On March 27, 2024, the Centers for Medicare & Medicaid Services (CMS) issued a final regulation addressing eligibility and enrollment in Medicaid and the Children’s Health Insurance Program (CHIP), titled “Streamlining the Medicaid, Children’s Health Insurance Program, and Basic Health Program Application, Eligibility Determination, Enrollment, and Renewal Processes” (“E&E Rule”). The E&E Rule streamlines Medicaid enrollment and renewal processes and includes notable protections for children, people with disabilities, and older adults. The ultimate impact of the rule will be a reduction of red tape and barriers that make it hard for eligible children and families to enroll or renew coverage in Medicaid and the Children’s Health Insurance Program (CHIP)  and for eligibility and call center workers to provide accurate program information based on aligned program rules. It will also promote government efficiency for seniors and people with disabilities so they can get the health care they need. Last but not least, it will improve program integrity efforts by modernizing requirements for proper documentation of eligibility determinations needed to verify state actions for audit purposes. 

Question #1: Does the E&E Rule expand Medicaid and CHIP eligibility or establish required periods of continuous eligibility?

No, the regulation does not expand Medicaid and CHIP eligibility or require any set period of continuous eligibility. 

Question #2: How does the E&E Rule help children enroll in CHIP and get health care?

The E&E Rule protects children from being forced into periods of uninsurance by eliminating CHIP “waiting periods” that delay uninsured eligible kids from enrolling in coverage. Waiting periods force children to go uninsured for as long as three months before they can get coverage. The rule also removes arbitrary annual or lifetime dollar limits on coverage, meaning that families can rest assured that their children’s CHIP coverage will still be there if their child develops a serious illness. In addition, the rule prevents states from punishing kids by using “lockouts” to block eligible kids from re-enrolling if their parents miss a premium payment. Finally, the rule improves the seamless transfer of coverage when kids are transitioning between CHIP and the Medicaid program, ensuring no kids fall through the cracks and end up needlessly uninsured. All of these changes will improve coverage for children and help promote program efficiency by aligning CHIP policies with existing Medicaid policies. 

Question #3: How does the E&E Rule help older adults and people with disabilities, including people who need mental health services?

Current enrollment policy uses a different and more onerous set of enrollment rules for seniors and people with disabilities (known as “non-MAGI” populations). This is not only unfair for seniors and people with disabilities but it also means that state eligibility systems have unnecessary complexity and duplicative policies. The E&E Rule takes important steps to align the enrollment standards for all populations. This means states and enrollees will not have to deal with two sets of procedures. It also means eligible people with disabilities and older adults have an easier time getting and staying enrolled. For example, under the current regulations, states can require older adults and people with disabilities to appear in person for an interview as part of their Medicaid application process; this is not allowed for other populations. States are also allowed to require older adults and people with disabilities to renew eligibility every 6 months, whereas other populations are only allowed to be renewed annually. Semi-annual renewals and in-person interviews add to states’ administrative workload, exacerbating state challenges in maintaining an adequate and well-trained workforce. The rule changes these and other policies that will improve enrollment for older adults and people with disabilities, and streamline state administrative processes.

Question #4: How else does the E&E Rule improve Medicaid enrollment and renewal processes?

Medicaid-eligible individuals have to go through complex processes and jump through unnecessary bureaucratic hoops to enroll in and renew their health coverage. The rule requires clear and improved processes for reviewing eligibility based on changes in circumstances in a household—for example when household income changes. The rule also establishes timeframes for renewal reviews and account transfers, to ensure families aren’t stuck waiting too long for their health insurance to renew or move to new coverage. Finally, the rule gives states more options and establishes specific policies for updating the address and contact information of enrollees, which is critical to ensure that families receive important notices, including paperwork that is required to stay enrolled. These policies will help ensure that eligible people can maintain their coverage.

Question #5: How does the E&E Rule promote streamlined and efficient Medicaid and CHIP enrollment processes?

In addition to aligning several CHIP enrollment policies with Medicaid, the E&E Rule creates a uniform set of enrollment procedures for all populations. These policies will reduce complexity, confusion, and red tape for families with children, seniors, and people with disabilities. Importantly, aligned policies reduce state administrative burden by making it easier for eligibility and call center workers to support enrollees and in maintaining costly eligibility systems. Finally, the rule updates and improves maintenance of eligibility and enrollment records (for the first time in nearly 40 years), which will improve efforts to identify any fraud in the program and more accurately report eligibility errors.

Question #6: How does the E&E Rule improve program integrity efforts?

Nearly three-fourths of Medicaid payment errors are due to insufficient documentation to verify eligibility. The E&E rule provides the first update to documentation requirements since 1986 during which time technology and digital document storage have evolved. The updates will ensure that states have the information they need to properly document eligibility determinations and avoid the erroneous reporting of payment errors.