CMS Guidance on 6 Month Redeterminations  

The Centers for Medicare & Medicaid Services (CMS) last week released a State Medicaid Director Letter (SMDL) to describe the changes to eligibility redeterminations made by Section 71107 of H.R. 1, which requires states to complete eligibility redeterminations once every six months, beginning with renewals scheduled on or after January 1, 2027, for most individuals enrolled in the Medicaid adult group. This SMDL provides states with an overview of the changes to federal renewal requirements, reminds states of federal renewal requirements that continue to apply, and addresses operational considerations for states when implementing 6-month renewals for the affected population. 

Section 71107 requires states to conduct renewals of eligibility once every 6 months, instead of once every 12 months, for almost all individuals enrolled under the state plan in the Medicaid adult group, and almost all individuals who are eligible for a state plan adult group but instead are enrolled in an equivalent section 1115 demonstration. This is essentially similar to the group of individuals subject to the new community engagement requirements under Section 71119 of H.R. 1, and CMS notes that “states will generally need to make policy, operational, and system updates to comply with sections 71107 and 71119, including a determination of compliance with community engagement, at each scheduled renewal on or after January 1, 2027.”  

CMS points out that other than verifying that individuals have met the community engagement requirements, the new law does not amend the steps involved in the renewal process. States must “begin the renewal process by checking available, reliable information contained in the individual’s account or more current information available to the state (including information accessed through certain data sources) to attempt to redetermine eligibility without contacting the beneficiary, known as an ex parte renewal,” sending a prepopulated renewal form only when the ex parte renewal is insufficient. 

CMS notes that some households will have multiple Medicaid beneficiaries who may have different eligibility periods, and reminds states that “if a beneficiary whose eligibility is being renewed provides information that affects the eligibility of other household members, such as a change in income or household composition,” the state must promptly act on that information. The agency also indicates that “when redetermining eligibility at renewal, states must consider all bases of eligibility prior to making a determination of ineligibility.” As a result, Medicaid beneficiaries might be redetermined eligible for a different eligibility group, which could result in a change to their eligibility period.