Guidance on implementing six-month renewals for the Medicaid adult expansion group, as required by H.R. 1 was sent to state Medicaid directors earlier today (March 6, 2026). The delayed guidance (which was due by December 31, 2025) has kept states waiting for key details that are needed to set state policy, make system changes, and prepare for the additional workload that semi-annual renewals will require.
States have two options for the timing of transitioning current expansion adults.
The guidance addresses a key question about timing for transitioning current expansion enrollees. H.R. 1 requires semi-annual renewals to begin for renewals that are “scheduled on or after the first day of the first quarter that begins after December 31, 2026.” CMS guidance points out that “scheduled” could refer to the date on which the renewal is “scheduled to be initiated in 2027 or could instead refer to the act of setting a future initiation date” for individuals enrolled on January 1, 2027.
Let’s start with option one because it is, by far, the best option. Under this scenario, the state would begin establishing a six-month renewal date starting with renewals that are “initiated” in January. States typically begin the “ex-parte” process to verify ongoing eligibility 60-90 days in advance. So, in January, a state might start the renewal process for an individual whose eligibility period ends March 31, 2027. In other words, states would continue their current process in 2027 except setting the next eligibility period to end in six months.
Option two would allow a state to reassign renewal dates that are as close as possible to six months for all expansion adults enrolled on January 1, 2027. This option means that any individual who enrolled or last renewed in the first six months of 2026 would have a new renewal date of January 2027 to avoid providing them with the full 12 months of coverage as option one does. The guidance indicates that states must send a notice to expansion enrollees informing them of a reduction in benefits – meaning a shortened eligibility period – with a 10-day advance notice of adverse action along with fair hearing rights. This option, in essence, doubles the state’s workload by needing to renew all expansion enrollees in the first six months of 2027, with a large cluster in January when states must also implement complex work reporting requirements. This approach would likely overwhelm state eligibility systems and workforces.
The guidance provides multiple examples of how each of the options would be applied.
States were reminded that current renewal requirements apply to expansion adults.
The guidance reviews state renewal requirements – primarily the need to attempt to verify ongoing eligibility through reliable data available to the state, known as the ex parte process. It also reminds states that they cannot align renewals among family members that include both expansion adults and children or other members of the family by either shortening or lengthening renewal periods. While states may coordinate Medicaid renewals with other benefits with a six-month eligibility period, it cannot hold up the Medicaid determination if the coordinated renewal is only missing information for the other program(s).
Reported changes for expansion adults at renewal may impact eligibility of other members of the family.
If the renewal for an expansion adult reflects information that affects the eligibility of other family members, such as income or household composition, the state must promptly act on that information for the affected individual and review eligibility. This would have been a good place for CMS to remind states that they must still provide 12-month continuous eligibility for children and through the end of the postpartum period for Medicaid enrollees regardless of whether they are enrolled through the pregnancy pathway or in the adult expansion group. The guidance does provide one example of what happens at the end of the postpartum period that is intended to illustrate when an expansion enrollee moves between eligibility groups.
States were informed that they must resolve existing application or renewal backlogs.
The guidance acknowledges the effort that will be required to comply with H.R. 1 and informs states that they must resolve existing application or renewal backlogs which will restrict the capacity of states to handle the new H.R. 1 administrative burdens. (You can view state data on timeliness of application processing and pending renewals in our H.R. 1 State Readiness Tracker.) The guidance warns states that if existing backlogs are not resolved or if new backlogs develop, states will be at greater risk of compliance action, although it did not specify what that means.
Details on how to implement work reporting requirements and the implications of these requirements for renewals is deferred
States are as eager for work reporting requirement answers as semi-annual renewals even though H.R. 1 gives CMS until June to publish an interim final rule (a process of rulemaking that finalizes a rule without an advance comment period). With the unreasonable expectation that states implement these major policy changes within 18 months of enactment, it is critical that CMS provide timely information and answers to questions to mitigate the chaos and confusion that is likely to engulf Medicaid by January 2027. Such information should be clear and transparent not only to states but also the many other Medicaid stakeholders.