Department of Health & Human Services, Centers for Medicare & Medicaid Services — SHO# 22-001
Summary
State Health Official letter SHO# 22-001 from the Centers for Medicare & Medicaid Services, Department of Health & Human Services, dated March 3, 2022. Its RE line reads Promoting Continuity of Coverage and Distributing Eligibility and Enrollment Workload in Medicaid, the Children's Health Insurance Program (CHIP), and Basic Health Program (BHP) Upon Conclusion of the COVID-19 Public Health Emergency, it expands on the guidance in SHO #21-002 published on August 13, 2021. The letter describes how states may distribute eligibility and enrollment work when routine operations resume, mitigate churn for eligible beneficiaries, and transition individuals between coverage programs. It states that CMS has approved almost 1,000 disaster relief actions for states during the PHE and that its contents do not have the force and effect of law.
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“Department of Health & Human Services, Centers for Medicare & Medicaid Services — SHO# 22-001.”
Original at www.medicaid.gov. Archived at Pandemic Darlings, https://pandemicdarlings.com/source-documents/sho-22-001-promoting-continuity-of-coverage-and-distrib-ea2cf3fca22b-38047a8639/
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DEPARTMENT OF HEALTH & HUMAN SERVICES
Centers for Medicare & Medicaid Services
7500 Security Boulevard, Mail Stop S2-26-12
Baltimore, Maryland 21244-1850
SHO# 22-001
RE: Promoting Continuity of
Coverage and Distributing
Eligibility and Enrollment
Workload in Medicaid, the
Children’s Health Insurance
Program (CHIP), and Basic
Health Program (BHP) Upon
Conclusion of the COVID-19
Public Health Emergency
March 3, 2022
Dear State Health Official:
The ongoing Coronavirus Disease 2019 (COVID-19) outbreak and implementation of federal
policies to address the public health emergency (PHE) have disrupted routine Medicaid,
Children’s Health Insurance Program (CHIP), and Basic Health Program (BHP) eligibility and
enrollment operations. Over the course of the PHE, states have made policy, programmatic, and
systems changes to respond effectively to COVID-19 and qualify for the temporary Federal
Medical Assistance Percentage (FMAP) increase under section 6008 of the Families First
Coronavirus Response Act (FFCRA) (P.L. 116-127), including by satisfying a “continuous
enrollment condition” for most Medicaid beneficiaries who were enrolled in the program as of or
after March 18, 2020.
It has been a top priority for the Centers for Medicare & Medicaid Services (CMS) to ensure,
when the PHE eventually ends and states resume routine operations, including terminations of
eligibility, that renewals of eligibility and transitions between coverage programs occur in an
orderly process that minimizes beneficiary burden and promotes continuity of coverage. This
State Health Official (SHO) letter expands on the guidance released in SHO #21-002, “Updated
Guidance related to Planning for the Resumption of Normal State Medicaid, CHIP, and BHP
Operations Upon Conclusion of the COVID-19 Public Health Emergency,” published on August
13, 2021 (“August 2021 SHO”), by describing how states may distribute eligibility and
enrollment work when states restore routine operations, mitigate churn for eligible beneficiaries,
and smoothly transition individuals between coverage programs, including coverage through the
Federally-facilitated Marketplace or a State-Based Marketplace (SBM).
As with previous SHO letters issued by CMS regarding the PHE, this SHO letter is intended to
assist states in their planning efforts whenever the federal PHE declaration eventually ends and
does not presuppose a specific time frame in which that will occur. The Department of Health
and Human Services (HHS) will determine when the federal PHE declaration will end, and CMS
will share with states any communication released by HHS.
The contents of this document do not have the force and effect of law and are not meant to bind the public in any way, unless
specifically incorporated into a contract. This document is intended only to provide clarity to the public regarding existing
requirements under the law.
