65, 457.340, 457.350, 457.805, and 457.810 would eliminate the State choice to impose a waiting period for families with children eligible for CHIP who were recently enrolled in a bunch health plan. Currently, 11 States with a separate CHIP program impose waiting periods between 1 month and 90 days. We estimate that the proposed amendments would require these 11 States to process CHIP applications sooner than under current rules and without evaluating whether the applicant just lost coverage through a bunch health plan. Subsequently, these States would wish to update their applications to eliminate the query asking for attestation of recently lost coverage and all related follow-up questions, resembling to judge whether the person falls into an exception for a waiting period. If the State uses a knowledge source to envision for other coverage, the State would wish to update the applying to remove the trigger to question the info source.

We estimate it might take a mean of 200 hours in each of those 11 States to develop and code the changes to every State’s application to remove all questions and queries related to recently lost coverage. Of those 200 hours, we estimate it might take a Database and Network Administrator and Architect 50 hours at $98.50/hr and a Computer Programmer 150 hours at $92.92/hr. In aggregate, we estimate a one-time burden of two,200 hours (11 States x 200 hr) at a price of $207,493 ([(50 hr x $98.50/hr) + (150 hr x $92.92/hr)] x 11 States) for completing the mandatory system changes. Considering the 50 percent Federal contribution to Medicaid and CHIP program administration, the estimated State share could be $103,747.

We estimate it might take a mean of three hours in each of 11 unique States to update each State’s CHIP SPAs in MMDL to document the opposite strategy(ies) the states will use to watch substitution of coverage. We estimate it might take a General and Operations Mgr. 1 hour at $110.82/hr and a Business Operations Specialist 2 hours at $77.25/hr for a per State total of $265. In aggregate, we estimate a one-time burden for all States of 33 hours (11 States x 3 hr) and $2,915 ([(1 hr x $110.82/hr) + (2 hr x $77.25/hr)] x 11 States) for completing the mandatory SPA updates. Considering the 50 percent Federal contribution to Medicaid and CHIP program administration, the estimated State share could be $1,458.

In total for the ICRs related to [Sec.] SEC 457.65, 457.340, 457.350, 457.805, and 457.810, and bearing in mind the 50 percent Federal contribution to Medicaid and CHIP program administration, the estimated State share could be $105,205 ($103,747 + $1,458).

17. ICRs Regarding Prohibiting Annual and Lifetime Limits on Advantages (SEC 457.480)

The next proposed CHIP State plan changes shall be submitted to OMB for review under control number 0938-1148 (CMS-10398 #17) as they relate to updating CHIP SPAs and under control number 0938-TBD (CMS-10819) as they relate to programming in mandatory system changes. Right now, the control number for CMS-10819 is to be determined (TBD). OMB will assign the control number upon their clearance of the proposed rule’s latest information collection request. The brand new control number shall be set out in the ultimate rule.

OMB Control Number 0938-TBD (CMS-10819)

The amendments proposed to SEC 457.480 would prohibit annual and lifelong dollar limits in the supply of all CHIP medical and dental advantages. Currently, 13 unique States place either an annual or lifetime dollar limit on at the least 1 CHIP profit. Twelve of the 13 States place an annual dollar limit on at the least one CHIP profit (AL, AR, CO, IA, MI, MS, MT, OK, PA, TN, TX, and UT), and 6 of the 13 States place a lifetime dollar limit on at the least one profit (CO, CT, MS, PA, TN, and TX). We estimate that the proposed amendments would require 13 States to update their systems and their CHIP SPAs to eliminate annual or lifetime profit limits.

We estimate it might take a mean of 20 hours to develop and code the changes to remove just 1 limit on either an annual or lifetime profit. Of those 20 hours, we estimate it might take a Database and Network Administrator and Architect 5 hours at $98.50/hr and a Computer Programmer 15 hours at $92.92/hr. In aggregate, we estimate a one-time burden across all 13 States of 260 hours (20 hr x 13 States) and $24,522 ([(5 hr x $98.50/hr) + (15 hr x $92.92/hr)] x 13 States) for completing the mandatory system changes. Considering the 50 percent Federal contribution to Medicaid and CHIP program administration, the estimated State share could be $12,261.

OMB Control Number 0938-1148 (CMS-10398 #17)

The amendments proposed to SEC 457.480 would require States submit updated CHIP SPAs. We estimate it might take a mean of three hours in each of 13 unique States to update each State’s CHIP SPAs in MMDL to remove 21 different limits on annual and/or lifetime advantages (calculated as 21/13, or roughly 1.62, limits per State). Of those 3 hours, we estimate it might take a General and Operations Mgr. 1 hour at $110.82/hr and a Business Operations Specialist 2 hours at $77.25/hr for a per State total of 5 hours (3 hr/limit x 1.62 limits). In aggregate, we estimate a one-time burden for all States of 65 hours (13 States x 5 hr) and $5,573 ([(1 hr x $110.82/hr) + (2 hr x $77.25/hr)] x 21 limits) for completing the mandatory SPA updates. Considering the 50 percent Federal contribution to Medicaid and CHIP program administration, the estimated State share could be $2,786.

In total for the ICRs related to SEC 457.480 under control numbers 0938-TBD (CMS-10819) and 0938-1148 (CMS-10398 #17), bearing in mind the 50 percent Federal contribution, we estimate a complete one-time State cost of $15,047 ($12,261 + $2,786).

C. Summary of Proposed Burden Estimates

In Table 2, we present a summary of the proposed requirements and burden estimates.

BILLING CODE 4120-01-P

See illustration in Original Document.

See illustration in Original Document.

See illustration in Original Document.

See illustration in Original Document.

BILLING CODE 4120-01-C

D. Submission of PRA-Related Comments

Now we have submitted a replica of this proposed rule to OMB for its review of the rule’s information collection requirements. The necessities should not effective until they’ve been approved by OMB.

To acquire copies of the supporting statement and any related forms for the proposed collections discussed above, please visit the CMS website at www.cms.hhs.gov/PaperworkReductionActof1995, or call the Reports Clearance Office at 410-786-1326.

We invite public comments on these potential information collection requirements. If you happen to want to comment, please submit your comments electronically as laid out in the DATES and ADDRESSES section of this proposed rule and discover the rule (CMS-2421-P), the ICR’s CFR citation, and OMB control number.

IV. Response to Comments

Due to large variety of public comments, we normally receive on Federal Register documents, we should not in a position to acknowledge or reply to them individually. We are going to consider all comments we receive by the date and time laid out in the DATES section of this preamble, and, once we proceed with a subsequent document, we’ll reply to the comments within the preamble to that document.

V. Regulatory Impact Evaluation

A. Statement of Need

Now we have learned through our experiences in working with States and other stakeholders that there are gaps in our regulatory framework related to Medicaid, CHIP, and BHP eligibility and enrollment. While we’ve made great strides in expanding access to coverage over the past decade, certain policies proceed to end in unnecessary burdens and create barriers to enrollment and retention of coverage. In response to the President’s Executive Order on Continuing to Strengthen Americans’ Access to Reasonably priced, Quality Health Coverage, we reviewed existing regulations to search for areas where access might be improved.

On this rulemaking, we seek to eliminate obstacles that make it harder for eligible people to stay enrolled, particularly those individuals who’re exempted from MAGI and didn’t profit from most of the enrollment simplifications in our 2012 and 2013 eligibility final rules. We seek to streamline enrollment for people known to be Medicaid eligible, like current enrollees who’re also eligible for but not enrolled within the MSPs. We seek to remove coverage barriers, like premium lock-out periods and waiting periods that should not permitted under other insurance affordability programs, and to cut back coverage gaps as individuals transition from one insurance affordability program to a different. Together, the changes on this proposed rule would streamline Medicaid, CHIP and BHP eligibility and enrollment processes, reduce administrative burden on States and enrollees, expand coverage of eligible applicants, increase retention of eligible enrollees, and improve health equity.

B. Overall Impact

Now we have examined the impacts of this rule as required by E.O. 12866 on Regulatory Planning and Review (September 30, 1993), E.O. 13563 on Improving Regulation and Regulatory Review (January 18, 2011), the Regulatory Flexibility Act (RFA) (September 19, 1980, Pub. L. 96354), section 1102(b) of the Act, section 202 of the Unfunded Mandates Reform Act (UMRA) of 1995 (March 22, 1995; Pub. L. 104-4), E.O. 13132 on Federalism (August 4, 1999), and the Congressional Review Act (5 U.S.C. 804(2)).

Executive Orders 12866 and 13563 direct agencies to evaluate all costs and advantages of obtainable regulatory alternatives and, if regulation is mandatory, to pick regulatory approaches that maximize net advantages (including potential economic, environmental, public health and safety effects, distributive impacts, and equity). Section 3(f) of Executive Order 12866 defines a “significant regulatory motion” as an motion that’s more likely to end in a rule: (1) (having an annual effect on the economy of $100 million or more in any 1 12 months, or adversely and materially affecting a sector of the economy, productivity, competition, jobs, the environment, public health or safety, or State, local or tribal governments or communities (also known as “economically significant”); (2) making a serious inconsistency or otherwise interfering with an motion taken or planned by one other agency; (3) materially altering the budgetary impacts of entitlement grants, user fees, or loan programs or the rights and obligations of recipients thereof; or (4) raising novel legal or policy issues arising out of legal mandates, the President’s priorities, or the principles set forth within the Executive Order.

A regulatory impact evaluation (RIA) have to be prepared for major rules with significant regulatory motion(s) or with economically significant effects ($100 million or more in any 1 12 months). Based on our estimates, OMB’s Office of Information and Regulatory Affairs has determined this rulemaking is “economically significant” as measured by the $100 million threshold. Accordingly, we’ve prepared a Regulatory Impact Evaluation that to the most effective of our ability presents the prices and advantages of the rulemaking.

The mixture economic impact of this proposed rule is estimated to be $61.93 billion (in real FY 2023 dollars) over 5 years. This represents additional health care spending made by the Medicaid and CHIP programs on behalf of Medicaid and CHIP beneficiaries, with $41.41 billion paid by the Federal government and $20.52 billion paid by the States.

The RFA requires agencies to investigate options for regulatory relief of small businesses. For purposes of the RFA, small entities include small businesses, nonprofit organizations, and small governmental jurisdictions. Most hospitals and most other providers and suppliers are small entities, either by nonprofit status or by having revenues of lower than $8.0 million to $41.5 million in anybody 12 months. Individuals and States should not included within the definition of a small entity. Since this proposed rule would only impact States and individuals, subsequently, we don’t consider that this proposed rule could have a big economic impact on a considerable variety of small businesses. We seek comment on the relevant impact.

As well as, section 1102(b) of the Act requires CMS to arrange an RIA if a rule can have a big impact on the operations of a considerable variety of small rural hospitals. This evaluation must conform to the provisions of section 603 of the RFA. For purposes of section 1102(b) of the Act, we define a small rural hospital as a hospital that’s situated outside a Metropolitan Statistical Area and has fewer than 100 beds. This proposed rule applies to State Medicaid and CHIP agencies and wouldn’t add requirements to rural hospitals or other small providers. Subsequently, we should not preparing an evaluation for section 1102(b) of the Act because we’ve determined, and the Secretary certifies, that this proposed rule wouldn’t have a big impact on the operations of a considerable variety of small rural hospitals.

Section 202 of the UMRA also requires that agencies assess anticipated costs and advantages before issuing any rule whose mandates require spending in anybody 12 months of $100 million in 1995 dollars, updated annually for inflation. In 2022, that’s roughly $165 million. We consider that this proposed rule would have such an effect on spending by State, local, or tribal governments but not by private sector entities.

Overall Assumptions

In developing these estimates, we’ve relied on several global assumptions. All estimates are based on the projections from the President’s FY 2023 Budget. Now we have assumed that latest enrollees would have the identical average costs as current enrollees by eligibility group, unless laid out in the outline of the estimates (for instance, some enrollees only would receive Medicare premium assistance). Now we have assumed that the rule could be effective on April 1, 2023. As well as, we’ve relied on the info sources and assumptions described in the subsequent section to develop estimates for specific provisions of this proposed rule.

C. Anticipated Effects

1. Facilitate Enrollment Through Medicare Part D LIS Leads Data

To calculate the impact of easing enrollment for individuals already receiving the LIS profit, we analyzed data from the Medicare Integrated Data Repository (IDR) from July 2020. We determined the number of people that were enrolled within the LIS program by: (1) State; (2) the category of LIS profit they received; and (3) whether or not they were also enrolled in Medicaid. We identified 13.1 million individuals receiving the Part D LIS, of which 11.1 million were enrolled in Medicaid and a pair of.0 million weren’t.

We developed a regression using the proportion of LIS enrollees who were also enrolled as dual eligibles because the dependent variable, and used several policy aspects as independent variables: State use of MIPPA applications; verification policies and procedures; grace period for providing verifications after initial denial; redetermination grace period; counting children towards income; income disregard; and asset disregard. While the latter three policies wouldn’t change under the proposed rule, we believed that they might explain a few of the variation in the proportion of LIS recipients who’re dual eligibles. We found that this model explained some amount of the variation in the proportion of LIS enrollees who’re enrolled as dual eligibles, and that probably the most significant variable was the State use of MIPPA applications. Other policies appeared to have weak correlations. The model suggested that using these policies–and particularly using the Part D LIS leads data–would end in a mean increase in the proportion of LIS recipients who’re dual eligible enrollees from 84.6 percent to 88.0 percent (a rise of three.4 percentage points). We estimated that about 0.44 million additional individuals would have been enrolled in Medicaid because of this of those changes, had they been made in 2020.

We assumed these enrollees, as QMBs, would receive payment for the Medicare Part B premium. The premium is $170.10 per 30 days in 2022.

To calculate future impacts to enrollment, we assumed that the rise in enrollment resulting from this provision would grow at the identical rate as Medicaid enrollment amongst aged individuals and individuals with disabilities. We estimate that this could increase enrollment by about 0.52 million individuals by FY 2027, and would increase total Medicaid spending by $4.84 billion from FY 2023 through FY 2027. Detailed estimates are shown in Table 3.

See illustration in Original Document.

2. Robotically Enroll Certain SSI Recipients Into QMB Program

To calculate the impact of mechanically enrolling SSI recipients into QMB Medicaid coverage, we examined data on SSI recipients and their health care coverage. /103/ As of 2017, about 17 percent of all SSI recipients had Medicare coverage but weren’t dually enrolled in Medicaid.

