§ 435.916 - Regularly scheduled renewals of Medicaid eligibility.

§ 435.916 Periodic renewal Regularly scheduled renewals of Medicaid eligibility.

Cross Reference

Link to an amendment published at 89 FR 22869, Apr. 2, 2024.

(a) Renewal of individuals whose Medicaid eligibility is based on modified adjusted gross income methods (MAGI).

(1)

Frequency of renewals. Except as provided in § 435.919:

(1) The eligibility of all Medicaid beneficiaries not described in paragraph (da)(2) of this section , the eligibility of Medicaid beneficiaries whose financial eligibility is determined using MAGI-based income must be renewed must be renewed once every 12 months, and no more frequently than once every 12 months.

(2) The eligibility of qualified Medicare beneficiaries described in section 1905(p)(1) of the Act must be renewed at least once every 12 months, and no more frequently than once every

12

6 months.

(

2)

b) Renewals of eligibility —

(1) Renewal on basis of information available to agency. The agency must make a redetermination of eligibility for all Medicaid beneficiaries without requiring information from the individual if able to do so based on reliable information contained in the individual's account or other more current information available to the agency, including but not limited to information

accessed

through any data bases accessed by the agency under §§ 435.948, 435.949, and 435.956

of this part

. If the agency is able to renew eligibility based on such information, the agency must, consistent with the requirements of this subpart and subpart E of part 431 of this chapter, notify the individual—

(i) Of the eligibility determination, and basis; and

(ii) That the individual must inform the agency, through any of the modes permitted for submission of applications under § 435.907(a)

of this subpart

, if any of the information contained in such notice is inaccurate, but that the individual is not required to sign and return such notice if all information provided on such notice is accurate.

(

3) Use of a pre-populated renewal form

2) Renewals requiring information from the individual. If the agency cannot renew eligibility for beneficiaries in accordance with paragraph (

a

b)(

2

1) of this section, the

agency must—

agency—

(i)

Provide

Must provide the individual with—

(A) A pre-populated renewal form containing information, as specified by the Secretary, available to the agency that is needed to renew eligibility.

(B) At least 30 calendar days from the date

of

the agency sends the renewal form to respond and provide any necessary information through any of the modes of submission specified in § 435.907(a)

of this part

, and to sign the renewal form under penalty of perjury in a manner consistent with § 435.907(f)

of the part;

.

(C) Notice of the agency's decision concerning the renewal of eligibility in accordance with this subpart and subpart E of part 431 of this chapter

;

.

(ii)

Verify

Must verify any information provided by the beneficiary in accordance with §§ 435.945 through 435.956

of this part;

.

(iii)

Reconsider in a timely manner the eligibility of an individual who is terminated for failure to submit

If the individual subsequently submits the renewal form or

necessary information, if the individual subsequently submits the renewal form

other needed information within 90 calendar days after the date of termination, or a longer period elected by the State, must treat the renewal form as an application and reconsider the eligibility of an individual whose coverage is terminated for failure to submit the renewal form or necessary information in accordance with the application time standards at § 435.912(c)(3) without requiring a new application

;

.

(iv) Not require an individual to complete an in-person interview as part of the renewal process.

(

b) Redetermination of individuals whose Medicaid eligibility is determined on a basis other than modified adjusted gross income. The agency must redetermine the eligibility of Medicaid beneficiaries excepted from modified adjusted gross income under § 435.603(j) of this part, for circumstances that may change, at least every 12 months. The agency must make a redetermination of eligibility in accordance with the provisions of paragraph (a)(2) of this section, if sufficient information is available to do so. The agency may adopt the procedures described at § 435.916(a)(3) for individuals whose eligibility cannot be renewed in accordance with paragraph (a)(2) of this section.(1

v) May request from beneficiaries only the information needed to renew eligibility. Requests for non-applicant information must be conducted in accordance with § 435.907(e).

(3) Special rules related to beneficiaries whose Medicaid eligibility is determined on a basis other than modified adjusted gross income.

(i) The agency may consider blindness as continuing until the reviewing physician under § 435.531

of this part

determines that a beneficiary's vision has improved beyond the definition of blindness contained in the plan; and

(

2

ii) The agency may consider disability as continuing until the review team, under § 435.541

of this part

, determines that a beneficiary's disability no longer meets the definition of disability contained in the plan.

(c) Procedures for reporting changesTimeliness of renewals. The agency must have procedures designed to ensure that beneficiaries make timely and accurate reports of any change in circumstances that may affect their eligibility and that such changes may be reported through any of the modes for submission of applications described in § 435.907(a) of this part.

(d) Agency action on information about changes.

(1) Consistent with the requirements of § 435.952 of this part, the agency must promptly redetermine eligibility between regular renewals of eligibility described in paragraphs (b) and (c) of this section whenever it receives information about a change in a beneficiary's circumstances that may affect eligibility.

(i) For renewals of Medicaid beneficiaries whose financial eligibility is determined using MAGI-based income, the agency must limit any requests for additional information from the individual to information relating to such change in circumstance.

(ii) If the agency has enough information available to it to renew eligibility with respect to all eligibility criteria, the agency may begin a new 12-month renewal period under paragraphs (a) or (b) of this section.

(2) If the agency has information about anticipated changes in a beneficiary's circumstances that may affect his or her eligibility, it must redetermine eligibility at the appropriate time based on such changes.

(e) The agency may request from beneficiaries only the information needed to renew eligibility. Requests for non-applicant information must be conducted in accordance with § 435.907(e) of this part.

(f

complete the renewal of eligibility in accordance with this section by the end of the beneficiary's eligibility period described in paragraph (a) of this section and in accordance with the time standards in § 435.912(c)(4).

(d) Determination of ineligibility and transmission of data pertaining to individuals no longer eligible for Medicaid.

(1) Prior to making a determination of ineligibility, the agency must consider all bases of eligibility, consistent with § 435.911

of this part

.

(2)

For

Prior to terminating coverage for individuals determined ineligible for Medicaid, the agency must determine eligibility or potential eligibility for other insurance affordability programs and comply with the procedures set forth in § 435.1200(e)

of this part

.

(

g)

e) Accessibility of renewal forms and notices. Any renewal form or notice must be accessible to persons who are limited English proficient and persons with disabilities, consistent with § 435.905(b)

of this subpart

.

[77 89 FR 1721022869, MarApr. 232, 20122024]