States and stakeholders now have the long-awaited CMS guidance on advance planning in Medicaid and CHIP for the end of the public health emergency (PHE). There’s a lot to digest in this 54-page State Health Official letter (SHO). It discusses what happens to the various pandemic-related authorities and waivers and what states must do to transition to normal operations. In the new year, we’ll unpack more of the details but, for now, I wanted to highlight what the guidance says about returning to normal eligibility and enrollment operations relating to the Families First continuous eligibility provision.
The guidance clearly establishes that CMS expects the states to be actively working to get back on track to the extent possible now. This means states that have not continued to process renewals, changes in circumstances, or post-eligibility verifications should start doing so before the PHE ends. It reminds states of their obligations and refers to the recent refresher on renewal requirements released by the agency a couple of weeks ago. Of course, until the end of the month when the PHE expires, states may not disenroll Medicaid beneficiaries (unless they move out of state or request voluntary termination) under the Families First maintenance of effort (MOE) continuous eligibility provision.
What the guidance doesn’t do — contrary to what many Medicaid experts believe is required by current regulations – it does NOT require states to conduct a full eligibility review for all beneficiaries with pending adverse actions. This provision only applies to determinations made in the 6 months prior to the end of the PHE and if the notice to the beneficiary met specific requirements. However, states will be required to send a second notice with fair hearing rights at least 10 days in advance of the termination date to all beneficiaries losing eligibility.
As states process overdue renewals and are able to verify ongoing eligibility on an ex parte basis, they have the option to extend eligibility until the end of original renewal period or to start a new 12-month renewal period. For example, if a state conducts a renewal in January for a beneficiary whose renewal was due in April 2019, the state has the option to extend eligibility to April 2020 or until January 2021. However, if the state requires a beneficiary to provide information needed to confirm ongoing eligibility, the state must start a new 12-month eligibility period.
Post PHE, states will be expected to meet timeliness standards for applications in four months and be current on all other COVID-related changes in six months. If states meet these expectations, delayed eligibility and enrollment action will not be considered untimely for the Payment Error Rate Measurement Program (PERM) or the Medicaid Eligibility Quality Control Program (MEQC).
The guidance discusses the need for states to develop a Post-COVID Eligibility and Enrollment Operational Plan, which adopts one of four risk-based approaches to prioritize needed eligibility actions on individuals more likely to not have ongoing eligibility. CMS is developing a COVID-related Pending Eligibility and Enrollment Actions Resolution Planning Tool to assist states in the planning process. The agency will also release guidance specific to COVID-19 program integrity issues, including beneficiary eligibility, to assist states as they assess whether to make changes adopted during the PHE permanent.
In the new year, we’ll unpack more of the details of this critical guidance. In the meantime, enjoy the holiday break and have a healthy 2021.