   FOOTNOTE 103 https://www.census.gov/content/dam/Census/library/publications/2021/demo/p70br-171.pdf. END FOOTNOTE

First, we estimated what number of individuals would enroll who already receive Medicare Part A without paying a premium. We estimated that there are 2.6 million people enrolled in SSI who’re enrolled in Part A and don’t pay the premium. Of those, we estimated about 67 percent reside in “1634 States” (about 1.7 million) and subsequently are mechanically enrolled in Medicaid. Of the remaining 0.9 million, we’ve assumed that 90 percent would enroll within the QMB group and receive Medicare Part B premium and cost-sharing assistance. We estimated those advantages to be about $5,000 per enrollee per 12 months for 2022.

Second, we estimated what number of individuals would enroll who receive Medicare Part A but need to pay a premium. We estimate that there are 5.2 million such people enrolled in SSI. We estimated that 27 percent of this population lives in States that don’t mechanically enroll these individuals within the QMB group. Of States that don’t mechanically enroll these individuals within the QMB group, we assumed that about 20 percent of States would use the choice provided on this proposed rule, and that about 50 percent of this population could be enrolled within the QMB group because of this. In total, this could end in a rise of about 0.15 million enrollees within the QMB group. We assumed these beneficiaries would receive Medicare Part B premium and cost-sharing assistance in addition to Medicare Part A premium assistance. We estimated those advantages could be about $11,000 per enrollee per 12 months in 2022.

See illustration in Original Document.

3. Other Provisions To Facilitate Medicaid Enrollment

For other provisions that may facilitate Medicaid enrollment (including the definition of family size; making the QMB effective date earlier; the electronic verification and reasonable compatibility standard; and the verification of citizenship and identity), we assumed that these provisions would increase enrollment by about 0.1 percent amongst aged enrollees and enrollees with disabilities, and would have a negligible impact on other categories of enrollees. We estimated that this could increase enrollment by about 20,000 person-year equivalents by 2027.

See illustration in Original Document.

It is probably going that those SSI enrollees newly gaining Medicaid coverage would even have higher Medicare costs following enrollment. Primarily, receiving cost-sharing assistance for Medicare would lead to those individuals in search of out more care which will have been difficult to afford previously, also often known as induction.

To estimate these impacts, we reviewed research on the results of adjusting out of pocket costs on total health care costs, and specifically on Medicare. Generally, we’ve historically estimated that reductions in out of pocket costs would increase total spending by $0.60 to $1.30 for each $1.00 reduction in out of pocket costs. Amongst research on health care costs, we relied totally on research that examined the impacts on changing Medicare out of pocket costs. /104/

   FOOTNOTE 104 B Garrett, A Gangopadhyaya, A Shartzer, and D Arnos, “A Unified Cost-Sharing Design for Medicare: Effects on Beneficiary and Program Spending,” The Urban Institute, July 2019. https://www.urban.org/sites/default/files/publication/100528/a_unified_cost-sharing_design_for_medicare_effects_on_beneficiary_an_1.pdf. [Accessed August 3 2022]. END FOOTNOTE

This research is beneficial, particularly due to the evaluation reviewing cost-sharing amongst those Medicare enrollees without some other coverage, those with supplemental coverage (resembling “Medigap” plans or retiree health advantages), and people with Medicaid. First, the evaluation found that Medicare enrollees without other coverage had a mean of $13,693 in costs, of which $2,399 was paid out of pocket (18 percent). Amongst those with supplemental coverage, average costs were $14,349, with $594 paid out of pocket (4 percent) and $2,095 paid through supplemental coverage (15 percent). Enrollees with Medicaid coverage had $26,181 in average costs, with $209 paid out of pocket (1 percent) and $3,190 paid by Medicaid (12 percent). A major amount of cost differences is probably going resulting from health status. Most notably, those with Medicaid coverage are on average older and more more likely to have a disability or chronic condition, which might end in higher costs no matter who pays for care.

The evaluation also examines the effect of adjusting Medicare cost-sharing structures on total, Medicare, and out of pocket spending. While the particular proposed profit changes should not related to this proposed rule, it does provide the relative magnitude of changes between Medicare and out of pocket costs. The evaluation found a bigger change in costs for those without some other coverage than those with supplemental coverage. For those without other coverage, out of pocket costs decreased by $428 while total costs increased by $764 (or $1.80 for each $1.00 reduction in out of pocket costs). For those with supplemental coverage, there was a decrease of $158 in out of pocket costs and a rise of $130 in total costs (or $0.80 for each $1.00 reduction in out of pocket costs).

We also reviewed what number of Medicare enrollees have supplemental coverage or Medicaid. Research from the Kaiser Family Foundation recently checked out this. /105/ This evaluation found that 26 percent of Medicare beneficiaries had annual income of lower than $20,000 (which is fairly near the SSI income limit of $1,767 monthly, which could be $21,204 annually). Of those beneficiaries, 37 percent had Medicaid and 11 percent had supplemental coverage. Excluding those with Medicaid and assuming the 2 groups are mutually exclusive, 17 percent of low-income beneficiaries without Medicaid had supplemental coverage. We consider it is cheap to assume that only a few beneficiaries had each Medicaid and other supplemental coverage.

   FOOTNOTE 105 W Koma, J Cubanski, and T Neuman, “A Snapshot of Coverage Amongst Medicare Beneficiaries in 2018,” Kaiser Family Foundation, March 23 2021. https://www.kff.org/medicare/issue-brief/a-snapshot-of-sources-of-coverage-among-medicare-beneficiaries-in-2018/. [Accessed August 3 2022]. END FOOTNOTE

We estimated the impact assuming that the general increase in total costs could be $0.80 for each $1.00 reduction in out of pocket costs. For those without supplemental coverage, this could be expected to end in a rise of 14 percent in total costs and 20 percent in Medicare costs, and for those without supplemental coverage, increases of three percent for total costs and 10 percent for Medicare costs. Using the evaluation on SSI enrollees and coverage, this can be a weighted average of an 18 percent increase in Medicare costs for those newly gaining Medicaid.

To calculate the annual impacts, we multiply the Medicare per enrollee costs annually by 18 percent and by the variety of SSI enrollees newly receiving Medicaid, after which adjust for cost-sharing to calculate the Federal Medicare spending amounts. Using total Medicare per enrollee costs (as projected within the 2022 Trustees Report), /106/ we project that this could increase Medicare spending by $11.1 billion over 2023 to 2027 under this proposed rule. Annual impacts are shown in Table 6.

   FOOTNOTE 106 “2022 Annual Report of the Boards of Trustees of the Federal Hospital Insurance and Federal Supplementary Medical Insurance Trust Funds.” https://www.cms.gov/files/document/2022-medicare-trustees-report.pdf. [Accessed August 3 2022]. END FOOTNOTE

See illustration in Original Document.

There may be a wide selection of possible costs resulting from this effect of the proposed rule. Most notably, and described previously on this section, is that the impact of reducing out of pocket costs could have different impacts than estimated here. Thus, individuals could use greater or lesser levels of additional services, resulting in numerous levels of Medicare spending changes than estimated here. This uncertainty is addressed within the high and low range estimates provided within the accounting statement (see section V.F. of this proposed rule).

4. Promoting Enrollment and Retention of Eligible Individuals

These provisions are expected to extend coverage by assisting individuals with gaining and maintaining Medicaid coverage. Now we have considered several effects of the provisions on this proposed rule.

First, we estimated the impacts of aligning non-MAGI enrollment and renewal requirements with MAGI policy. We anticipate that this provision would increase the variety of member months of coverage amongst enrollees eligible based on non-MAGI criteria (older adults and individuals with disabilities). In an evaluation of dually eligible enrollees from 2015 to 2018, CMS found that about 29 percent of recent dually eligible enrollees lost coverage for at the least 1 month in the primary 12 months of coverage, and about 24 percent lost coverage for at the least 3 months. While a few of this lack of coverage is probably going resulting from enrollees now not being eligible, we expect that many enrollees should still be eligible despite losing coverage, and that this provision would assist enrollees in continuing coverage. We assumed that this provision would increase enrollment amongst aged enrollees and enrollees with disabilities by about 1 percent.

For all other provisions under this section, we assumed that they might increase coverage for kids by about 1 percent and for all other enrollees by about 0.75 percent. Particularly, we assumed that provisions for acting on changes in circumstances, timely eligibility determinations and redeterminations, and motion on returned mail would all contribute to modest increases in enrollment (mostly through continuing coverage for individuals already enrolled) and that the supply to enhance transitions between Medicaid and CHIP would further increase Medicaid enrollment.

In total, we estimated these provisions would increase enrollment by about 880,000 person-year equivalents by 2027.

See illustration in Original Document.

5. Eliminating Barriers To Access in Medicaid

We assumed that removing or limit requirements to use for other advantages as a condition of Medicaid enrollment would result in a rise in Medicaid coverage. Now we have not assessed the impacts across different advantages (that’s, SSI, TANF, etc.). We assumed that this could increase overall enrollment by about 0.5 percent, or about 410,000 person-year equivalents by 2027.

Now we have assumed that removing optional limitations on the variety of reasonable opportunity periods would have a negligible impact on Medicaid enrollment and expenditures.

See illustration in Original Document.

6. CHIP Proposed Changes and Eliminating Access Barriers in CHIP

We estimated that proposed changes to CHIP enrollment (including timely determinations and redeterminations, acting on changes in circumstances, acting on returned mail, and improving transitions between CHIP and Medicaid) would increase CHIP enrollment by about 1 percent. These are comparable to the impacts on Medicaid children of the comparable Medicaid provisions.

For prohibitions on premium lockout periods and waiting periods, there are currently 14 States which have such lockout periods and 11 States which have waiting periods for CHIP enrollment. We assumed that in those States, removing these barriers to coverage would increase enrollment by about 1 percent. We assumed that prohibiting annual and lifelong limits on advantages in CHIP would have a negligible impact.

In total, we estimate these provisions would increase enrollment by about 120,000 by 2027.

See illustration in Original Document.

7. Impacts on the Marketplaces

We anticipate that most of the enrollees that may either be gaining Medicaid or CHIP coverage or retaining Medicaid or CHIP coverage because of this of this proposed rule would have had other coverage under current policies. Particularly, we expect that lots of the youngsters and adults would have enrolled within the Marketplace and been eligible for subsidized care (excluding those age 65 or older and people with disabilities who’re enrolled in Medicare).

To estimate the impacts this proposed rule would have on Marketplace expenditures, we began by calculating the fee of care and Federal subsidy payments for various households shifting from Marketplace coverage to Medicaid and CHIP. We made the next assumptions. We estimated that health care prices are 30 percent higher in Marketplace plans than in Medicaid and CHIP, and that the typical percentage of costs for non-benefit costs in managed care was 10 percent–this also considers that some beneficiaries receive all or a part of their care outside of managed care. Next, we assumed that individuals would scale back health spending by 10 percent within the Marketplace resulting from increased cost sharing requirements. We used an actuarial value of 70 percent, consistent with silver level plans on the Marketplace, and assumed that the typical percentage of non-benefit costs in Marketplace plans was 20 percent. Finally, we assumed that the typical income of individuals shifting from Marketplace coverage to Medicaid and CHIP could be 125 percent of the Federal poverty level (FPL) and that the premium tax credits could be calculated assuming that they might not need to pay any contribution in 2023, 2024, and 2025 under the Inflation Reduction Act of 2022, and that they might need to pay 2 percent of income for coverage for 2026 and beyond.

We calculated the quantity of Federal subsidies (measured by premium tax credits) for households of 1 adult, two adults, one adult and one child, one adult and two children, and two adults and two children, after which calculated the full Federal cost of Marketplace coverage to be consistent with the distribution of projected enrollment change in Medicaid and CHIP under the proposed rule. We made a final assumption that 60 percent of people would have enrolled in Marketplace coverage, and the remaining 40 percent would have either received other coverage or change into uninsured.

We estimated that Marketplace costs would have decreased by $3.8 billion in 2022 under the policies within the proposed rule. To project costs for future years that may be affected by the proposed rule, we assumed that per capita costs, premiums, and Federal subsidies would increase consistent with the projected growth rates within the President’s Budget with adjustments to account for the impacts of the Inflation Reduction Act of 2022, and that enrollment would increase consistent with the projections made for the Medicaid and CHIP provisions of this proposed rule.

See illustration in Original Document.

There may be a wide selection of possible savings resulting from this effect of the proposed rule. For these estimates, participation within the Marketplace and health care costs and costs may vary from what we assumed here. Thus, actual savings might be greater or lesser than estimated here. This uncertainty is addressed within the high and low range estimates provided within the accounting statement (see section V.F. of this proposed rule).

8. Total

In total, we project that these provisions would increase Medicaid enrollment by 2.81 million by 2027, and would increase total Medicaid spending by $99,290 million from 2023 through 2027. Of that quantity, we estimate that $60,280 million could be paid by the Federal government and $39,010 million could be paid by the States. We expect nearly all of the extra enrollment and value to be provided for older adults and individuals with disabilities. We also estimate that CHIP enrollment would increase by 0.12 million by 2027, and that total CHIP expenditures would increase by $1,690 million from 2023 to 2027 ($1,170 Federal and $520 million State costs). Table 11 shows the web impacts for Medicaid and for CHIP.

See illustration in Original Document.

See illustration in Original Document.

Along with the results on Medicaid and CHIP, we’ve also estimated impacts on Medicare and the Federal subsidies for Marketplace coverage. Table 13 shows the web impact on Federal spending for Medicaid, CHIP, Medicare, and Federal Marketplace subsidies.

See illustration in Original Document.

9. Administrative Burden

We anticipate a discount in administrative burden for States resulting from the proposed elimination of the requirement to use for other advantages outlined within the preamble of this proposed rule. Specifically, we estimate that this provision would save State Eligibility Interviewers on average 1 hour per enrollee at $46.70/hr from now not needing to arrange and send notices and requests for extra details about applying for other advantages, or to process requests for good cause exemptions. In aggregate for all States, we estimate an annual savings of minus 2,300,000 hours (1 hr x 2.3M enrollees) and minus $106,122,000 (2,300,000 hrs x $46.70/hr).

We also estimate that this provision would save each enrollee who otherwise meets all requirements to be enrolled or remain enrolled in Medicaid but who, absent this provision, would lose Medicaid coverage resulting from failure to supply information on application for other advantages on average 2 hours at $28.01/hr. In aggregate, we estimate that enrollees in all States would save minus 4,600,000 hours (2 hrs x 2,300,000 enrollees) and $128,846,000 (4,600,000 hrs x $28.01/hr) annually.

D. Alternatives Considered

In developing this proposed rule, the next alternatives were considered:

1. Not Proposing the Rule

We considered not proposing this rule and maintaining the established order. Nevertheless, we consider this proposed rule will result in more eligible individuals having access to coverage and maintaining their coverage across all States. As well as, we consider that provisions on this proposed rule, resembling updates to the recordkeeping requirements, will reduce the incidence of improper payments and improve the integrity of the Medicaid program and CHIP.

