AARP Hearing Center
Background
Medicaid eligibility criteria and enrollment processes vary by state. State policies can make completing the eligibility process and staying enrolled more or less difficult. States are required to assess initial eligibility and renewals for Medicaid enrollees based on current information available to the state agency. This is known as an ex parte renewal. If the state needs additional information, it must contact the individual. States must provide options for individuals to submit information by phone, mail, in-person, and online.
States must reverify eligibility annually, but enrollees are required to notify the state if they experience any changes in income during the year as this can affect their eligibility. Some states have instituted continuous enrollment periods for certain groups (most commonly children and pregnant women for 12 months) which means the coverage is fixed for one year regardless of any changes in income. Continuous eligibility can help to reduce administrative burden for the state and improves continuity of care for the enrollee. This is done through waivers approved by the Centers for Medicaid & Medicare Services, and approval must be renewed every few years (see more information on waivers later in this chapter).
States have varied in their use of data for ex parte renewals. This has prompted scrutiny during renewals following the pandemic-related pause in disenrollments. Recent rule changes have eliminated some policy options that made it harder for individuals to enroll and stay enrolled, such as requiring in-person interviews and processing renewals more than once per year for some enrollees.
States are required to:
- create procedures that allow people to apply for, become enrolled in, or renew enrollment in Medicaid or a waiver program on a website that is linked to the state’s exchange website and the state’s Children’s Health Insurance Program (CHIP) website;
- allow people to enroll or re-enroll using an electronic signature;
- ensure that applicants for Medicaid under the state plan or a waiver, as well as those who apply for CHIP but are found ineligible, are screened for eligibility for a qualified exchange plan and any premium assistance;
- create procedures for using the state’s website to enroll those who have been identified by the exchange as being Medicaid-eligible under a state plan or waiver or CHIP-eligible without any further enrollment determination by the state;
- ensure the use of a secure electronic interface that can make eligibility determinations for Medicaid, CHIP, premium assistance, or enrollment in a qualified health plan; and
- conduct outreach to and enroll individuals from groups that have been discriminated against and other underserved populations who are eligible for Medicaid or CHIP.
MEDICAID ELIGIBILITY, ENROLLMENT, AND COVERAGE: Policy
MEDICAID ELIGIBILITY, ENROLLMENT, AND COVERAGE: Policy
Enrollment and redeterminations
To improve Medicaid participation among eligible individuals, states should conduct outreach activities to ensure that all who are potentially eligible are aware of the program and enroll, particularly for Medicare Savings Programs and the state Children’s Health Insurance Program.
States should guarantee that beneficiaries receive information about all health and LTSS options they are eligible for (i.e., Medicare, Medicaid services, and other programs). This information should also be provided to family caregivers or representatives when appropriate. States must ensure this information is easy to understand, culturally competent, and linguistically appropriate.
States should monitor Medicaid participation rates and report enrollment rates on an ongoing basis, giving particular attention to underserved areas.
Policymakers should work to reduce enrollment barriers in Medicaid and eliminate or refuse to adopt policies that create barriers to continued enrollment, such as frequent recertification. Examples of reducing barriers include enrollment simplification, making enrollment and redetermination options for other low-income programs available on websites, and conducting more outreach to potentially eligible people.
A qualified third party should be required to evaluate artificial intelligence and algorithmic tools used to improve coordination, determine eligibility, or decide benefit amounts for reliability, accuracy, and fairness. Review should take place before deployment and routinely thereafter. The results of these evaluations should be made public without revealing personal or proprietary information (see also Artificial Intelligence).
Continuity of coverage
To improve Medicaid access for people with low incomes, Congress should ensure continuous Medicaid coverage for vulnerable people of all ages. This should include people with disabilities and working people whose incomes fall below the poverty line. Congress should further require all states to have a medically needy program. Such programs provide full Medicaid benefits to people of all ages when they have exhausted their financial resources for health care needs.
In addition, Congress should take steps to ensure that states do not eliminate Medicaid’s optional eligibility categories or alter eligibility criteria to reduce the amount of their Medicare payments (known as a “claw-back” strategy) and thereby deny or withdraw needy beneficiaries’ access to important health benefits.
Continuity of coverage during transitions to Medicare
The federal government should require states to have procedures ensuring continuity of coverage for beneficiaries transitioning to Medicare. The federal government should require states to have procedures to re-evaluate modified adjusted gross income (MAGI)-related Medicaid beneficiaries for potential non-MAGI-related Medicaid coverage (see this chapter’s section, Medicaid Eligibility Expansion, for a definition of MAGI).
States should provide notices to consumers about coverage evaluations. Such procedures would be used when these individuals become Medicare-eligible at age 65 or when they are eligible for Social Security Disability Insurance and have completed the two-year waiting period to become Medicare-eligible (see also Medicare). This reassessment capability should include an evaluation of eligibility for full Medicaid benefits (including long-term services and support), Medicare Savings Programs, and the Medicare Part D Low-Income Subsidy.