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In addition to resuming normal eligibility and enrollment operations, authority for other types of
disaster relief flexibilities will conclude when the PHE eventually ends, and states will need to
return to regular operations across their programs. CMS has approved almost 1,000 disaster
relief actions for states during the PHE, many for non-eligibility and enrollment-related
flexibilities, including section 1135 waivers to delay provider revalidations, disaster relief state
plan amendments (SPAs) to extend telehealth flexibilities, and section 1915(c) Appendix Ks to
allow the provision of services by family members, among many others.
States need to determine which temporary flexibilities they intend to extend temporarily or
permanently, as allowable, and make plans to terminate other flexibilities after the PHE
eventually ends. Guidance to support states in these planning efforts is available in SHO #20-
004, “Planning for the Resumption of Normal State Medicaid, Children’s Health Insurance
Program (CHIP), and Basic Health Program (BHP) Operations Upon Conclusion of the COVID-
19 Public Health Emergency” (“December 2020 SHO”). 1 This guidance, which was released on
December 23, 2020, provides information on returning to normal operations across these
programs, including requirements for making temporary changes permanent and ending
temporary authorities, as well as operational and managed care considerations for returning to
normal operations. Additional information will continue to be provided to states on streamlined
processes to temporarily extend authorities initially adopted through disaster relief SPAs, as well
as to add or modify authorities needed on a temporary basis as a state returns to normal
operations. 2
Table of Contents
I. Executive Summary............................................................................................................. 3
II. Restoring Routine Eligibility and Enrollment Operations after the PHE Ends ................... 5
III. Prioritization and Distribution of Pending Eligibility and Enrollment Work .................... 14
IV. Notices and Fair Hearings.................................................................................................. 21
V. Strategies to Promote Continuity of Coverage and Mitigate Churn .................................. 23
VI. Facilitating Transitions between Medicaid, CHIP, BHP, and the Marketplace ................ 27
VII. Monitoring State Progress and Corrective Action ............................................................. 28
VIII. PERM or MEQC Programs ............................................................................................... 29
IX. Closing ............................................................................................................................... 29
Appendix A: 12-Month Unwinding Timeline .............................................................................. 31
Appendix B: Strategies to Promote Continuity of Coverage and Mitigate Churn ....................... 33
Appendix C: Processing Returned Mail ....................................................................................... 41
1 SHO #20-004, “Planning for the Resumption of Normal State Medicaid, Children’s Health Insurance Program (CHIP), and
Basic Health Program (BHP) Operations Upon Conclusion of the COVID-19 Public Health Emergency,” available at:
https://www.medicaid.gov/sites/default/files/2020-12/sho20004.pdf.
2 Details on extending Medicaid disaster relief SPA provisions, either temporarily or indefinitely, were provided during the
February 15, 2022 All-State Medicaid and CHIP call. Information discussed during the call is available at:
https://www.medicaid.gov/resources-for-states/downloads/covid19allstatecall02152022.pdf.
Page 3 – State Health Official
Appendix D: Related CMS Guidance........................................................................................... 44
I. Executive Summary
This SHO letter is part of a series of guidance and tools that outlines how states may address the
large volume of pending eligibility and enrollment actions that will need to be addressed when
they restore routine operations, including terminations of coverage. This letter expands on the
August 2021 SHO by describing how states may distribute eligibility and enrollment work in the
post-PHE period, mitigate churn for eligible beneficiaries who lose coverage and later reenroll,
and smoothly transition individuals between coverage programs, including coverage through the
Marketplace with financial subsidies. This SHO reiterates options for states to align work on
pending eligibility and enrollment actions after the PHE eventually ends and provides that states
must initiate, rather than complete, all pending actions during the 12-month unwinding period.
In addition, this SHO informs states that they are at risk of inappropriately terminating coverage
for eligible individuals if they plan to initiate a high volume of renewals in a given month and
that CMS intends to collect information on all states’ plans to adopt strategies that will promote
continuity of coverage and guard against inappropriate terminations.