2. Providing States With Discretion Regarding the Date of Application for QMBs

Section 406.26 describes enrollment in Medicare Part A through the buy-in process. We considered proposing modifications to SEC 406.26(b) to supply States with discretion to make use of the Part A conditional enrollment filing date because the date of the Medicaid application for QMB eligibility. As background, the QMB eligibility group covers Part A premiums for people who don’t qualify for premium-free Part A. Nevertheless, to use for the QMB eligibility group, a person have to be entitled to Part A–and many cannot afford the monthly premium ($499 in 2022). Such individuals need to navigate a posh two-step process where they first apply for conditional enrollment in Part A at SSA, then go to the State Medicaid agency to use for the QMB eligibility group. Providing States the choice to make use of the date of application at SSA for conditional enrollment because the date of application for a QMB application could permit States to supply an earlier effective date for QMB. We selected to not propose a regulatory change at the moment because we do not need enough information to accurately assess its impact. Nevertheless, we seek comments on this alternative considered that may be adopted in the ultimate rule based on comments received.

3. Maintaining Records in Paper Format

We considered allowing States, which haven’t yet transitioned their enrollee records into an electronic format, to proceed to take care of a paper-based record keeping system. As documented by the OIG and PERM eligibility reviews, many existing enrollee case records lack adequate information to confirm decisions of Medicaid eligibility. A move to electronic recordkeeping won’t only help States to make sure adequate documentation of their eligibility decisions, but may also make it easier to report such information to State auditors and other relevant parties. Subsequently, we proposed to require State Medicaid agencies to store records in electronic format (estimated above, within the Collection of Information section, as a one-time cost of $108,260) and sought comment on whether States should retain flexibility to take care of records in paper or other formats that reflect evolving technology.

E. Limitations of the Evaluation

There are numerous caveats to those estimates. Foremost, there is critical uncertainty concerning the actual effects of those provisions. Each of those provisions might be roughly effective than we’ve assumed in developing these estimates, and for lots of these provisions we’ve made assumptions concerning the impacts they might have. In lots of cases, determining the the explanation why an individual is probably not enrolled despite being eligible for Medicaid or CHIP is difficult to do in an evaluation resembling this. Subsequently, these assumptions rely heavily on our judgment concerning the impacts of those provisions. While we consider these are reasonable estimates, we note that this might have a substantially greater or lesser impact than we’ve projected.

Second, there’s uncertainty even under current policy in Medicaid and CHIP. As a consequence of the COVID-19 pandemic and laws to deal with the pandemic, Medicaid enrollment (and to a lesser extent, CHIP enrollment) have experienced significant increases in enrollment for the reason that starting of 2020. Actual underlying economic and public health conditions may differ than what we assume here.

Along with the sources of uncertainty described previously, there are other reasons the actual impacts of those provisions may differ from the estimates. There could also be differences within the impacts of those provisions across eligibility groups or States that should not reflected in these estimates. There can also be different costs per enrollee than we’ve assumed here–those gaining coverage altogether or keeping coverage for longer durations of time can have different costs than those that were already assumed to be enrolled in this system. Lastly, to the extent that States have discretion in provisions which are optional on this proposed rule or within the administration of their programs more broadly, States’ efforts to implement these provisions may result in larger or smaller impacts than estimated here.

To deal with these limitations, we’ve developed a spread of impacts. We consider that the actual impacts would likely fall inside a spread 50 percent higher or lower than the estimates we’ve developed. While this can be a significant range, we might note that within the context of the whole Medicaid program ($743 billion in FY 2021), this continues to be a comparatively narrow range.

F. Accounting Statement

As required by OMB Circular A-4 (available at https://www.whitehouse.gov/wp-content/uploads/legacy_drupal_files/omb/circulars/A4/a-4.pdf), we’ve prepared an accounting statement in Table 14 showing the classification of the transfer payments with the provisions of this proposed rule. These impacts are classified as transfers, with the Federal government and States incurring additional costs and beneficiaries receiving medical advantages and reductions in out-of-pocket health care costs.

This provides our greatest estimates of the transfer payments outlined within the “Section C. Detailed Economic Evaluation” above. To deal with the numerous uncertainty related to those estimates, we’ve assumed that the prices might be 50 percent greater than or lesser than we’ve estimated here. We recognize that this can be a relatively wide selection, but we note several reasons for uncertainty regarding these estimates. First, there are many provisions that affect Medicaid and CHIP on this rule. For several provisions, we’ve limited information, evaluation, or comparisons to prior experience to make use of in developing our estimates. Thus, the range reflects that impacts of those provisions might be greater or lesser than we assume. As well as, given the variety of provisions, there could also be cases where multiple provisions would help a person maintain coverage. This could lead on to those estimates “double counting” some effects. We also note that there are expected impacts on Medicare and the Marketplace subsidies; we consider this range adequately accounts for the potential variation in costs or savings to those programs as well. Finally, given the numerous effects of the COVID-19 pandemic and laws intended to deal with this, the present outlook for Medicaid and CHIP are less certain than typically. We offer this wider range to account for this uncertainty as well. This range provides the high cost and low price ranges shown in Table 14.

See illustration in Original Document.

Chiquita Brooks-LaSure, Administrator of the Centers for Medicare & Medicaid Services, approved this document on August 25, 2022.

   List of Subjects

42 CFR Part 406

Diseases, Health facilities, Medicare.

42 CFR Part 431

Grant programs–health, Health facilities, Medicaid, Privacy, Reporting and recordkeeping requirements.

42 CFR Part 435

Aid to Families with Dependent Children, Grant programs–health, Medicaid, Reporting and recordkeeping requirements, Supplemental Security Income (SSI), Wages.

42 CFR Part 457

Administrative practice and procedure, Grant programs–health, Medical health insurance, Reporting and recordkeeping requirements.

42 CFR Part 600

Administrative practice and procedure, Health care, Medical health insurance, Intergovernmental relations, Penalties, Reporting and recordkeeping requirements.

For the explanations set forth within the preamble, the Centers for Medicare & Medicaid Services proposes to amend 42 CFR chapter IV as set forth below:

PART 406–HOSPITAL INSURANCE ELIGIBILITY AND ENTITLEMENT

   1. The authority citation for part 406 is revised to read as follows:

Authority: 42 U.S.C. 1302, 1395i-2, 1395i-2a, 1395p, 1395q and 1395hh.

   2. Section 406.21 is amended by adding paragraph (c)(5) to read as follows:

SEC 406.21Individual enrollment.

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(c) * * *

(5) If a person resides in a State that pays premium hospital insurance for Qualified Medicare Beneficiaries under SEC 406.32(g) and enrolls or reenrolls during a general enrollment period after January 1, 2023, QMB coverage is effective the month entitlement begins (if the person is decided eligible for QMB before the month following the month of enrollment), or a month later than the month entitlement begins (if the person is decided eligible for QMB the month entitlement begins or later).

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   PART 431–STATE ORGANIZATION AND GENERAL ADMINISTRATION

   3. The authority citation for part 431 is revised to read as follows:

Authority:42 U.S.C. 1302.

   4. Section 431.10 is amended by–

   a. Redesignating paragraphs (c)(1)(i)(A)(2) and (3) as (c)(1)(i)(A)(4) and (5), respectively; and

   b. Adding latest paragraphs (c)(1)(i)(A)(2) and (3).

The additions read as follows:

SEC 431.10Single State agency.

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(c) * * *

(1) * * *

(i) * * *

(A) * * *

(2) The separate Kid’s Health Insurance Program agency;

(3) The Basic Health Program agency;

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   5. Section 431.17 is revised to read as follows:

SEC 431.17 Maintenance of records.

(a) Basis and purpose. This section, based on section 1902(a)(4) of the Act, prescribes the sorts of records a Medicaid agency must maintain, the minimum retention period for such records, and the conditions under which those records have to be provided or made available.

(b) Content of records. A State plan must provide that the Medicaid agency will maintain or supervise the upkeep of the records mandatory for the right and efficient operation of the plan. The records must include the entire following–

(1) Individual records on each applicant and beneficiary that contain the entire following:

(i) All information provided on the initial application submitted through any modality described in SEC 435.907 of this subchapter by, or on behalf of, the applicant or beneficiary, including the signature on and date of application.

(ii) The electronic account and any information or other documentation received from one other insurance affordability program in accordance with SEC 435.1200(c) and (d) of this subchapter.

(iii) The date of, basis for, and all documents or other evidence to support any determination, denial, or other antagonistic motion, including decisions made at application, renewal, and because of this of a change in circumstance, taken with respect to the applicant or beneficiary, including all information provided by, or on behalf of, the applicant or beneficiary, and all information obtained electronically or otherwise by the agency from third-party sources.

(iv) The supply of, and payment for, services, items and other medical assistance, including the service or item provided, relevant diagnoses, the date that the service or item was provided, the practitioner or provider rendering, providing or prescribing the service or item, including their National Provider Identifier, and the complete amount paid or reimbursed for the service or item, and any third-party liabilities.

(v) Any changes in circumstances reported by the person and any actions taken by the agency in response to such reports.

(vi) All renewal forms and documentation returned by, or on behalf of, a beneficiary, to the Medicaid agency in accordance with SEC 435.916 of this subchapter, whatever the modality through which such forms are submitted, including the signature on the shape and date received.

(vii) All notices provided to the applicant or beneficiary in accordance with SEC 431.206 and [Sec.] SEC 435.917 and 435.918 of this subchapter.

(viii) All records pertaining to any fair hearings requested by, or on behalf of, the applicant or beneficiary, including each request submitted and the date of such request, the whole record of the hearing decision, as described in SEC 431.244(b), and the ultimate administrative motion taken by the agency following the hearing decision and date of such motion.

(ix) The disposition of income and eligibility verification information received under [Sec.] SEC 435.940 through 435.960 of this subchapter, including evidence that no information was returned from an electronic data source.

(2) Statistical, fiscal, and other records mandatory for reporting and accountability as required by the Secretary.

(c) Retention of records. The State plan must provide that the records required under paragraph (b) of this section shall be retained for the period when the applicant or beneficiary’s case is energetic, plus a minimum of three years thereafter.

(d) Accessibility and availability of records. The agency must–

(1) Maintain the records described in paragraph (b) of this section in an electronic format; and

(2) Make the records available to the Secretary, Federal and State auditors and other parties who request, and are authorized to review, such records inside 30 calendar days of the request, if not otherwise specified, and to the extent permissible by Federal law.

SEC 431.213 [Amended]

   6. Section 431.213 is amended by removing and reserving paragraph (d).

   PART 435–ELIGIBILITY IN THE STATES, DISTRICT OF COLUMBIA, THE NORTHERN MARIANA ISLANDS, AND AMERICAN SAMOA

   7. The authority citation for part 435 is revised to read as follows:

Authority: 42 U.S.C. 1302.

   8. Section 435.4 is amended by adding a definition for “Low Income Subsidy Application data (LIS leads data)” in alphabetical order to read as follows:

SEC 435.4 Definitions and use of terms.

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Low-Income Subsidy Application data (LIS leads data) means data from a person’s application for low-income subsidies under section 1860D-14 of the Act that the Social Security Administration electronically transmits to the suitable State Medicaid agency as described in section 1144 (c)(1) of the Act.

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   9. Section 435.222 is amended by revising the section heading to read as follows:

SEC 435.222Optional eligibility for reasonable classifications of people under age 21 with income below a MAGI-equivalent standard.

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   10. Section 435.223 is added as follows:

SEC 435.223Other optional eligibility for reasonable classifications of people under age 21.

(a) Basis. This section implements section 1902(a)(10)(A)(ii) of the Act.

(b) Eligibility. The agency may provide Medicaid to individuals under age 21 (or, at State option, under age 20, 19, or 18) or to 1 or more reasonable classifications of people under age 21 who meet the necessities described in any clause of section 1902(a)(10)(A)(ii) of the Act and implementing regulations on this subpart, if any.

   11. Section 435.407 is amended by–

   a. Adding paragraphs (a)(7) and (8);

   b. Removing paragraphs (b)(2) and (11);

   c. Redesignating paragraphs (b)(3) through (b)(10) as paragraphs (b)(2) through (b)(9), and paragraphs (b)(12) through (b)(18) as paragraphs (b)(10) through (b)(16), respectively; and

   d. In newly redesignated paragraph (b)(16), removing the reference to paragraph “(17)” and adding instead a reference to paragraph “(15)”.

The additions read as follows:

SEC 435.407 Kinds of acceptable documentary evidence of citizenship.

(a) * * *

(7) Verification with a State vital statistics agency documenting a record of birth.

(8) A knowledge match with the Department of Homeland Security Systematic Alien Verification for Entitlements (SAVE) Program or some other process established by DHS to confirm that a person is a citizen.

*****

   12. Section 435.601 is amended–

   a. In paragraph (b)(2) by removing the phrase “laid out in paragraphs (c) and (d) of this section or in SEC 435.121 or as permitted under SEC 435.831(b)(1), in determining” and adding instead the phrase “laid out in paragraphs (c) through (e) of this section or in SEC 435.121 of this part or as permitted under (f)(1)(ii)(B) of this paragraph, in determining”;

   b. In paragraph (d)(1) introductory text by removing the phrase “permitted under SEC 435.831(b)(1) in determining eligibility” and adding instead the phrase “permitted under paragraph (e) or (f)(1)(ii)(B) of this section in determining eligibility”;

   c. By adding paragraph (e); and

   d. By revising paragraph (f).

The addition and revision read as follows:

SEC 435.601 Application of economic eligibility methodologies.

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(e) Procedures for determining eligibility for the Medicare Savings Program groups. When a State determines eligibility for a Medicare Savings Program group, for income eligibility the agency must include at the least the individuals described in SEC 423.772 in determining family of the scale involved.

(f) State plan requirements. (1)(i) The State plan must specify that, except to the extent precluded in SEC 435.602, in determining financial eligibility of people, the agency will apply the money assistance financial methodologies and requirements, unless the agency chooses the choice described in paragraph (f)(1)(ii)(B) of this section, or chooses to use less restrictive income and resource methodologies in accordance with paragraph (d) of this section, or each.

(ii) Within the case of people for whom this system most closely categorically-related to the person’s status is AFDC (individuals under age 21, pregnant individuals and fogeys and other caretaker relatives who should not disabled, blind or age 65 or older), the agency may apply–

(A) The financial methodologies and requirements of the AFDC program; or

(B) The MAGI-based methodologies defined in SEC 435.603, except that, the agency must comply with the terms of SEC 435.602.

(2) [Reserved]

SEC 435.608[Removed and Reserved]

   13. Section 435.608 is removed and reserved.

   14. Section 435.831 is amended by–

   a. Redesignating paragraphs (g)(2) and (3) as paragraphs (g)(3) and (4), respectively; and

   b. Adding latest paragraph (g)(2).

