What is Medicaid Redetermination and Why Does It Matter?

Will Medicaid renew automatically? What do family caregivers need to know? Care recipients receiving government assistance must qualify for the benefits every year. This is called redetermination. As a family caregiver, you check yearly if your loved one still meets the Medicaid requirements. Otherwise, they may have a break in care. Understanding Medicaid redetermination will help you support your loved one's health.

What is Medicaid redetermination?

Medicaid redetermination is the process of verifying that people who are enrolled in Medicaid or the Children's Health Insurance Program (CHIP) still meet the eligibility criteria for Medicaid, such as income, residency, citizenship, and disability status. The redetermination process applies to all Medicaid beneficiaries, not only those enrolled in waiver programs. 

Redetermination is usually done once a year, but it can also be triggered by a life event, such as getting a new job, moving to another state, or having a baby. Medicaid redetermination helps ensure that Medicaid and CHIP resources are used efficiently and effectively for those who need them most.

Continuous eligibility vs. redetermination

Continuous enrollment allows eligible Medicaid beneficiaries to maintain coverage for a set period, typically 12 months, without frequent reevaluations or redeterminations of eligibility. This provision helps ensure that individuals, especially low-income and vulnerable populations, have consistent access to healthcare services without the risk of losing coverage due to temporary fluctuations in income or changes in circumstances.

During the COVID-19 pandemic, some states and the federal government took additional steps to streamline Medicaid enrollment processes and temporarily enhance Medicaid coverage to respond to the public health emergency. These actions included suspending certain eligibility redeterminations and easing enrollment requirements to ensure individuals could access healthcare services during the crisis. This was part of a policy that was enacted as part of the Families First Coronavirus Response Act (FFCRA) in 2020, which required states to maintain continuous Medicaid coverage for enrollees during the COVID-19 public health emergency (PHE) in order for them to receive a 6.2 percentage point increase in federal matching funds. This means that states could not terminate Medicaid coverage for anyone enrolled as of March 18, 2020, or who became enrolled during the PHE unless the individual voluntarily requested to end coverage or moved out of state.

Unwinding the continuous enrollment provision post-COVID

The unwinding of this provision refers to ending the continuous enrollment condition and resuming regular Medicaid operations after the PHE. A recent law, the Consolidated Appropriations Act of 2023, delinked the FFCRA's Medicaid continuous enrollment condition from the end of the PHE. As a result, the Medicaid continuous enrollment condition ended March 31, 2023, with states able to begin terminating Medicaid enrollment for individuals no longer eligible for Medicaid as early as April 1, 2023. States will have to redetermine eligibility for all Medicaid enrollees and disenroll those who are no longer eligible or may remain eligible but cannot complete the renewal process.

How Medicaid redetermination works

Medicaid redetermination is the process by which Medicaid authorities review and verify an individual's eligibility for Medicaid benefits to ensure they continue meeting the program's requirements. The specifics of the redetermination process can vary from state to state, as Medicaid is administered by states within federal guidelines. Here are the general steps and components of how Medicaid redetermination typically works:

1. Notification: The Medicaid agency will send a notice to the Medicaid recipient, usually by mail, indicating that it's time for their annual or periodic redetermination. This notice will provide instructions on what the recipient must do to complete the redetermination process.
2. Required documentation: Medicaid recipients must typically provide updated information about their income, household composition, and other factors relevant to their eligibility. This information may include pay stubs, tax returns, utility bills, bank statements, and other financial documents.
3. Submission of documents: Recipients must submit the requested documentation by a specified deadline, often within a specific timeframe from receiving the redetermination notice.
4. Review and evaluation: Once the necessary documents are submitted, the Medicaid agency will review the information to assess the recipient's eligibility. This review includes verifying income, household size, and other state Medicaid program eligibility criteria.
5. Eligibility determination: Based on the information provided and verified, the Medicaid agency will determine whether the individual remains eligible for Medicaid. If the recipient meets the eligibility criteria, their Medicaid coverage will be renewed.
6. Notification of results: The Medicaid agency will inform the recipient of the results of the redetermination process. If the recipient is found eligible, their Medicaid coverage will be extended. If there are changes in eligibility, the notice may include details about the changes in benefits or any required actions.
7. Appeals process: If a recipient disagrees with the outcome of the redetermination process and believes they are still eligible for Medicaid, they have the right to appeal the decision. The notice of determination typically provides information on how to initiate an appeal.

The redetermination process is crucial for maintaining the integrity of the Medicaid program and ensuring that benefits are provided to individuals who continue to qualify. Failing to complete the redetermination process or provide the required documentation within the specified timeframe can result in the termination of Medicaid benefits. Therefore, recipients should carefully follow the instructions in the redetermination notice and promptly submit any requested information to avoid disruptions in coverage. Additionally, the specific policies and timelines may vary from state to state, so individuals should refer to their state's Medicaid agency for detailed information on how redetermination works in their area.

How long does Medicaid redetermination take?

The redetermination process usually takes 45-90 days from start to finish. The exact timing depends on several factors, including how backlogged your local Medicaid office is with processing other redetermination cases. 

Offices with higher volumes of renewals to get through may experience delays in processing each request. Additionally, the completeness and accuracy of the paperwork you submit can impact timelines if errors or missing information cause requests for additional documentation. Seasonal factors like open enrollment periods for Medicare and the Affordable Care Act health insurance can also extend redetermination timeframes around certain busy times of the year. 

Any mistakes or system errors related to processing renewals on the state Medicaid agency's end may lead to more extended redetermination periods. Planning avoids risks from potential delays.

Complete the paperwork accurately and submit it well beforehand to avoid delays that could risk benefits lapsing. Be proactive and start the redetermination process when you receive a notification to renew.

Will Medicaid automatically renew?

Some Medicaid recipients may qualify for automatic redetermination, meaning coverage renews without submitting paperwork. This happens if they are eligible for SNAP food assistance or meet other criteria. 

But if you receive a redetermination notice from Medicaid directly, you likely have to complete the entire renewal process. Only assume your loved one will automatically keep benefits after confirming with your caseworker first.

If you do not receive a notification

If you don't receive a Medicaid redetermination notification, it may mean that your state has already confirmed your eligibility for Medicaid without needing any information from you. However, it is possible that your notification was lost or delayed in the mail or that your state has not processed your redetermination yet. To be sure, you should contact your state Medicaid agency and ask about the status of your redetermination. It is essential to complete your redetermination on time to avoid losing coverage.

Who has to do Medicaid redetermination?

Does your care recipient need to complete a redetermination? Different groups need to complete annual Medicaid redetermination:

• Children on Medicaid, including those with special health care needs or disabilities. Redetermination is required for adopted children and those receiving Medicaid waivers, too.
• Seniors and people with disabilities who receive SSI or SSDI benefits. This includes those who get AABD Medicaid coverage.
• Low-income adults under 65 without disabilities who don't receive SSI or SSDI. This includes newly eligible expansion population members doing the first redetermination.

If your loved one falls into one of these categories, follow up on their Medicaid benefits each year. When you receive their redetermination documents, complete them and send them as soon as possible to avoid any loss of benefits. 

Navigating Medicaid redetermination as a caregiver

Handling Medicaid redetermination might seem daunting, but being proactive can make the process smoother for you and your loved one. Don't let paperwork pile up - stay on top of notices and respond promptly. 

With some planning and follow-through, family caregivers can successfully navigate redetermination and keep Medicaid benefits in place. Staying organized and communicating with the Medicaid office will help the process go smoothly each year and guarantee your loved one receives the vital healthcare they need.