A. Background
The ongoing COVID-19 outbreak and implementation of federal policies to address the PHE
have disrupted routine Medicaid, CHIP, and BHP eligibility and enrollment operations.
Medicaid and CHIP enrollment has grown to nearly 85 million individuals due, in large part, to
the continuous enrollment condition. 3 It is critical to ensure, when the PHE eventually ends, that
renewals of eligibility occur in an orderly process that minimizes beneficiary burden and
promotes continuity of coverage, including for individuals eligible for other insurance
affordability programs, and maximizes state effectiveness.
B. Operational Plans and Timelines to Complete Eligibility and Enrollment Actions
As discussed in prior guidance, states will need to develop a comprehensive “unwinding
operational plan” to restore routine operations in their Medicaid, CHIP, and BHP programs. This
unwinding operational plan is intended to reflect how states will complete outstanding work and
maximize uninterrupted coverage for eligible individuals.
CMS acknowledges that states will have some pending applications that will need to be
completed and will continue to receive new applications as they work to resume normal
processing of renewals. This SHO permits states to use a phased approach to complete
processing of any pending applications and resume timely and accurate determinations of
eligibility on all new applications within four months after the eventual end of the PHE.
To account for the time needed to complete renewals, CMS will consider states to be in
compliance with the 12-month unwinding period announced in the August 2021 SHO provided
that the state has initiated all renewals and other outstanding eligibility actions by the last month
of the 12-month period. States will have two additional months (14 months total) to complete all
3 Medicaid and CHIP Enrollment Snapshots (September 2021). Available at https://www medicaid.gov/medicaid/program-
information/medicaid-chip-enrollment-data/medicaid-and-chip-enrollment-trend-snapshot/index html.
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pending actions initiated during the 12-month unwinding period. Prior guidance suggested all
renewals and other actions must be completed within the 12-month unwinding period.
C. Adopting a Risk-Based Approach and Speed of State Unwinding
CMS expects states to adopt a risk-based approach to prioritize pending renewals, changes in
circumstances, and post-enrollment verifications that the state needs to address during the
unwinding period. A risk-based approach must take into consideration the need to prevent
inappropriate terminations and promote smooth transitions for individuals no longer eligible for
Medicaid, CHIP, or a BHP to other coverage. States may select among four risk-based
approaches to address the backlog of pending cases: (1) Population-Based Approach prioritizing
outstanding actions for cohorts of beneficiaries more likely to have become eligible for more
expansive benefits or for different coverage (e.g., a Qualified Health Plan (QHP)); (2) Time or
Age-Based Approach prioritizing cases based on the length of time the action has been pending;
(3) Hybrid Approach combining population- and time-based approaches; or (4) State-Developed
Approach meeting the goals of keeping eligible individuals enrolled, reducing churn,
maximizing successful transition to other coverage where appropriate, and achieving a
sustainable renewal schedule. This letter also outlines various alignment strategies, which can
support states in achieving an even distribution of work both during the 12-month unwinding
period and in subsequent years.
Over the course of the 12-month unwinding period, states will need to initiate a renewal of every
beneficiary enrolled in their Medicaid and CHIP programs as of the end of the month prior to
their unwinding period. We refer in this letter to these beneficiaries enrolled in Medicaid and
CHIP as of such month as the state’s “total caseload.” States have flexibility to determine
whether their total caseload is based on the total number of individuals enrolled in the program
or the total number of households with one or more family members enrolled in Medicaid in the
state as of the end of the month prior to the month in which the state’s unwinding period begins.
States will need to distribute these renewals in a reasonable manner over the course of the
unwinding period in order to mitigate the risk of inappropriate terminations and churn as well as
to ensure that the state also resumes timely processing of new applications during the unwinding
period. As this SHO letter explains, CMS is concerned that if states attempt to initiate more than
1/9 of their total caseload in a given month, there will be an increased risk that state processes
will not meet federal renewal requirements, and eligible individuals will be erroneously
determined ineligible or lose coverage for avoidable procedural reasons. CMS will work with
states and provide continued technical assistance to ensure they are able to restore routine
operations in a manner that promotes continuity of coverage for eligible individuals and seamless
coverage transitions for those who become eligible for other insurance affordability programs.