The addition reads as follows:

SEC 435.831 Income eligibility.

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(g) * * *

(2) May include expenses for services that the agency has determined are reasonably constant and predictable, including, but not limited to, services identified in a person-centered service plan developed pursuant to SEC 441.301(b)(1)(i), SEC 441.468(a)(1), SEC 441.540(b)(5), or SEC 441.725 and expenses for prescribed drugs, projected to the top of the budget period on the Medicaid reimbursement rate.

*****

   15. Section 435.907 is amended by adding paragraph (c)(4) and revising paragraph (d) to read as follows:

SEC 435.907 Application.

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(c) * * *

(4) Any MAGI-exempt applications and supplemental forms have to be accepted through all modalities described at 435.907(a).

(d)(1) If the agency must request additional information from the applicant to find out and confirm eligibility in accordance with SEC 435.911, the agency must–

(i) Provide the applicant with a minimum of the next variety of days, measured from the date the agency sends the request, to reply and supply any mandatory information:

(A) Thirty (30) calendar days for applicants who apply for Medicaid on the idea of disability, and

(B) Fifteen (15) calendar days for all other applicants;

(ii) Allow applicants to supply requested information through any of the modes of submission laid out in paragraph (a) of this section; and

(iii)(A) Within the case of a person who’s denied eligibility for failure to submit requested information and who subsequently submits the requested information throughout the period allowed by the agency in accordance with paragraph (d)(1)(ii) of this section, reconsider eligibility without requiring a latest application;

(B) For purposes of the applying timeliness standards at SEC 435.912(c)(3) of this subpart, the date of application for people described in paragraph (d)(1)(iv)(A) of this section is taken into account the date upon which the person submits the extra information requested by the agency; and

(C) For purposes of the effective date of eligibility under SEC 435.915 of this subpart, the date of application for people described in paragraph (d)(1)(iiii)(A) of this section is date on which the unique application was submitted.

(2) The agency may not require an in-person interview as a part of the applying process.

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   16. Section 435.909 is revised to read as follows:

SEC 435.909Automatic entitlement to Medicaid following a determination of eligibility under other programs.

(a) Automatic enrollment of certain individuals in Medicaid. The agency must not require a separate application for Medicaid from a person, if the agency has an agreement with the Social Security Administration (SSA) under section 1634 of the Act for determining Medicaid eligibility; and–

(1) The person receives SSI;

(2) The person receives a compulsory State complement under either a federally-administered or State-administered program; or

(3) The person receives an optional State complement and the agency provides Medicaid to beneficiaries of optional supplements under SEC 435.230.

(b) Automatic enrollment of SSI recipients within the Qualified Medicare Beneficiary group. (1) The agency must deem individuals eligible for the Qualified Medicare Beneficiary group as described in SEC 400.200 of this chapter if the person receives SSI and is decided eligible for medical assistance under SEC 435.120 or SEC 435.121 and–

(i) The person is entitled to Part A under part 406, subpart B of this chapter; or

(ii) The person is entitled to Part A under SEC 406.20 of this chapter and the agency has a State buy-in agreement authorized under section 1843 of the Act and modified under section 1818(g) of the Act.

(2) The agency may deem individuals eligible for the Qualified Medicare Beneficiary group as described in SEC 400.200 of this chapter if the person receives SSI and is decided eligible for medical assistance under SEC 435.120 or SEC 435.121; and–

(i) The person is entitled to Part A under SEC 406.5(b) of this chapter; and

(ii) The agency uses the group payer arrangement under SEC 406.32(g) of this chapter to pay Part A premiums for Qualified Medicare Beneficiaries.

(3) The automated enrollment of SSI recipients within the Qualified Medicare Beneficiaries group described in paragraphs (b)(1) and (2) of this section is effective no sooner than the effective date of coverage under a buy-in agreement for people described in SEC 407.47(b) of this chapter.

   17. Section 435.911 is amended by revising paragraph (c) introductory text and adding paragraph (e) to read as follows:

SEC 435.911 Determination of eligibility.

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(c) For every individual who has submitted an application described in SEC 435.907, whose eligibility is being renewed in accordance with SEC 435.916, or whose eligibility is being redetermined in accordance with SEC 435.919 and who meets the non-financial requirements for eligibility (or for whom the agency is providing an inexpensive opportunity to confirm citizenship or immigration status in accordance with SEC 435.956(b)), the State Medicaid agency must comply with the following–

*****

(e) The agency must–

(1) Accept, via secure electronic interface, Low Income Subsidy application data (LIS leads data) transmitted to the agency from the Social Security Administration;

(2) Treat received LIS leads data regarding a person as an application for eligibility under section 1902(a)(10)(E) of the Act and, promptly and without undue delay, consistent with timeliness standards established under SEC 435.912, determine the eligibility of the person under such section, without requiring submission of one other application;

(3) Request additional information needed by the agency to make a determination of eligibility for the Medicare Savings Programs;

(4) Not request information or documentation from the person already provided to SSA through the LIS application and included within the transmission to the agency by the Social Security Administration; and

(5) Accept any information verified by SSA, without further verification, if the knowledge provided through the LIS leads data supports a determination of eligibility under section 1902(a)(10)(E) of the Act.

(6) Collect such additional information as could also be needed–

(i) Consistent with SEC 435.907(b), to find out whether such individual is eligible for Medicaid on the idea of the applicable modified adjusted gross income standard, and furnish Medicaid on such basis;

(ii) Consistent with SEC 435.907(c), to find out whether such individual is eligible for Medicaid advantages on any basis apart from the applicable modified adjusted gross income standard or under section 1902(a)(10)(E) of the Act, and furnish Medicaid on such basis; and

(iii) Consistent with SEC 435.956, to confirm a person’s U.S. citizenship or satisfactory immigration status, including providing the required reasonable opportunity period under 435.956(b).

(7) If any of the LIS leads data doesn’t support a determination of eligibility under section 1902(a)(10)(E) of the Act, the agency must–

(i) Determine whether additional information is required to make a determination of eligibility under section 1902(a)(10)(E) of the Act;

(ii) If such information is required, notify the person who they might be eligible for assistance with their Medicare premium and/or cost sharing charges, but that additional information is required for the agency to make a determination of such eligibility;

(iii) Provide the person with a minimum of 30 days to furnish information any information needed by the agency to make such determination of eligibility; and

(iv) Confirm the person’s eligibility under section 1902(a)(10)(E) of the Act in accordance with the agency’s verification plan developed in accordance with SEC 435.945(j).

   18. Section 435.912 is revised to read as follows:

SEC 435.912Timely determination and redetermination of eligibility.

(a) Definitions. For purposes of this section–

Performance standards are overall standards for determining, renewing and redetermining eligibility in an efficient and timely manner across a pool of applicants or beneficiaries, and include standards for accuracy and consumer satisfaction, but don’t include standards for a person applicant’s determination, renewal, or redetermination of eligibility.

Timeliness standards discuss with the utmost periods of time, subject to the exceptions in paragraph (e) of this section and in accordance with SEC 435.911(c), through which every applicant is entitled to a determination of eligibility, a redetermination of eligibility at renewal, and a redetermination of eligibility based on a change in circumstances.

(b) State plan requirements. Consistent with guidance issued by the Secretary, the agency must establish in its State plan timeliness and performance standards for, promptly and without undue delay–

(1) Determining eligibility for Medicaid for people who submit applications to the one State agency or its designee in accordance with SEC 435.907, including determining eligibility or potential eligibility for, and transferring individuals’ electronic accounts to, other insurance affordability programs pursuant to SEC 435.1200(e);

(2) Determining eligibility for Medicaid for people whose accounts are transferred from other insurance affordability programs, including at initial application, in addition to at a regularly-scheduled renewal or resulting from a change in circumstances;

(3) Redetermining eligibility for current beneficiaries at regularly-scheduled renewals in accordance with SEC 435.916, including determining eligibility or potential eligibility for, and transferring individuals’ electronic accounts to, other insurance affordability programs pursuant to 435.1200(e);

(4) Redetermining eligibility for current beneficiaries based on a change in circumstances reported by the beneficiary in accordance with SEC 435.919(b)(1) or received from a 3rd party in accordance with SEC 435.919(b)(2), including determining eligibility or potential eligibility for, and transferring individuals’ electronic accounts to, other insurance affordability programs pursuant to 435.1200(e); and

(5) Redetermining eligibility for current beneficiaries based on anticipated changes in circumstances in accordance with SEC 435.919(b)(3), including determining eligibility or potential eligibility for, and transferring individuals’ electronic accounts to, other insurance affordability programs pursuant to 435.1200(e).

(c) Timeliness and performance standard requirements–(1) Period covered. The timeliness and performance standards adopted by the agency under paragraph (b) of this section must–

(i) For determinations of eligibility at initial application or upon receipt of an account transfer from one other insurance affordability program, as described in paragraphs (b)(1) and (2) of this section, cover the period from the date of application or transfer from one other insurance affordability program to the date the agency notifies the applicant of its decision or the date the agency transfers the person’s electronic account to a different insurance affordability program in accordance with SEC 435.1200(e);

(ii) For regularly-scheduled renewals of eligibility under SEC 435.916, cover the period from the date that the agency initiates the steps required to renew eligibility on the idea of data available to the agency, as required under SEC 435.916(b)(1), to the date the agency sends the person notice required under SEC 435.916(b)(1)(i) or (b)(2)(i)(C) of its decision to approve their renewal of eligibility or, as applicable, to the date the agency terminates eligibility and transfers the person’s electronic account to a different insurance affordability program in accordance with SEC 435.1200(e);

(iii) For redeterminations of eligibility resulting from changes in circumstances under SEC 435.919(b), cover the period from the date the agency receives information reported by the beneficiary, as described at SEC 435.919(b)(1)(i), or received from the third party, as described at SEC 435.919(b)(2)(i), to the date the agency notifies the person of its decision or, as applicable, to the date the agency terminates eligibility and transfers the person’s electronic account to a different insurance affordability program in accordance with SEC 435.1200(e); and

(iv) For redeterminations of eligibility based on anticipated changes in circumstances under SEC 435.919(b)(3), cover the period from the date the agency begins the redetermination of eligibility, to the date the agency notifies the person of its decision or, as applicable, to the date the agency terminates eligibility and transfers the person’s electronic account to a different insurance affordability program in accordance with SEC 435.1200(e).

(2) Criteria for establishing standards. To advertise accountability and a consistent, prime quality consumer experience amongst States and between insurance affordability programs, the timeliness and performance standards included within the State plan must address–

(i) The capabilities and value of generally available systems and technologies;

(ii) The final availability of electronic data matching, ease of connections to electronic sources of authoritative information to find out and confirm eligibility, and the time needed by the agency to judge information obtained from electronic data sources;

(iii) The demonstrated performance and timeliness experience of State Medicaid, CHIP and other insurance affordability programs, as reflected in data reported to the Secretary or otherwise available;

(iv) The needs of applicants and beneficiaries, including preferences for mode of application and submission of data at renewal or redetermination (resembling through an online website, telephone, mail, in-person, or other commonly available electronic means), the time needed to return a renewal form or any additional information needed to finish a determination of eligibility at application or renewal, in addition to the relative complexity of adjudicating the eligibility determination based on household, income or other relevant information; and

(v) The advance notice that have to be provided to beneficiaries in accordance with [Sec.] SEC 431.211, 431.213, and 431.214 of this subchapter when the agency makes a determination leading to termination or other motion as defined in SEC 431.201 of this subchapter.

(3) Standard for brand spanking new applications and transferred accounts. Except as provided in paragraph (e) of this section, the determination of eligibility for any applicant or individual whose account was transferred from one other insurance affordability program may not exceed–

(i) Ninety (90) days for applicants who apply for Medicaid on the idea of disability; and

(ii) Forty-five (45) days for all other applicants.

(4) Standard for renewals. Except as provided in paragraph (e) of this section, the redetermination of eligibility for a beneficiary at a regularly-scheduled renewal may not exceed–

(i) The tip of the beneficiary’s eligibility period, within the case of a beneficiary whose eligibility could be renewed based on information available to the agency as described at SEC 435.916(b)(1) or within the case of a beneficiary whose renewal requires additional information and who returns a renewal form 25 or more calendar days prior to the top of the eligibility period described in SEC 435.916(a);

(ii) The tip of the month following the top of the beneficiary’s eligibility period, within the case of a beneficiary whose eligibility is being redetermined on the idea for which the beneficiary has been receiving Medicaid (the applicable modified adjusted gross income standard described in SEC 435.911(b)(1) and (2) or one other basis) and who returns a renewal form lower than 25 calendar days prior to the top of the beneficiary’s eligibility period; and

(iii) The next time periods, within the case of a beneficiary who is decided ineligible on the idea for which they’re currently receiving Medicaid and for whom the agency is considering eligibility on one other basis–

(A) Ninety (90) calendar days from the date the agency determines the beneficiary just isn’t eligible on the present basis, if eligibility is being determined on the idea of disability;

(B) Twenty-five (25) calendar days from the date the agency determines the beneficiary just isn’t eligible on the present basis, for all bases of determination apart from the idea of disability.

(5) Standard for redeterminations based on changes in circumstances. Except as provided in paragraph (e) of this section, the redetermination of eligibility for a beneficiary based on a change in circumstances reported by the beneficiary or received from a 3rd party may not exceed the top of the month that occurs–

(i) Thirty (30) calendar days following the agency’s receipt of data related to the change in circumstances, unless the agency must request additional information from the beneficiary; and

(ii) Sixty (60) calendar days following the agency’s receipt of data related to the change in circumstances if the agency must request additional information from the beneficiary.

(6) Standard for redeterminations based on anticipated changes. Except as provided in paragraph (e) of this section, the redetermination of eligibility for a beneficiary based on an anticipated change in circumstances, may not exceed–

(i) The date of the anticipated change, or at State option the last day of the month through which the anticipated change occurs, within the case of a beneficiary who returns requested information or documentation 25 or more calendar days prior to the date of the change (or the last day of the month if elected by the State);

(ii) The tip of the month following the month through which the anticipated change occurs, within the case of a beneficiary whose eligibility is being redetermined on the idea for which the beneficiary has been receiving Medicaid (the applicable modified adjusted gross income standard described in SEC 435.911(b)(1) and (2) or one other basis, as described in SEC 435.911(c)(2)) and who returns requested information or documentation lower than 25 calendar days prior to the date of the change (or the last day of the month if elected by the State); and

(iii) The next time periods, within the case of a beneficiary who is decided ineligible on the idea for which they’re currently receiving Medicaid and for whom the agency is considering eligibility on one other basis–

(A) Ninety (90) calendar days from the date the agency determines the beneficiary just isn’t eligible on the present basis, if eligibility is being determined on the idea of disability;

(B) Twenty-five (25) calendar days from the date the agency determines the beneficiary just isn’t eligible on the present basis, for all other beneficiaries.

