PHE unwinding work may aid Medicaid, CHIP final rule compliance

April 11, 2024 - The eligibility and enrollment processes for Medicaid and the Children’s Health Insurance Program (CHIP) have been riddled with inefficiencies. Policies like annual coverage limits and waiting periods have created barriers for low-income adults and children seeking coverage through the public programs.

The Biden administration aims to address these issues in the Streamlining the Medicaid, Children’s Health Insurance Program, and Basic Health Program Application, Eligibility Determination, Enrollment, and Renewal Processes rule.

Witnessing the benefits of continuous Medicaid coverage requirements during the COVID-19 public health emergency perhaps motivated the federal government to streamline eligibility and enrollment processes, according to Kinda Serafi, partner at Manatt Health.

“We’ve learned a lot over the last decade or so when it comes to implementing the Affordable Care Act, and we’ve had this public health emergency that has shone a real light on states’ current processes and their state of compliance with even just the underlying rules of the Affordable Care Act,” Serafi told HealthPayerIntelligence.

“The requirements in these final rules will have an impact on churn and help to ensure those who are eligible are able to enroll and maintain coverage.”

Per the final rule, states cannot conduct Medicaid renewals more than once a year, nor can they require in-person interviews for older adults and beneficiaries with disabilities. States must offer individuals at least 15 days to provide any additional information when applying for the first time and 30 days to return documentation for those renewing coverage.

The final rule addresses crucial CHIP policies that created access barriers for kids. CMS eliminated annual and lifetime limits on children’s coverage, waiting periods for coverage, and the blackout period for families who cannot pay premiums. Additionally, the rule aims to improve transitions from Medicaid to CHIP.

The regulations streamlined processes to create a universal experience for MAGI (modified adjusted gross income) populations—which includes children, pregnant people, and those receiving coverage through Medicaid expansion—and non-MAGI populations like older adults and those with disabilities.

While compliance with the final rule may require additional technology and resources, states may be more prepared to comply with the policies than it seems.

“During the unwinding process, a lot of states tried to align their processes across all populations because it was always a state option. It was always something they could do; they just weren’t mandated to do it,” Serafi explained.

Some states have already started pre-populated renewals, eliminating in-person interview requirements, and limiting renewals to no more than once every 12 months for their non-MAGI populations.

Similarly, some states sought temporary waivers to rely on their managed care plans to send them contact information, making it easier to reach out to beneficiaries about renewal reminders. The final rule made these waivers permanent, meaning the states in question will have no trouble complying with that aspect.

“You could have a state go through these rules and say, ‘We’re doing about 60 percent of these requirements already,’ like the states that have been committed to aligning the rules across all their Medicaid populations,” Serafi indicated.

While no state will be fully compliant with all of the rules straight away, states that have adopted certain flexibilities during the unwinding period will be ahead when it comes to the resources needed. For states that have not implemented these kinds of processes yet, significant investments will be necessary. However, CMS has given states three years to achieve compliance—time that states should use to make a clear plan.

“These rules are not being released in a vacuum,” Serafi noted. “Some states are still in the throes of their unwinding processes and haven’t yet completed that process. There are states that, during the course of unwinding, have identified that they’re not in compliance with the original underlying federal renewal requirements and have created plans to come into compliance with [these] requirements. And now we have this new set of rules that they’re going to have to adjust to.”

States must take the time to lay out a roadmap and timeline to identify what policies they have to change, what operational processes are needed, and what IT systems will help with compliance.

“[States should] not just look at these final rules in a siloed way but integrate their whole-scale compliance analysis across the original renewal requirements and these new layered-on renewal requirements,” Serafi concluded. “States have their work cut out for them, but CMS has tried to take that into account with their three-year glide path.”