- States must have procedures in place designed to ensure that beneficiaries in Medicaid, CHIP, and a BHP can timely and accurately report changes in circumstances that may affect their eligibility.
- Beneficiaries must be able to report information on changes in circumstances online, by phone, by mail, and in person.
- Whenever the state receives information on a change in circumstances that may affect a beneficiary’s eligibility, it must act promptly to determine whether the beneficiary continues to meet the eligibility criterion to which the change relates.
- States also have the option to seek information about any changes in circumstances through periodic data checks or other information available to the agency.
- When processing a change in circumstances:
- The agency must request additional information from the beneficiary if third-party data indicates the individual is no longer eligible
- The agency must limit requests for additional information to information relating to the change in circumstance
- Prior to making a determination of ineligibility, the agency must determine whether an individual may be eligible for Medicaid on another basis, and request information needed to make such determination if applicable
- Upon determination of ineligibility, the agency must assess potential eligibility for other insurance affordability programs and transfer an individual’s account, as appropriate
- States must provide a reasonable period of time (minimum 10 days) for Medicaid beneficiaries to provide information requested by the agency.
- CMS believes it would be reasonable for states to allow beneficiaries 30 days to respond and provide any necessary information needed to verify eligibility following a change in circumstances. (see CMS Informational Bulletin at https://www.medicaid.gov/federal-policy-guidance/downloads/cib120420.pdf)
Changes in Circumstances During Unwinding
During the unwinding period:
- States may not redetermine eligibility based solely on a change in circumstances unless the beneficiary was determined or renewed for eligibility in the previous 12 months.
- States must conduct a full renewal for beneficiaries who have an identified change in circumstances but whose eligibility has not been renewed (either because the state did not complete the renewal timely, or the individual was determined ineligible at renewal and enrollment was maintained during the PHE).
- States have the option to conduct a full renewal either when a change in circumstances is reported/detected or later in the unwinding period as part of a beneficiary’s scheduled renewal.
- For beneficiaries who were determined eligible or whose eligibility was renewed in the previous 12 months (and is therefore within their 12-month eligibility period), the agency has the option to
- Redetermine the beneficiary’s eligibility either when a change in circumstances is reported/detected as it ordinarily would, or
- Align acting on the change as part of a beneficiary’s scheduled renewal during the state’s unwinding period.
To discuss your NJ Medicaid matter, please contact Fredrick P. Niemann, Esq. toll-free at (855) 376-5291 or email him at fniemann@hnlawfirm.com. Please ask us about our video conferencing or telephone consultations if you are unable to come to our office.
By Fredrick P. Niemann, Esq. of Hanlon Niemann & Wright, a Freehold Township, Monmouth County, NJ Medicaid Attorney