(d) Availability of data. The agency must inform individuals of the timeliness standards adopted in accordance with this section.

(e) Exceptions. The agency must determine or redetermine eligibility throughout the standards except in unusual circumstances, for example–

(1) When the agency cannot reach a call since the applicant or beneficiary, or an examining physician, delays or fails to take a required motion, or

(2) When there’s an administrative or other emergency beyond the agency’s control.

(f) Case documentation. The agency must document the rationale(s) for delay within the applicant’s or beneficiary’s case record.

(g) Prohibitions. The agency must not use the timeliness standards–

(1) As a waiting period before determining eligibility;

(2) As a reason for denying or terminating eligibility (since it has not determined or redetermined eligibility throughout the timeliness standards); or

(3) As a reason for delaying termination of a beneficiary’s coverage or taking other antagonistic motion.

SEC 435.914 [Amended]

   19. Section 435.914 is amended–

   a. In paragraph (a), by removing the phrase “case record facts to support the agency’s decision on his application” and adding instead the phrase “and beneficiary’s case record the knowledge and documentation described in SEC 431.17(b)(1) of this subchapter”; and

   b. In paragraph (b) introductory text, by removing the phrase “by a finding of eligibility or ineligibility” and adding instead the phrase “and renewal by a finding of eligibility or ineligibility”.

   20. Section 435.916 is revised to read as follows:

SEC 435.916 Usually-scheduled renewals of Medicaid eligibility.

(a) Frequency of renewals. Except as provided in SEC 435.919:

(1) The eligibility of all Medicaid beneficiaries not described in paragraph (a)(2) of this section have to be renewed once every 12 months, and no more steadily than once every 12 months.

(2) The eligibility of qualified Medicare beneficiaries described in section 1905(p)(1) of the Act have to be renewed at the least once every 12 months, and no more steadily than once every 6 months.

(b) Renewals of eligibility. (1) Renewal on basis of data available to agency. The agency must make a redetermination of eligibility for all Medicaid beneficiaries without requiring information from the person if in a position to achieve this based on reliable information contained in the person’s account or other more current information available to the agency, including but not limited to information through any data bases accessed by the agency under [Sec.] SEC 435.948, 435.949, and 435.956. If the agency is in a position to renew eligibility based on such information, the agency must, consistent with the necessities of this subpart and subpart E of part 431 of this subchapter, notify the individual–

(i) Of the eligibility determination, and basis; and

(ii) That the person must inform the agency, through any of the modes permitted for submission of applications under SEC 435.907(a), if any of the knowledge contained in such notice is inaccurate, but that the person just isn’t required to sign and return such notice if all information provided on such notice is accurate.

(2) Renewals requiring information from the person. If the agency cannot renew eligibility for beneficiaries in accordance with paragraph (b)(1) of this section, the agency —

(i) Must provide the person with–

(A) A pre-populated renewal form containing information, as specified by the Secretary, available to the agency that is required to renew eligibility.

(B) At the least 30 calendar days from the date the agency sends the renewal form to reply and supply any mandatory information through any of the modes of submission laid out in SEC 435.907(a), and to sign the renewal form under penalty of perjury in a way consistent with SEC 435.907(f);

(C) Notice of the agency’s decision in regards to the renewal of eligibility in accordance with this subpart and subpart E of part 431 of this chapter;

(ii) Must confirm any information provided by the beneficiary in accordance with [Sec.] SEC 435.945 through 435.956;

(iii) If the person subsequently submits the renewal form or other needed information inside 90 calendar days after the date of termination, or an extended period elected by the State, must treat the renewal form as an application and reconsider the eligibility of a person whose coverage is terminated for failure to submit the renewal form or mandatory information in accordance with the applying time standards at SEC 435.912(c)(3) without requiring a latest application;

(iv) Not require a person to finish an in-person interview as a part of the renewal process.

(v) May request from beneficiaries only the knowledge needed to renew eligibility. Requests for non-applicant information have to be conducted in accordance with SEC 435.907(e).

(3) Special rules related to beneficiaries whose Medicaid eligibility is decided on a basis apart from modified adjusted gross income.

(i) The agency may consider blindness as continuing until the reviewing physician under SEC 435.531 determines that a beneficiary’s vision has improved beyond the definition of blindness contained within the plan; and

(ii) The agency may consider disability as continuing until the review team, under SEC 435.541, determines that a beneficiary’s disability now not meets the definition of disability contained within the plan.

(c) Timeliness of renewals. The agency must complete the renewal of eligibility in accordance with this section by the top of the beneficiary’s eligibility period described in paragraph (a) of this section and in accordance with the time standards in SEC 435.912(c)(4).

(d) Determination of ineligibility and transmission of information pertaining to individuals now not eligible for Medicaid. (1) Prior to creating a determination of ineligibility, the agency must consider all bases of eligibility, consistent with SEC 435.911.

(2) Prior to terminating coverage for people determined ineligible for Medicaid, the agency must determine eligibility or potential eligibility for other insurance affordability programs and comply with the procedures set forth in SEC 435.1200(e).

(e) Accessibility of renewal forms and notices. Any renewal form or notice have to be accessible to individuals who’re limited English proficient and individuals with disabilities, consistent with SEC 435.905(b).

   21. Section 435.919 is added to read as follows:

SEC 435.919 Changes in circumstances.

(a) Procedures for reporting changes. The agency must:

(1) Have procedures designed to make sure that beneficiaries understand the importance of constructing timely and accurate reports of changes in circumstances which will affect their eligibility; and

(2) Accept reports made under paragraph (a)(1) of this section and some other beneficiary reported information through any of the modes permitted for submission of applications under SEC 435.907(a);

(b) Agency motion on details about changes. Consistent with the necessities of SEC 435.952, the agency must promptly redetermine eligibility between regularly-scheduled renewals of eligibility required under SEC 435.916(a) each time it receives details about a change in a beneficiary’s circumstances.

(1) Changes reported by the beneficiary. When a beneficiary reports details about a change in circumstances, the agency must:

(i) Evaluate whether the reported change may impact the beneficiary’s eligibility for Medicaid or the quantity of medical assistance for which the beneficiary is eligible, premiums or cost sharing charges. If additional information is required to find out whether the beneficiary is not any longer eligible resulting from the reported change, the agency must redetermine eligibility based on available information, if in a position to achieve this, and if the extra information just isn’t available to the agency, request such information from the beneficiary;

(ii) If the agency determines that the reported change leads to an antagonistic motion, as defined in SEC 431.201 of this subchapter, take appropriate motion in accordance with paragraph (b)(4) of this section.

(iii) If the agency finds that the reported change may end in eligibility for extra medical assistance or lower premium or cost sharing charges, the agency must confirm the reported change in accordance with [Sec.] SEC 435.940 through 435.960 and the agency’s verification plan developed under SEC 435.945(j) prior to furnishing additional assistance or lowering applicable premiums or cost sharing charges. The agency may not terminate the beneficiary’s coverage if the beneficiary doesn’t reply to agency requests for extra information under this paragraph;

(iv) If the agency’s evaluation pursuant to paragraph (b)(1)(i) of this section indicates that the reported change has no impact on eligibility, the agency must provide the beneficiary with notice acknowledging receipt of the knowledge from the beneficiary and explaining that the beneficiary’s eligibility just isn’t impacted.

(2) Information received from a 3rd party. If the agency receives information regarding a beneficiary’s change in circumstances from a 3rd party, the agency must:

(i) Evaluate the reliability of the knowledge received and determine whether, if accurate, the knowledge received would impact the beneficiary’s eligibility, the quantity of medical assistance for which the beneficiary is eligible, premiums or cost sharing charges;

(ii) If the agency finds that the third-party information is reliable and will adversely impact the beneficiary, the agency must request information from the beneficiary to confirm or dispute the knowledge received, consistent with SEC 435.952. If the agency determines that the reported change leads to an antagonistic motion, take appropriate motion in accordance with paragraph (b)(4) of this section.

(iii) If the agency determines that the third-party information is reliable and leads to eligibility for extra medical assistance or lower premium or cost sharing charges, the agency must notify the beneficiary of such determination. Prior to providing such notice or additional medical assistance or lowering premium or cost sharing charges, the agency may confirm third-party information with the beneficiary; the agency may not terminate the beneficiary’s coverage if the beneficiary doesn’t reply to the agency’s request for extra assistance under this paragraph (b). The agency may accept the third-party information if the beneficiary doesn’t reply to agency requests for extra information under this paragraph (b);

(iv) Except as provided in paragraphs (f) and (g) of this section, if the agency determines that the third-party information just isn’t reliable or doesn’t impact the beneficiary’s eligibility, no motion is required.

(3) Anticipated changes. If the agency has details about anticipated changes in a beneficiary’s circumstances which will affect his or her eligibility, it must initiate a redetermination of eligibility at an appropriate time based on such changes consistent with the timeliness standards at SEC 435.912(c)(6).

(4) Determination of ineligibility and transmission of information pertaining to individuals now not eligible for Medicaid. (i) The agency must comply with the necessities at SEC 435.916(d)(1) (regarding consideration of eligibility on other bases) and SEC 435.916(d)(2) (regarding determining potential eligibility for other insurance affordability programs) prior to terminating a beneficiary in accordance with this section.

(ii) The agency must provide advance notice of antagonistic motion and fair hearing rights, in accordance with the necessities of part 431, subpart E of this chapter, prior to taking any antagonistic motion resulting from a change in a beneficiary’s circumstances.

(c) Response times and time standards–(1) Beneficiary response times. The agency must–

(i) Provide beneficiaries with at the least 30 days from the date the agency sends the notice requesting the beneficiary to supply the agency with any additional information needed for the agency to redetermine eligibility.

(ii) Allow beneficiaries to supply any requested information through any of the modes of submission laid out in SEC 435.907(a).

(2) Time standards for redetermining eligibility. The agency must redetermine eligibility throughout the time standards described in SEC 435.912(c)(5) and (6), except in unusual circumstances, resembling those described in SEC 435.912(e); States must document the rationale for delay in the person’s case record.

(d) Ninety (90)-day reconsideration period. If a person terminated for not returning requested information in accordance with this section subsequently submits the knowledge inside 90 days after the date of termination, or an extended period elected by the State, the agency must–

(1) Reconsider the person’s eligibility without requiring a latest application in accordance with the applying timeliness standards established under SEC 435.912(c)(3).

(2) Request additional information needed to find out eligibility consistent with SEC 435.907(e) and procure a signature under penalty of perjury consistent with SEC 435.907(f) if such information or signature just isn’t available to the agency or included in the knowledge described on this paragraph (d).

(e) Scope of redeterminations following a change in circumstance. For redeterminations of eligibility for Medicaid beneficiaries accomplished in accordance with this section–

(1) The agency must limit any requests for extra information under this section to information regarding a change in circumstance which will impact the beneficiary’s eligibility.

(2) If the agency has enough information available to it to renew eligibility with respect to all eligibility criteria, the agency may begin a latest eligibility period, as defined in SEC 435.916(a).

(f) Agency motion on returned mail: At any time when beneficiary mail is returned to the agency by the USA Postal Service (USPS), the agency–

(1) Must check the next sources for updated mailing address and other contact information–

(i) The agency’s Medicaid Enterprise System;

(ii) The agency’s contracted managed care plans, if applicable; and

(iii) A number of of the next: the State agency that administers Supplemental Nutrition Assistance Program; the State agency that administers Temporary Assistance for Needy Families; the State Department of Motor Vehicles; the USPS National Change of Address (NCOA) database; or other sources laid out in the State’s verification plan described in SEC 435.945(j).

(2) Must send the beneficiary a notice by mail to the address currently on file within the beneficiary’s case record, the forwarding address (if provided on the returned mail), and any address identified by the agency per paragraph (f)(1) of this section.

(i) Consistent with paragraph (c)(1) of this section, the agency must provide beneficiaries with at the least 30 days from the date the agency sends the notice to confirm the accuracy of the brand new contact information.

(ii) [Reserved]

(3) Must send the beneficiary at the least two notices, by a number of modalities apart from mail, resembling by phone, electronic notice, email or text messaging.

(i) For a beneficiary who elected to receive electronic notices and communications in accordance with SEC 435.918, at the least one communication attempt must use the beneficiary contact information on file via the popular electronic format and such notice must provide at the least 30 days from the date the agency sends the notice to confirm the accuracy of the brand new contact information. If there’s a failed electronic communication attempt then the agency cannot use that very same electronic modality as the choice modality to satisfy this proposed requirement and will use telephonic or electronic contact information obtained in (f)(1) of this section, as feasible.

(ii) The notices required under this paragraph have to be sent to the contact information within the beneficiary’s case record, if available, and will be sent to other contact information obtained by the agency per paragraph (f)(1) of this section.

(iii) The agency may elect to utilize any combination or order of other modalities.

(iv) The primary and last such notice have to be separated by a minimum of 3 business days.

(v) If the agency doesn’t have contact information for any alternative modality, the agency must make an observation of that fact within the beneficiary’s case record.

(4) Within the case of beneficiary mail returned with an in-state forwarding address, whose current address the agency is unable to substantiate pursuant to paragraphs (f)(1) through (3) of this section–

(i) May not terminate a beneficiary’s coverage for failure to answer a request to substantiate their address or State residency.

(ii) Must accept and update the beneficiary’s case record with–

(A) The in-state forwarding address provided on the returned beneficiary mail;

(B) An in-state address obtained from the managed care organization pursuant to paragraph (f)(1)(i) or (ii) of this section, provided that such address was received by the plan directly from, or was verified with, the beneficiary; or

(C) The in-state address obtained from the USPS NCOA database pursuant to paragraph (f)(1)(iii) of this section.

(5) Within the case of a beneficiary mail returned with an out-of-state address, whose current address the agency is unable to substantiate pursuant to paragraphs (f)(1) through (3) of this section, the agency must provide advance notice of termination and fair hearing rights consistent with 42 CFR part 431, subpart E.

(6) If a beneficiary’s whereabouts are unknown, as indicated by the return of beneficiary mail with no forwarding address and the beneficiary’s failure to answer the notices described in paragraphs (f)(2) and (3) of this section, and the agency has not updated the beneficiary’s address based on a reliable third-party source pursuant to paragraph (f)(1) of this section, the agency must take appropriate steps to terminate or suspend the beneficiary’s coverage or move the beneficiary to a fee-for-service delivery system.

(i) If the agency elects to terminate or suspend coverage in accordance with this paragraph, the agency must send notice to the beneficiary’s last known address or via electronic notification, in accordance with the beneficiary’s election under SEC 435.918 of this subpart, no later than the date of termination or suspension and supply notice of fair hearing rights in accordance with 42 CFR part 431 subpart E.

