Streamlining eligibility & enrollment notice of proposed rulemaking (NPRM)

Sept. 1, 2022
This proposed rule includes several provisions aimed at simplifying the enrollment process and maintaining continuity of coverage for eligible beneficiaries.

The Centers for Medicare & Medicaid Services’ (CMS’) new proposed rule would make it easier for millions of eligible people to enroll in and retain their Medicaid coverage. The rule would reduce red tape and simplify applications, verifications, enrollment, and renewals for health care coverage through Medicaid and the Children’s Health Insurance Program (CHIP). The proposed rule responds to President Biden’s January 2021 and April 2022 Executive Orders to strengthen Medicaid and access to affordable, quality health coverage.

Certain current Medicaid and CHIP enrollment policies can contribute to coverage disruptions and create churning as people lose their Medicaid or CHIP coverage and then re-enroll within a short period of time. When people lose access to coverage, they lose access to vital health services. CMS has identified opportunities to ease administrative burden for states and reduce barriers to enrollment and retention of coverage for eligible individuals. For example:

  • Children in some CHIP programs remain subject to potentially harmful policies that delay access to care. Barriers to coverage that are not permitted under any other insurance affordability program – including lock-outs for children terminated due to non-payment of premiums, required periods of uninsurance prior to enrollment, and annual or lifetime caps on benefits – remain state options under separate CHIPs.
  • Individuals whose eligibility is based on being age 65 or older, having blindness, or a disability are excluded from many of the enrollment simplifications established under the Affordable Care Act (ACA), leaving such individuals at greater risk than other Medicaid enrollees of being denied or losing coverage due to procedural reasons, even if they continue to meet eligibility requirements.
  • There are no regulations that ensure consumers have access to an efficient and streamlined enrollment process for the Medicare Savings Programs (MSPs), through which Medicaid covers the cost of Medicare premiums and/or cost sharing for Medicare enrollees highly likely or certain to be eligible for the MSPs based on receipt of other program benefits (e.g., Extra Help for Medicare Part D). As a result, millions of eligible individuals are not enrolled.
  • There is currently no guidance providing clear and consistent timeframes for applicants and beneficiaries to return information needed to determine eligibility, or for states to process and act upon information received. This leads to unnecessary delays in processing applications and renewals, some individuals being denied services for which they are eligible, and some ineligible individuals retaining coverage.
  • Recordkeeping regulations, which are critical to enabling appropriate oversight and identifying errors in state policies and operations, were last updated over three decades ago, resulting in inconsistent practices across states and contributing to eligibility error rates.

In this rulemaking, CMS seeks to close these and other gaps, further streamlining Medicaid and CHIP eligibility and enrollment processes, reducing administrative burden on states and applicants/enrollees, and increasing enrollment and retention of eligible individuals.

  • This proposed rule includes several provisions aimed at simplifying the enrollment process and maintaining continuity of coverage for eligible beneficiaries, including children and individuals dually enrolled in Medicare and Medicaid, many of whom are over 65 and/or have a disability.
  • CMS estimates that this proposed rule would remove barriers to enrollment and increase the number of eligible individuals who obtain coverage and are continuously enrolled in Medicaid and CHIP.

There will be a 60-day comment period, and comments on the notice of proposed rulemaking must be submitted to the Federal Register no later than November 7, 2022. For more information on how to submit comments or to review the rule in its entirety, visit the Federal Register.

CMS Fact Sheet

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