In an Informational Bulletin (CIB) released on March 15, 2024, CMS reminds states of their obligation to comply with all existing federal renewal requirements in Medicaid and CHIP. The CIB is the result of questions CMS has received from states, stakeholders, and external partners regarding the permissibility of certain renewal practices. The CIB describes 10 specific actions that are not permissible and, importantly, directs states to change these practices as quickly as possible and to reach out to CMS for technical assistance. The 10 “Do Nots” are:

1. Do not terminate Medicaid or CHIP coverage for an individual who has returned their renewal form or documentation requested by the state within the eligibility period, even if processing the renewal form and documents will need to occur after the eligibility period has ended.
2. Do not terminate Medicaid coverage without first determining eligibility on all other bases.
3. Do not require a new application from individuals who are eligible on the basis of Modified Adjusted Gross Income (MAGI) and who respond to a renewal request within 90 days after a procedural termination.
4. Do not exclude an individual from ex parte renewal because wage data show that a household earner is working for an employer that is different from that reflected in the case record, if income remains below the applicable standard.
5. Do not exclude individuals from an ex parte renewal in Medicaid solely because the state has aligned renewal dates with those for the Supplemental Nutrition Assistance Program (SNAP) or other human services benefit programs.
6. Do not transition an individual to the Marketplace, or to an eligibility category with lesser benefits or increased premiums or cost sharing, based on an ex parte review, without first sending a renewal form and request for information.
7. Do not terminate coverage, or take other adverse action, until after advance notice, including an explanation of fair hearing rights, is provided.
8. Do not conduct ex parte renewals at the household level.
9. Do not provide fewer than 30 days for the response to a renewal form for individuals whose eligibility is based on MAGI.
10. Do not send renewal forms and other notices only in English, without providing language services, to households that have requested information in other languages or fail to ensure effective communication with individuals with disabilities.

The CIB goes into more detail about each of the 10 practices, citing the relevant regulation and providing a rationale for why these practices are disallowed. But it doesn’t take much to read between the lines and know there is evidence that each of these practices is a problem in more than a handful of states. Otherwise, CMS would not issue a CIB; they’d just work directly with a state(s) on corrective action.

CMS recommends that states conduct a thorough assessment of their renewal processes and bring any compliance questions to the agency’s attention. The CIB reminds states that the single state Medicaid agency is fully responsible for ensuring that it, and its delegated agencies (including other state or local agencies), are compliant with the Medicaid statute, federal regulations, and the Medicaid state plan. Moreover, the CIB reiterates that failure to comply with statutory and regulatory requirements could lead to CMS taking compliance action. Despite the reminder of possible CMS action, as best we know, CMS has not issued corrective action plans during the unwinding of the Medicaid continuous enrollment requirement.

We’re thankful the agency took public action so that states cannot argue that CMS wasn’t clear about where the regulations stand, and that the broader Medicaid community can continue to help monitor state practices and provide feedback to CMS on concerns and issues facing enrollees and applicants. The list of 10 “Do Nots” is a good start, but there are many improvements and changes that are needed for states to comply with all federal regulations, including phasing out mitigation strategies in use during the unwinding.

Mitigation strategies were approved by CMS to address an area where the state is not in compliance – such as not being able to document and store a telephonic signature when accepting renewals by phone as required. But strategies that waive key renewal requirements and consumer protections should not be continued indefinitely. Since these are documented, CMS should set realistic but swift deadlines for states to phase out their mitigation strategies as they resume normal operations and work toward full compliance. States should be given a date certain, not too far in the distant future, to be fully compliant.

The fact is that most of the current federal renewal requirements became effective during implementation of the Affordable Care Act in late 2013 and 2014. Ten years is a long time to wait for the promise of streamlined, data-driven processes that support enrollment and retention of eligible kids and families in Medicaid and CHIP. Because some states continue to resist the concept, while others lack the leadership, resources, or adequate oversight of contractors to get the job done, we’re not there yet.