(ii) If whereabouts of a beneficiary whose coverage was terminated or suspended in accordance with this paragraph change into known throughout the beneficiary’s eligibility period, as defined in SEC 435.916(b), the agency–

(A) Must reinstate coverage back to the date of termination without requiring the person to supply additional information to confirm their eligibility, unless the agency has other information available to it that indicates the beneficiary may not meet all eligibility requirements.

(B) May begin a latest eligibility period, consistent paragraph (e)(2) of this section, if the agency has sufficient information available to it to renew eligibility with respect to all eligibility criteria without requiring additional information from the beneficiary.

(g) Agency motion on updated address information from other sources. (1) At any time when the agency obtains updated in-state mailing address information from the USA Postal Service National Change of Address (NCOA) or agency’s contracted managed care plans, the agency–

(i) Within the case of updated mailing address information from a contracted managed care plan, must make sure that an address was received by the plan directly from, or was verified with, the beneficiary;

(ii) Must send the beneficiary a notice by mail to each the address currently on file within the beneficiary’s case record and the brand new in-state address and supply the person with an inexpensive time frame to confirm the accuracy of the brand new contact information;

(iii) Must send the beneficiary at the least two notices, by a number of modalities apart from mail, resembling by phone, electronic notice, email or text messaging consistent with paragraph (f)(3) of this section;

(iv) May not terminate a beneficiary’s coverage for failure to answer a request to substantiate an in-state change of address;

(v) May accept the in-state address because the beneficiary’s latest address and update the beneficiary’s case record accordingly, if the beneficiary doesn’t reply to a request to substantiate their address or State residency, provided the beneficiary is given at the least 30 days from the date the agency sent the notice; and

(vi) Must accept the in-state address because the beneficiary’s latest address and update the beneficiary’s case record accordingly, if the beneficiary confirms their address or State residency.

(2) Upon approval from the Secretary, the agency may treat updated in-state address information from other trusted data sources in accordance with paragraph (g)(1) of this section.

(3) At any time when the agency obtains updated mailing address information from any source not listed in paragraph (g)(1) or (2) of this section, including out-of-state mailing address information, the agency must follow the steps outlined in paragraphs (f)(2) through (6) of this section.

   22. Section 435.940 is revised as follows:

SEC 435.940 Basis and scope.

The income and eligibility verification requirements set forth on this section and [Sec.] SEC 435.945 through 435.960 are based on sections 1137, 1902(a)(4), 1902(a)(19), 1902(a)(46)(B), 1902(ee), 1903(r)(3), 1903(x), 1940, and 1943(b)(3) of the Act, and section 1413 of the Reasonably priced Care Act. Nothing within the regulations on this subpart needs to be construed as limiting the State’s program integrity measures or affecting the State’s obligation to make sure that only eligible individuals receive advantages, consistent with parts 431 and 455 of this subchapter, or its obligation to supply for methods of administration which are in the most effective interest of applicants and beneficiaries and are mandatory for the right and efficient operation of the plan, consistent with SEC 431.15 of this subchapter and section 1902(a)(19) of the Act.

   23. Section 435.952 is amended by revising paragraphs (b) and (c) and adding paragraph (e) to read as follows:

SEC 435.952 Use of data and requests for extra information from individuals.

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(b) If information provided by or on behalf of a person (on the applying or renewal form or otherwise) is fairly compatible with information obtained by the agency, including information obtained in accordance with SEC 435.948, SEC 435.949, or SEC 435.956, the agency must determine or renew eligibility based on such information.

(c) A person must not be required to supply additional information or documentation unless information needed by the agency in accordance with SEC 435.948, SEC 435.949, or SEC 435.956 can’t be obtained electronically or information obtained electronically just isn’t reasonably compatible, as provided within the verification plan described in SEC 435.945(j), with information provided by or on behalf of the person.

(1) Income and resource information obtained through an electronic data match shall be considered reasonably compatible with income and resource information provided by or on behalf of a person if each are either above or at or below the applicable standard or other relevant threshold.

(2) [Reserved]

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(e) When determining eligibility for people applying for the Medicare Savings Programs laid out in sections 1902(a)(10)(E)(i), (iii), and (iv) and 1905(p) of the Act, the agency must accept attestation (either self-attestation by the person or attestation by an adult who’s within the applicant’s household, as defined in SEC 435.603(f), or family, as defined in section 36B(d)(1) of the Internal Revenue Code, a certified representative, or, if the person is a minor or incapacitated, someone acting responsibly for the person) of the next income and asset information without requiring further information (including documentation) from the person:

(1) Income and interest income. (i) Except as provided in paragraph (e)(1)(ii) of this section, the agency must accept an applicant’s attestation of the worth of any dividend and interest income earned on resources owned by the applicant or the applicant’s spouse.

(ii) If the agency has information that just isn’t reasonably compatible with an applicant’s attestation, the agency must seek additional information from the person in accordance with paragraph (c) of this section.

(iii) The agency may confirm interest and dividend income after the agency has determined that an applicant is eligible for the Medicare Savings Programs, in accordance with paragraph (c) of this section. If the agency requests documentation in accordance with this paragraph, the agency must provide the person with at the least 90 days from the date of the request to supply any mandatory information requested and must allow the person to submit such documentation through any of the modalities described in SEC 435.907(a).

(2) Non-liquid resources. (i) Except as provided in paragraph (e)(2)(ii) of this section, the agency must accept an applicant’s attestation of the worth of any non-liquid resources owned.

(ii) If the agency has information that just isn’t reasonably compatible with an applicant’s attestation, the agency must seek additional information from the person in accordance with paragraph (c) of this section.

(iii) The agency may confirm the worth of non-liquid resources after the agency has determined that an applicant is eligible for the Medicare Savings Programs, in accordance with paragraph (c) of this section. If the agency requests documentation in accordance with this paragraph, the agency must provide the person with at the least 90 days from the date of the request to supply any mandatory information requested and must allow the person to submit such documentation through any of the modalities described in SEC 435.907(a).

(3) Burial funds. (i) Except as provided in paragraph (e)(3)(ii) of this section, the agency must accept an applicant’s attestation that as much as $1,500 of their resources, and as much as $1,500 of their spouse’s resources, are put aside in a separate account and should not countable as resources when determining eligibility for the Medicare Savings Programs.

(ii) If the agency has information that just isn’t reasonably compatible with an applicant’s attestation, the agency must seek additional information from the person in accordance with paragraph (c) of this section.

(iii) The agency may confirm resources in burial funds after the agency has determined that an applicant is eligible for the Medicare Savings Programs, in accordance with paragraph (c) of this section. If the agency requests documentation in accordance with this paragraph, the agency must provide the person with at the least 90 days from the date of the request to supply any mandatory information requested and must allow the person to submit such documentation through any of the modalities described in SEC 435.907(a).

(4) Life insurance policies. (i) Except as provided in paragraph (e)(4)(ii) of this section, the agency must accept an applicant’s attestation of the face value of life insurance.

(A) If a person attests to a face value of life insurance policy that’s above $1,500, the State may accept an attestation of the money give up value of the life insurance policy for the aim of determining resource eligibility for the Medicare Savings Programs.

(ii) If the agency has details about either the face value or the money give up value that just isn’t reasonably compatible with an applicant’s attestation, the agency must seek additional information from the person in accordance with paragraph (c) of this section, which can include an inexpensive explanation of the discrepancy or documentation.

(iii) The agency may confirm the face value of a life insurance policy after the agency has determined that an applicant is eligible for a Medicare Savings Program, in accordance with paragraph (c) of this section.

(iv)(A) When a person must provide documentation of the money give up value of a life insurance policy, the agency must assist the person with obtaining this information and documentation by requesting that the person provide the name of the insurance company and policy number and authorize the agency to acquire such documentation from the issuer of the policy on the person’s behalf. The agency can also request, but may not require, additional information from the applicant to help the agency is obtaining the needed documentation, resembling the name of an agent.

(B) If the person doesn’t provide the knowledge and authorization in paragraph (e)(4)(iv)(A), the agency may require that the person provide documentation of the money give up value.

(C) The agency must allow the person to submit documentation through any of the modalities described in SEC 435.907(a) and supply the person with at the least 15 days to supply information or documentation described on this paragraph if such information or documentation is requested pursuant to paragraph (e)(4)(i) or (ii) of this section and at the least 90 days if required pursuant to paragraph (e)(4)(iii) of this section.

   24. Section 435.956 is amended by revising paragraph (b)(4) to read as follows:

SEC 435.956Verification of other non-financial information.

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(b) * * *

(4) The agency may not limit the variety of reasonable opportunity periods a person may receive.

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   25. Section 435.1200 is amended–

   a. By revising the heading for paragraph (b) introductory text;

   b. By revising paragraph (b)(1);

   c. In paragraph (b)(3)(i), by removing the phrase “a number of insurance affordability program” and adding instead the phrase “a number of insurance affordability programs”;

   d. By revising paragraph (b)(3)(ii);

   e. By adding paragraphs (b)(3)(vi) and (b)(4);

   f. By revising paragraphs (c) and (e)(1);

   g. By adding paragraph (e)(4);

   h. By revising paragraphs (h)(1) and (h)(3)(i) introductory text; and

   i. By redesignating the “(i)” paragraph following (h)(3)(i)(B) as paragraph (h)(3)(ii).

The revisions and additions read as follows:

SEC 435.1200 Medicaid agency responsibilities for a coordinated eligibility and enrollment process with other insurance affordability programs.

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(b) General requirements. * * *

(1) Fulfill the responsibilities set forth in paragraphs (c) through (h) of this section.

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(3) * * *

(ii) Ensure compliance with paragraphs (c) through (h) of this section;

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(vi) Seamlessly transition the eligibility of beneficiaries between Medicaid and the Kid’s Health Insurance Program (CHIP) when an agency administering considered one of these programs determines that a beneficiary is eligible for the opposite program.

(4) Accept a determination of eligibility for Medicaid made using MAGI-based methodologies by the State agency administering a separate CHIP within the State. With a view to comply with this requirement, the agency may:

(i) Apply the identical MAGI-based methodologies in accordance withSEC 435.603, and verification policies and procedures in accordance with [Sec.] SEC 435.940 through 435.956 as those utilized by the separate CHIP in accordance with [Sec.] SEC 457.315 and 457.380 of subchapter D, such that the agency will accept any finding regarding a criterion of eligibility made by a separate CHIP without further verification, in accordance with this paragraph (d)(4);

(ii) Utilize a shared eligibility service through which determinations of Medicaid eligibility are governed exclusively by the Medicaid agency and any functions performed by the separate CHIP are solely administrative in nature;

(iii) Enter into an agreement in accordance with SEC 431.10(d) of this chapter under which the Medicaid agency delegates authority to the separate CHIP in accordance with SEC 431.10(c) of this chapter to make final determinations of Medicaid eligibility; or

(iv) Adopt other procedures approved by the Secretary.

(c) Provision of Medicaid for people found eligible for Medicaid by one other insurance affordability program. (1) For every individual determined Medicaid eligible in accordance with paragraph (c)(2) of this section, the agency must–

(i) Establish procedures to receive, via secure electronic interface, the electronic account containing the determination of Medicaid eligibility;

(ii) Comply with the provisions of SEC 435.911 to the identical extent as if an application had been submitted to the Medicaid agency; and

(iii) Comply with the provisions of SEC 431.10 of this chapter to make sure it maintains oversight for the Medicaid program.

(2) For purposes of paragraph (c)(1) of this section, individuals determined eligible for Medicaid on this paragraph include:

(i) Individuals determined eligible for Medicaid by one other insurance affordability program, including the Exchange, pursuant to an agreement between the agency and the opposite insurance affordability program in accordance with SEC 431.10(d) of this chapter (including because of this of a call made by this system or this system’s appeals entity in accordance with paragraph (g)(6) or (g)(7)(i)(A) of this section); and

(ii) Individuals determined eligible for Medicaid by a separate CHIP (including as the results of a call made by a CHIP review entity) in accordance with paragraph (b)(4) of this section.

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(e) * * *

(1) Individuals determined not eligible for Medicaid. For every individual who submits an application to the agency which incorporates sufficient information to find out Medicaid eligibility or whose eligibility is being renewed in accordance with SEC 435.916 (regarding regularly-scheduled renewals of eligibility) or SEC 435.919 (regarding changes in circumstances) and whom the agency determines is ineligible for Medicaid, and for every individual determined ineligible for Medicaid in accordance with a good hearing under subpart E of part 431 of this chapter, the agency must promptly and without undue delay, consistent with timeliness standards established under SEC 435.912:

(i) Determine eligibility for a separate CHIP if operated within the State, and if eligible, transfer the person’s electronic account, via secure electronic interface, to the separate CHIP agency and make sure that the person receives a combined eligibility notice as defined at SEC 435.4; and

(ii) If not eligible for CHIP, determine potential eligibility for BHP (if offered by the State) and coverage available through the Exchange, and if potentially eligible, transfer the person’s electronic account, via secure electronic interface, to this system for which the person is potentially eligible.

*****

(4) Ineligible individuals. For purposes of paragraph (e)(1) of this section, a person is taken into account ineligible for Medicaid in the event that they should not eligible for any eligibility group covered by the agency that gives minimum essential coverage as defined at SEC 435.4. A person who’s eligible just for a limited profit group, resembling the eligibility group for people with tuberculosis described at SEC 435.215, could be considered ineligible for Medicaid for purposes of paragraph (e)(1).

*****

(h) * * *

(1) Include within the agreement into which the agency has entered under paragraph (b)(3) of this section that a combined eligibility notice, as defined in SEC 435.4, shall be provided:

(i) To a person, by either the agency or a separate CHIP, when a determination of Medicaid eligibility is accomplished for such individual by the State agency administering a separate CHIP in accordance with paragraph (b)(4) of this section, or a determination of CHIP eligibility is accomplished by the Medicaid agency in accordance with paragraph (e)(1)(i) of this section; and

(ii) To the utmost extent feasible to a person who just isn’t described in paragraph (i) of this section but who’s transferred between the agency and one other insurance affordability program by the agency, Exchange, or other insurance affordability program, in addition to to multiple members of the identical household included on the identical application or renewal form.

*****

(3) * * *

(i) Provide the person with notice, consistent with SEC 435.917, of the ultimate determination of eligibility on all bases, including coordinated content regarding, as applicable.

*****

   PART 457–ALLOTMENTS AND GRANTS TO STATES

   26. The authority citation for part 457 continues to read as follows:

Authority: 42 U.S.C. 1302.

   27. Section 457.65 is amended by revising paragraph (d) to read as follows:

SEC 457.65 Effective date and duration of State plans and plan amendments.

