Redetermination of Medicaid Benefits

In Medicaid redetermination, a beneficiary’s eligibility for continued coverage is reviewed by the Medicaid agency. Typically, this process occurs annually. However, during the pandemic, the federal government enacted the Families First Coronavirus Response Act (FFCRA), requiring continuous Medicaid enrollment without redetermination until the public health emergency (PHE) is legally declared over May 11, 2023.

Early January of 2023, the Department of Health and Human Services (HHS) released a Medicaid federal policy guide covering key dates for the end of the continuous enrollment provision no longer linked to the end of the public health emergency. In fact, the expiration has already occurred. As of April 2023, states may terminate Medicaid coverage and request a beneficiary redetermination.

Previous Spike in Medicaid Enrollment

Medicaid enrollment increased substantially during the pandemic. Now that continuous enrollment is ending, millions of Americans are at risk of losing their existing Medicaid coverage. Medicaid disenrollments happen at the state level, but states must comply with the federal rules to conduct renewals. Each state’s process may vary slightly.

The Kaiser Family Foundation (KFF), a non-profit focusing on national health issues, estimates between 5.3 to 14.2 million people will lose Medicaid coverage. HHS estimates as many as 15 million people may be disenrolled, including 6.8 million who may remain eligible but need to re-enroll.

Those who temporarily lose Medicaid coverage and re-enroll quickly are called “churn.” Churn may account for those individuals who experience short-term changes in circumstances or income that temporarily render them ineligible or face barriers in maintaining coverage because of the redetermination process that the end of the continuous enrollment provision brings.

Eligibility Checks

The federal government required states to develop plans to resume routine operations during the unwinding of the continuous enrollment process. Each state has renewal priorities and estimates for the time needed to complete the redetermination process and apply updated standards to reduce inappropriate coverage loss.

Streamlining renewal processes can help the continuity of coverage under the Affordable Care Act (ACA). Medicaid agency services can check eligibility through available data sources like the state wage databases before sending renewal forms or document requests to an enrollee. These electronic data checks can verify ongoing eligibility. However, of the 42 participating states, only 11 report completing 50 percent or more redeterminations using this process. The renewal process will be lengthy and cumbersome for most beneficiaries.

Medicaid Redetermination Process

Individuals who don’t renew automatically must go through the Medicaid redetermination process to continue receiving coverage. Absent the FFCRA provision for ongoing enrollment, the process will return to its annual renewal basis to ensure individuals receiving Medicaid benefits are still eligible.

The Medicaid agency will request that beneficiaries provide updated income, assets, and household information. They may also require the beneficiary to provide documentation such as pay stubs, tax returns, and bank statements to verify eligibility.

If the agency determines a beneficiary is no longer eligible for Medicaid, they may send a notice of termination and allow the individual to appeal the decision. If the beneficiary disagrees with the appeal decision, they can request a fair hearing to have their case reviewed by an impartial hearing officer.

Medicaid beneficiaries must respond promptly to any request for information from the Medicaid agency and keep their contact information current to receive important notices about their eligibility for benefits.

An Elder Law Attorney Helps with Redetermination Approval

An elder law attorney with disability experience can help during the Medicaid redetermination process in several ways, including:

• Assisting a beneficiary in preparing and submitting the necessary documentation and information to the Medicaid agency to support their continued eligibility for benefits. Preparation may include obtaining medical records, documenting changes in income or household composition, and responding to additional requests for information from the Medicaid agency.
• Helping a beneficiary understand their rights and options if their Medicaid benefits are terminated or reduced due to the redetermination process. Options may include appealing the decision, requesting a fair hearing, and advocating for the beneficiary’s rights and interests throughout the process. The attorney may represent and speak for them at an agency hearing.
• Assisting a beneficiary in navigating the complex rules and regulations of the Medicaid program, including any changes in eligibility criteria or program requirements. These changes may impact their ability to receive benefits, particularly since the end of the ongoing provision prompted requirements to change. Keeping current with program rules and regulations and any changes is particularly important for individuals with disabilities or chronic health conditions who may require ongoing medical care and support.

The prediction for millions of individuals to lose their Medicaid coverage, some temporarily and others more permanently, as the system returns to pre-pandemic annual eligibility reviews may be a costly disruption for some. For others, losing Medicaid coverage may be catastrophic to their health.

Medicaid is a joint federal and state program, and while the federal government has general rules which all state Medicaid programs must follow, each state runs its program. All states can now terminate Medicaid coverage and request a beneficiary redetermination process putting many at risk.

Contact one of our elder law attorneys to represent you if you are a Medicaid beneficiary facing the redetermination process. We protect your rights and access to vital healthcare services needed to maintain health and well-being.

This article offers a summary of aspects of estate planning. It is not legal advice and does not create an attorney-client relationship. For assistance, please contact our Forty Fort office or call (570) 288-1800.