*****

(d) Amendments regarding enrollment procedures. A State plan amendment that institutes or extends using waiting lists, enrollments caps or closed enrollment periods is taken into account an amendment that restricts eligibility and must meet the necessities in paragraph (b) of this section.

*****

   28. Section 457.340 is amended by–

   a. Revising the paragraph (d) heading;

   b. Revising paragraph (d)(1);

   c. Removing paragraph (d)(3); and

   d. Revising paragraph (f)(1),

The revisions read as follows:

SEC 457.340 Application for and enrollment in CHIP.

*****

(d) Timely determination and redetermination of eligibility. (1) The terms in SEC 435.912 of this chapter apply equally to CHIP, except that–

(i) The terms of SEC 435.912(c)(4)(iii) and (c)(6)(iii) of this chapter (regarding timelines for completing renewals and redeterminations when States must consider other bases of eligibility) don’t apply; and

(ii) The standards for transferring electronic accounts to other insurance affordability programs are pursuant to SEC 457.350 and the standards for receiving applications from other insurance affordability programs are pursuant to SEC 457.348.

*****

(f) * * *

(1) Include within the agreement into which the State has entered under SEC 457.348(a) that, a combined eligibility notice, as defined in SEC 457.10, shall be provided:

(i) To a person, by the State agency administering a separate CHIP or the Medicaid agency, when a determination of CHIP eligibility is accomplished for such individual by the State agency administering Medicaid in accordance with SEC 457.348(e), or a determination of Medicaid eligibility is accomplished by the State in accordance with SEC 457.350(b)(1);

(ii) To the utmost extent feasible, to a person who just isn’t described in paragraph (f)(1)(i) of this section but who’s transferred between the State and one other insurance affordability program in accordance with SEC 457.348 or SEC 457.350; and

(iii) To the utmost extent feasible, to multiple members of the identical household included on the identical application or renewal form.

*****

   29. Section 457.344 is added to read as follows:

SEC 457.344 Changes in circumstances.

(a) Procedures for reporting changes. The State must:

(1) Have procedures designed to make sure that enrollees understand the importance of constructing timely and accurate reports of changes in circumstances which will affect their eligibility; and

(2) Accept reports made under paragraph (a)(1) of this section and some other enrollee reported information through any of the modes permitted for submission of applications under SEC 435.907(a), as referenced at SEC 457.330.

(b) State motion on details about changes. Consistent with the necessities of SEC 457.380(f), the State must promptly redetermine eligibility between regularly-scheduled renewals of eligibility required under SEC 457.343, each time it receives details about a change in an enrollee’s circumstances.

(1) Changes reported by the enrollee. When an enrollee reports details about a change in circumstances, the State must:

(i) Evaluate whether the reported change may impact the enrollee’s eligibility for CHIP or the quantity of kid health assistance or pregnancy-related assistance for which the enrollee is eligible, premiums or cost sharing charges. If additional information is required to find out whether the enrollee is not any longer eligible resulting from the reported change, the State must redetermine eligibility based on available information, if in a position to achieve this, and if the extra information just isn’t available to the State, request such information from the enrollee;

(ii) If the State determines that the reported change leads to an antagonistic motion, take appropriate motion in accordance with paragraph (b)(4) of this section.

(iii) If the State finds that the reported change may end in eligibility for extra child health or pregnancy-related assistance or lower premium or cost sharing charges, the State must confirm the knowledge in accordance with SEC 457.380 and the State’s verification plan prior to furnishing additional assistance or lowering applicable premiums or cost sharing charges. The State may not terminate the enrollee’s coverage if the enrollee doesn’t reply to agency requests for extra information under this paragraph (b).

(iv) If the State’s evaluation pursuant to paragraph (b)(1)(i) of this section indicates that the reported change has no impact on eligibility, the State must provide the enrollee with notice acknowledging receipt of the knowledge from the enrollee and explaining that the enrollee’s eligibility just isn’t impacted.

(2) Information received from a 3rd party. If the State receives information regarding an enrollee’s change in circumstances from a 3rd party, the State must:

(i) Evaluate the reliability of the knowledge received and whether, if accurate, the knowledge received would impact the enrollee’s eligibility for CHIP, the quantity of kid health assistance or pregnancy-related assistance for which the enrollee is eligible, premiums or cost sharing charges.

(ii) If the State finds that the third-party information is reliable and will adversely impact the enrollee, the State must request information from the enrollee to confirm or dispute the knowledge received, consistent with SEC 457.380(f). If the State determines that the reported change leads to an antagonistic motion, take appropriate motion in accordance with paragraph (b)(4) of this section.

(iii) If the State determines that the third-party information is reliable and leads to eligibility for extra child health assistance or pregnancy-related assistance or lower premium or cost sharing charges, the State must notify the enrollee of such determination. Prior to providing such notice or additional child health assistance or pregnancy-related assistance or lowering premium or cost sharing charges, the State may confirm third-party information with the enrollee; the State may not terminate the enrollee’s coverage if the enrollee doesn’t reply to the State’s request for extra or pregnancy-related assistance under this paragraph.

(iv) Except as provided paragraphs (f) and (g) of this section, if the State determines that the third-party information just isn’t reliable or doesn’t impact the enrollee’s eligibility, no motion is required.

(3) Anticipated changes. If the State has details about anticipated changes in an enrollee’s circumstances which will affect his or her eligibility, it must initiate a determination of eligibility at the suitable time based on such changes consistent with the necessities at SEC 435.912(c)(6) of this chapter as referenced in SEC 457.340(d)(1).

(4) Determination of ineligibility and transmission of information pertaining to individuals now not eligible for CHIP. (i) The State must comply with the necessities at SEC 435.916(d)(2) of this chapter as referenced in SEC 457.343 (regarding determining potential eligibility for other insurance affordability programs), prior to terminating an enrollee’s eligibility in accordance with this section.

(ii) The State must provide notice of antagonistic motion and State review rights, in accordance with the necessities of SEC 457.340(e), SEC 457.1260 (if enrolled in managed care), and subpart K of this part, prior to taking any antagonistic motion resulting from a change in an enrollee’s circumstances.

(c) Enrollee response times–(1) State requirements. The State must–

(i) Provide enrollees with at the least 30 days from the date the State sends the notice requesting the enrollee to supply the State with any additional information needed for the State to redetermine eligibility.

(ii) Allow enrollees to supply any requested information through any of the modes of submission laid out in SEC 435.907(a) of this chapter as referenced in SEC 457.330 of this subpart.

(2) Time standards for redetermining eligibility. The State must redetermine eligibility throughout the time standards described in SEC 435.912(c)(5) and (6) of this chapter, except in unusual circumstances, resembling those as described in SEC 435.912(e) of this chapter, as referenced in SEC 457.340(d); States must document the rationale for delay in the person’s case record.

(d) Ninety (90)-day reconsideration period. If a person terminated for not returning requested information in accordance with this section subsequently submits the knowledge inside 90 days after the date of termination, or an extended period elected by the State, the State must–

(1) Reconsider the person’s eligibility without requiring a latest application in accordance with the timeliness standards described at SEC 435.912(c)(3) of this chapter as referenced in SEC 457.340(d).

(2) Request additional information needed to find out eligibility and procure a signature under penalty of perjury consistent with SEC 435.907(e) and (f) of this chapter respectively as referenced in SEC 457.330 if such information or signature just isn’t available to the State or included in the knowledge described on this paragraph (d).

(e) Scope of redeterminations following a change in circumstances. For redeterminations of eligibility for CHIP enrollees accomplished in accordance with this section–

(1) The State must limit any requests for extra information under this section to information regarding change in circumstances which can impact the enrollee’s eligibility.

(2) If the State has enough information available to it to renew eligibility with respect to all eligibility criteria, the State may begin a latest eligibility period under SEC 457.343.

(f) State motion on returned mail. At any time when beneficiary mail is returned to the State by the USA Postal Service (USPS), the State–

(1) Must check the next sources for updated mailing address and other contact information–

(i) The State’s Medicaid Enterprise System;

(ii) The State’s contracted managed care plans, if applicable; and

(iii) A number of of the next: the State agency that administers Supplemental Nutrition Assistance Program; the State agency that administers Temporary Assistance for Needy Families; the State Department of Motor Vehicles; the USPS National Change of Address (NCOA) database; or other sources laid out in the State’s verification plan described in SEC 457.380(j).

(2) Must send the enrollee a notice by mail to the address currently on file within the enrollee’s case record, the forwarding address (if provided on the returned mail), and any address identified by the State per paragraph (f)(1) of this section;

(i) Consistent with paragraph (c)(1) of this section, the State must provide beneficiaries with at the least 30 days from the date the State sends the notice to confirm the accuracy of the brand new contact information.

(ii) [Reserved]

(3) Must send the enrollee at the least two notices, by a number of modalities apart from mail, resembling by phone, electronic notice, email or text messaging.

(i) For an enrollee who elected to receive electronic notices and communications in SEC 457.110, at the least one communication attempt must use the enrollee contact information on file via the popular electronic format and such notice must provide at the least 30 days from the date the agency sends the notice to confirm the accuracy of the brand new contact information. If there’s a failed electronic communication attempt then the State cannot use that very same electronic modality as the choice modality to satisfy this proposed requirement and will use telephonic or electronic contact information obtained in paragraph (f)(1) of this section, as feasible.

(ii) The notices required under this paragraph have to be sent to the contact information within the enrollee’s case record, if available, and will be sent to other contact information obtained by the State per paragraph (f)(1) of this section.

(iii) The State may elect to utilize any combination or order of other modalities.

(iv) The primary and last such notice have to be separated by a minimum of 3 business days.

(v) If the State doesn’t have contact information for any alternative modality, the State must make an observation of that fact within the enrollee’s case record.

(4) Within the case of enrollee mail returned with an in-state forwarding address, whose current address the State is unable to substantiate pursuant to paragraphs (f)(1) through (3) of this section, a State–

(i) May not terminate an enrollee’s coverage for failure to answer a request to substantiate their address or State residency.

(ii) Must accept and update the enrollee’s case record with–

(A) The in-state forwarding address provided on the returned enrollee mail;

(B) An in-state address obtained from the managed care organization pursuant to paragraph (f)(1)(i) or (ii) of this section, provided that such address was received by the plan directly from, or was verified with, the enrollee; or

(C) The in-state address obtained from the USPS NCOA database pursuant to paragraph (f)(1)(iii) of this section.

(5) Within the case of an enrollee whose mail is returned with an out-of-state address (or an address outside of the geographic area for separate CHIPs that should not Statewide) and whose current address the State is unable to substantiate pursuant to paragraphs (f)(1) through (3) of this section, the State must provide sufficient notice of termination including information describing a person’s right to a CHIP review process, consistent with SEC 457.340(e)(1).

(6) If an enrollee’s whereabouts are unknown, as indicated by the return of enrollee mail with no forwarding address and the enrollee’s failure to answer the notices described in paragraphs (f)(2) and (3) of this section, and the State has not updated the enrollee’s address based on a reliable third-party source pursuant to paragraph (f)(1) of this section, the State must take appropriate steps to terminate coverage, suspend coverage, or move the person to the fee-for-service delivery system, if available.

(i) If the State elects to terminate or suspend coverage in accordance with this paragraph, the State must send notice to the enrollee’s last known address or via electronic notification, in accordance with the enrollee’s election under SEC 457.110, no later than the date of termination or suspension and supply notice of a person’s rights to a CHIP review in accordance with SEC 457.340(e).

(ii) If whereabouts of a beneficiary whose coverage was terminated or suspended in accordance with this paragraph change into known throughout the beneficiary’s eligibility period, as defined in SEC 435.916(b) of this chapter as referenced in SEC 457.343, the State–

(A) Must reinstate coverage back to the date of termination without requiring the person to supply additional information to confirm their eligibility, unless the agency has other information available to it that indicates the enrollee may not meet all eligibility requirements.

(B) May begin a latest eligibility period, consistent paragraph (e)(2) of this section, if the State has sufficient information available to it to renew eligibility with respect to all eligibility criteria without requiring additional information from the enrollee.

(g) State motion on updated address information from other sources. (1) At any time when the State obtains updated in-state mailing address information from the USA Postal Service National Change of Address (NCOA) or the State’s contracted managed care plans, if applicable, the State–

(i) Within the case of updated mailing address information from a contracted managed care plan, must make sure that an address was received by the plan directly from, or was verified with, the enrollee;

(ii) Must send the enrollee a notice by mail to each the address currently on file within the enrollee’s case record and the brand new in-state address and supply the person with an inexpensive time frame to confirm the accuracy of the brand new contact information;

(iii) Must send the enrollee at the least two notices, by a number of modalities apart from mail, resembling by phone, electronic notice, email or text messaging consistent with paragraph (f)(3) of this section;

(iv) May not terminate an enrollee’s coverage for failure to answer a request to substantiate an in-state change of address;

(v) May accept the in-state address because the enrollee’s latest address and update the enrollee’s case record accordingly, if the enrollee doesn’t reply to a request to substantiate their address or State residency, provided the beneficiary is given at the least 30 days from the date the agency sent the notice; and

(vi) Must accept the in-state address because the enrollee’s latest address and update the beneficiary’s case record accordingly, if the enrollee confirms their address or State residency.

(vii) For separate CHIPs that should not Statewide, if the address obtained from NCOA or the State’s managed care plans are outside of the State’s specific geographic area for its separate CHIP, the necessities of paragraphs (f)(1) through (3) of this section to confirm out-of-state addresses are applicable.

(2) Upon approval from the Secretary, the State may treat updated in-state address information from other trusted data sources in accordance with paragraph (g)(1) of this section.

(3) At any time when the State obtains updated mailing address information from any source not listed in paragraph (g)(1) or (2) of this section, including out-of-state mailing address information, the State must follow the steps outlined in paragraphs (f)(2) through (6) of this section.

   30. Section 457.348 is amended–

   a. In paragraph (a)(4), by removing the phrase “Provide for coordination of notices with other insurance” and adding instead the phrase “Provide for a combined eligibility notice and coordination of notices with other insurance”;

   b. By adding paragraph (a)(6);

   c. By revising paragraph (b);

   d. In paragraph (c)(3), by removing the reference to “SEC 457.350(i)” and adding instead the reference “SEC 457.350(g)”; and

   e. By adding paragraph (e).

The additions and revision read as follows:

SEC 457.348Determinations of Kid’s Health Insurance Program eligibility by other insurance affordability programs.

(a) * * *

(6) Seamlessly transition the enrollment of beneficiaries between CHIP and Medicaid when a beneficiary is decided eligible for one program by the agency administering the opposite.

(b) Provision of CHIP for people found eligible for CHIP by one other insurance affordability program. (1) For every individual determined CHIP eligible in accordance with paragraph (b)(2) of this section, the State must–

(i) Establish procedures to receive, via secure electronic interface, the electronic account containing the determination of CHIP eligibility and notify such program of the receipt of the electronic account;

(ii) Comply with the provisions of SEC 457.340 to the identical extent as if the applying had been submitted to the State; and

(iii) Maintain proper oversight of the eligibility determinations made by the opposite program.

(2) For purposes of paragraph (b)(1) of this section, individuals determined eligible for CHIP on this paragraph include:

(i) Individuals determined eligible for CHIP by one other insurance affordability program, including the Exchange, pursuant to an agreement between the State and the opposite insurance affordability program (including because of this of a call made by this system or this system’s appeal entity in accordance with paragraph (a) of this section)); and

(ii) Individuals determined eligible for CHIP by the State Medicaid agency (including as the results of a call made by the Medicaid appeals entity) in accordance with paragraph (e) of this section.

*****

(e) CHIP determinations made by other insurance affordability programs. The State must accept a determination of eligibility for CHIP from the Medicaid agency within the State. With a view to comply with this requirement, the agency may:

(1) Apply the identical MAGI-based methodologies in accordance withSEC 457.315, and verification policies and procedures in accordance with SEC 457.380 as those utilized by the Medicaid agency in accordance with [Sec.] SEC 435.940 through 435.956 of subchapter C, such that the agency will accept any finding regarding a criterion of eligibility made by a Medicaid agency without further verification;

(2) Enter into an agreement under which the State delegates authority to the Medicaid agency to make final determinations of CHIP eligibility; or

(3) Adopt other procedures approved by the Secretary.

   31. Section 457.350 is revised to read as follows:

SEC 457.350 Eligibility screening and enrollment in other insurance affordability programs.

(a) State plan requirement. The State plan shall include an outline of the coordinated eligibility and enrollment procedures used, at an initial and any follow-up eligibility determination, including any periodic redetermination, to make sure that:

(1) Only targeted low-income children are furnished CHIP coverage under the plan; and

(2) Enrollment is facilitated for applicants and enrollees found to be eligible or potentially eligible for other insurance affordability programs in accordance with this section.

(b) Evaluation of eligibility for other insurance affordability programs. (1) For people described in paragraph (b)(2) of this section, promptly and without undue delay, consistent with the timeliness standards established under SEC 457.340(d), the State must:

(i) Determine eligibility for Medicaid on the idea of getting household income at or below the applicable modified adjusted gross income standard, as defined in SEC 435.911(b) of this chapter (“MAGI-based Medicaid”); and

(ii) If unable to make a determination of eligibility for MAGI-based Medicaid, discover potential eligibility for other insurance affordability programs, including Medicaid on a basis apart from MAGI, eligibility for the Basic Health Program (BHP) in accordance with 42 CFR 600.305(a), or insurance affordability programs available through the Exchange as indicated by information provided on the applying or renewal form provided by or on behalf of the beneficiary.

(2) Individuals to whom paragraph (b)(1) of this section applies include:

(i) Any applicant who submits an application to the State which incorporates sufficient information to find out CHIP eligibility;

(ii) Any enrollee whose eligibility is being redetermined at renewal or resulting from a change in circumstance per SEC 457.343; and

(iii) Any enrollee whom the State determines just isn’t eligible for CHIP, or who is decided not eligible for CHIP because of this of a review conducted in accordance with subpart K of this part.

(3) In determining eligibility for Medicaid as described in paragraph (b)(1) of this section, the State must utilize the choice the Medicaid agency has elected at SEC 435.1200(b)(4) of this chapter to just accept determinations of MAGI-based Medicaid eligibility made by a separate CHIP, and which have to be detailed within the agreement described at SEC 457.348(a).

(c) Income eligibility test. To find out eligibility as described in paragraph (b)(1)(i) of this section and to discover the individuals described in paragraph (b)(1)(ii) of this section who’re potentially eligible for BHP or insurance affordability programs available through an Exchange, a State must apply the MAGI-based methodologies used to find out household income described in SEC 457.315 or such methodologies as are applied by such other programs.

(d) Individuals found eligible for Medicaid based on MAGI. For people identified in paragraph (b)(1) of this section, the State must–

(1) Promptly and without undue delay, consistent with the timeliness standards established under SEC 457.340(d), transfer the person’s electronic account to the Medicaid agency via a secure electronic interface; and

(2) Except as provided in SEC 457.355, find the applicant ineligible for CHIP.

(e) Individuals potentially eligible for Medicaid on a basis apart from MAGI. For people identified as potentially eligible for Medicaid on a non-MAGI basis, as described in paragraph (b)(1)(ii) of this section, the State must–

(1) Promptly and without undue delay, consistent with the timeliness standards established under SEC 457.340(d), transfer the electronic account to the Medicaid agency via a secure electronic interface.

(2) Complete the determination of eligibility for CHIP in accordance with SEC 457.340 or evaluation for potential eligibility for other insurance affordability programs in accordance with paragraph (b) of this section.

(3) Include within the notice of CHIP eligibility or ineligibility provided under SEC 457.340(e), as appropriate, coordinated content relating to–

(i) The transfer of the person’s electronic account to the Medicaid agency per paragraph (e)(1) of this section;

(ii) The transfer of the person’s account to a different insurance affordability program in accordance with paragraph (g) of this section, if applicable; and

(iii) The impact that an approval of Medicaid eligibility could have on the person’s eligibility for CHIP or one other insurance affordability program, as appropriate.

(4) Dis-enroll the enrollee from CHIP if the State is notified in accordance with SEC 435.1200(d)(5) of this chapter that the applicant has been determined eligible for Medicaid.

(f) Children found ineligible for Medicaid based on MAGI, and potentially ineligible for Medicaid on a basis apart from MAGI. If a State uses a screening procedure apart from a full determination of Medicaid eligibility under all possible eligibility groups, and the screening process reveals that the kid doesn’t seem like eligible for Medicaid, the State must provide the kid’s family with the next in writing:

(1) An announcement that based on a limited review, the kid doesn’t appear eligible for Medicaid, but Medicaid eligibility can only be determined based on a full review of a Medicaid application under all Medicaid eligibility groups;

(2) Details about Medicaid eligibility rules, covered advantages, and restrictions on cost sharing; and

(3) Details about how and where to use for Medicaid under all eligibility groups.

(4) The State will determine the written format and timing of the knowledge regarding Medicaid eligibility, advantages, and the applying process required under this paragraph (f).

(g) Individuals found potentially eligible for other insurance affordability programs. For people identified in paragraph (b)(1)(ii) of this section who’ve been identified as potentially eligible for BHP or insurance affordability programs available through the Exchange, the State must promptly and without undue delay, consistent with the timeliness standards established under SEC 457.340(d), transfer the electronic account to the opposite insurance affordability program via a secure electronic interface.

(h) Evaluation of eligibility for Exchange coverage. A State may enter into an arrangement with the Exchange for the entity that determines eligibility for CHIP to make determinations of eligibility for advance payments of the premium tax credit and value sharing reductions, consistent with 45 CFR 155.110(a)(2).

(i) Waiting lists, enrollment caps and closed enrollment. The State must establish procedures to make sure that–

(1) The procedures developed in accordance with this section have been followed for every child applying for a separate child health program before placing the kid on a waiting list or otherwise deferring motion on the kid’s application for the separate child health program;

(2) Children placed on a waiting list or for whom motion on their application is otherwise deferred are transferred to other insurance affordability programs in accordance with paragraph (h) of this section; and

(3) Families are informed that a baby could also be eligible for other insurance affordability programs, while the kid is on a waiting list for a separate child health program or if circumstances change, for Medicaid.

   32. Section 457.480 is amended by–

   a. Revising the section heading;

   b. Redesignating paragraphs (a) and (b) as paragraphs (b) and (c), respectively; and

   c. Adding a latest paragraph (a).

The revision and addition read as follows:

SEC 457.480 Prohibited coverage limitations, preexisting condition exclusions, and relation to other laws.

(a) Prohibited coverage limitations. The State may not impose any annual, lifetime or other aggregate dollar limitations on any medical or dental services that are covered under the State plan.

*****

   33. Section 457.570 is amended by–

   a. Revising paragraph (c)(1);

   b. Removing paragraph (c)(2);

   c. Redesignating paragraph (c)(3) as paragraph (c)(2); and

   d. Revising newly redesignated paragraph (c)(2).

The revisions read as follows:

SEC 457.570 Disenrollment protections.

*****

(c) * * *

(1) Impose a specified time frame that a CHIP eligible targeted low-income child or targeted low-income pregnant woman who has an unpaid premium or enrollment fee won’t be permitted to reenroll for coverage in CHIP.

(2) Require the gathering of late premiums or enrollment fees as a condition of eligibility for reenrollment if a person was terminated for failure to pay premiums.

*****

   34. Section 457.805 is amended by revising paragraph (b) to read as follows:

SEC 457.805 State plan requirement: Procedures to deal with substitution under group health plans.

*****

(b) Limitations. A State may not, under this section, impose a waiting period before enrolling an eligible individual in CHIP that has been disenrolled from group health plan coverage. States should conduct monitoring activities to stop substitution of coverage.

   35. Section 457.810 is amended by revising paragraph (a) to read as follows:

SEC 457.810 Premium assistance programs: Required protections against substitution.

*****

(a) Prohibition of imposing a waiting period. A State may not, under this section, impose a waiting period before enrolling an eligible individual who has, but just isn’t enrolled in, group health plan coverage into CHIP premium assistance coverage.

*****

SEC 457.960[Removed]

   36. Section 457.960 is removed.

   37. Section 457.965 is revised to read as follows:

SEC 457.965 Documentation.

(a) Basis and purpose. This section, based on section 2101 of the Act, prescribes the sorts of records a State must maintain, the minimum retention period for such records, and the conditions under which those records have to be provided or made available.

(b) Content of records. A State plan must provide that the State will maintain or supervise the upkeep of the records mandatory for the right and efficient operation of the plan. The records must include the entire following–

(1) Individual records on each applicant and enrollee that contain–

(i) All information provided on the initial application submitted through any modality described in SEC 435.907(a) of this chapter as referenced in SEC 457.330, by, or on behalf of, the applicant or enrollee, including the signature on and date of application;

(ii) The electronic account and any information or other documentation received from one other insurance affordability program in accordance with SEC 457.348(c) and (d);

(iii) The date of, basis for, and all documents or other evidence to support any determination, denial, or other antagonistic motion taken with respect to the applicant or enrollee, including all information provided by the applicant or enrollee, and all information obtained electronically or otherwise by the State from third-party sources;

(iv) The supply of, and payment for, services, items and other child health assistance or pregnancy-related assistance, including the service or item provided, relevant diagnoses, the date that the item or service was provided, the practitioner or provider rendering, providing or prescribing the service or item, including their National Provider Identifier, and the complete amount paid or reimbursed for the service or item, and any third-party liabilities;

(v) Any changes in circumstances reported by the person and any actions taken by the State in response to such reports;

(vi) All renewal forms returned by, or on behalf of, a beneficiary, to the State in accordance with SEC 457.343, whatever the modality through which such forms are submitted, including the signature on the shape and date received.

(vii) All notices provided to the applicant or enrollee in accordance with [Sec.] SEC 457.340(e) and 457.1180; and

(viii) All records pertaining to any State reviews requested by, or on behalf of, the applicant or enrollee, including each request submitted and the date of such request, the whole record of the review decision, as described in subpart K of this part, and the ultimate administrative motion taken by the agency following the review decision and date of such motion; and

(ix) The disposition of income and eligibility verification information received under SEC 457.380, including evidence that no information was returned from an electronic data source.

(2) Statistical, fiscal, and other records mandatory for reporting and accountability as required by the Secretary.

(c) Retention of records. The State plan must provide that the records required under paragraph (b) of this section shall be retained for the period when the applicant or enrollee’s case is energetic, plus a minimum of three years thereafter.

(d) Accessibility and availability of records. The agency must–

(1) Maintain the records described in paragraph (b) of this section in paper in an electronic format; and

(2) Make the records available to the Secretary, Federal and State auditors and other parties who request, and are authorized to review, such records inside 30 calendar days of the request if not otherwise specified, and to the extent permissible by Federal law.

   38. Section 457.1140 is amended by revising paragraph (d)(4) to read as follows:

SEC 457.1140 Program specific review process: Core elements of review.

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(d) * * *

(4) Receive continued enrollment and advantages in accordance with SEC 457.1170.

   39. Section 457.1170 is revised to read as follows:

SEC 457.1170 Program specific review process: Continuation of enrollment.

(a) A State must ensure the chance for continuation of enrollment and advantages pending the completion of review of the next:

(1) A suspension or termination of enrollment, including a call to disenroll for failure to pay cost sharing and;

(2) A failure to make a timely determination of eligibility at application and renewal.

(b) [Reserved]

   40. Section 457.1180 is revised to read as follows:

SEC 457.1180 Program specific review process: Notice.

A State must provide enrollees and applicants timely written notice of any determinations required to be subject to review under SEC 457.1130 that features the explanations for the determination, a proof of applicable rights to review of that determination, the usual and expedited time frames for review, the style through which a review could be requested, and the circumstances under which enrollment and advantages may proceed pending review.

   PART 600–ADMINISTRATION, ELIGIBILITY, ESSENTIAL HEALTH BENEFITS, PERFORMANCE STANDARDS, SERVICE DELIVERY REQUIREMENTS, PREMIUM AND COST SHARING, ALLOTMENTS, AND RECONCILATION

   41. The authority citation for part 600 continues to read as follows:

Authority:Section 1331 of the Patient Protection and Reasonably priced Care Act of 2010 (Pub. L. 111-148, 124 Stat. 119), as amended by the Health Care and Education Reconciliation Act of 2010 (Pub. L. 111-152, 124 Stat 1029).

   42. Section 600.330 is amended by revising paragraph (a) to read as follows:

SEC 600.330Coordination with other insurance affordability programs.

(a) Coordination. The State must establish eligibility and enrollment mechanisms and procedures to maximise coordination with the Exchange, Medicaid, and CHIP. The terms of 45 CFR 155.345(a) regarding the agreements between insurance affordability programs apply to a BHP. The State BHP agency must fulfill the necessities of 42 CFR 435.1200(d), (e)(1)(ii), and (e)(3) and, if applicable, paragraph (c) of this section for BHP eligible individuals.

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   43. Section 600.525 is amended by revising paragraph (b)(2) to read as follows:

SEC 600.525 Disenrollment procedures and consequences for nonpayment of premiums.

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(b) * * *

(2) A State electing to enroll eligible individuals all year long must comply with the reenrollment standards set forth in SEC 457.570(c) of this chapter.

   Dated: August 29, 2022.

Xavier Becerra,

Secretary, Department of Health and Human Services.

[FR Doc. 2022-18875 Filed 8-31-22; 4:15 pm]

BILLING CODE 4120-01-P

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