D. Facilitating Transitions to the Marketplace
Facilitating smooth transitions to the Marketplace for individuals eligible for enrollment in a
QHP will be critical to minimizing periods of uninsurance as states identify beneficiaries who are
no longer eligible for Medicaid, CHIP or a BHP. States are required to transfer to the
Marketplace the electronic accounts of beneficiaries whom the state assesses as potentially
eligible for coverage through the Marketplace; such transfer must include all eligibility-related
information available to the state. This SHO letter identifies strategies for states to improve
successful transitions and enrollment in a QHP, including improving notice language and
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transmitting all available contact information and other information that the state has for an
individual, regardless of the minimum technical requirements for account transfers.
E. Monitoring State Progress, Corrective Action, Payment Error Rate Measurement
(PERM) or Medicaid Eligibility Quality Control (MEQC) Programs, and Technical
Assistance
This SHO letter explains that CMS will (1) not consider eligibility and enrollment actions
delayed due to the PHE as untimely for purposes of the PERM or MEQC programs if such
actions are initiated within the timelines detailed in the SHO letter and completed before the end
of the 14th month once the state begins its 12-month unwinding period; (2) release an updated
planning template to support state efforts to develop unwinding operational plans; (3) provide
states with data reporting tools to monitor and evaluate state progress to complete outstanding
work after the PHE ends; (4) monitor states’ progress in meeting the timelines and completing
required eligibility and enrollment actions described in the letter; and (5) be available to provide
technical assistance to states individually and through various forums.
II. Restoring Routine Eligibility and Enrollment Operations after the PHE Ends
CMS recognizes that states will not be able to immediately address the large number of pending
eligibility and enrollment actions that continue to accumulate during the PHE, and states will
need time to complete the work in a manner that prevents inappropriate terminations of
coverage. CMS also understands many Medicaid beneficiaries’ circumstances may have
changed and that these individuals may now be eligible for other insurance affordability
programs, such as CHIP, BHP, or coverage through the Marketplace with financial subsidies.
States will need to be able to distribute work in a systematic way that maintains coverage for
eligible beneficiaries, manages coverage transitions, and reestablishes a renewal schedule that is
sustainable for the state agency in future years.
A. Developing a Plan to Address PHE-Related Eligibility and Enrollment Work
As discussed in the December 2020 SHO, states will need to develop and document a
comprehensive plan to restore routine operations in their Medicaid, CHIP, and BHP programs
(“unwinding operational plan”). 4 This plan is intended to help states plan for how they will
complete outstanding work in accordance with the timelines specified in this letter and the
August 2021 SHO and maximize continuous coverage for eligible individuals.
States will have a significant volume of eligibility actions to complete once they begin the
unwinding period, including pending applications, renewals, and redeterminations necessitated
by changes in beneficiary circumstances. Some states also will have outstanding verifications
for individuals determined eligible for enrollment based on self-attested information pending
post-enrollment verification. 5 States’ unwinding operational plans should include a description
of how the state intends to address these outstanding actions in an efficient manner that reduces
4 State Health Official Letter SHO #20-004, Planning for the Resumption of Normal State Medicaid, Children’s Health Insurance
Program (CHIP), and Basic Health Program (BHP) Operations Upon Conclusion of the COVID-19 Public Health Emergency,
(December 2020). Available at https://www.medicaid.gov/federal-policy-guidance/downloads/sho20004.pdf.
5 States have the option to enroll individuals based on self-attested information and verify eligibility criteria post-enrollment,
consistent with the state verification plan.
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erroneous loss of coverage for beneficiaries, ensures a sustainable distribution of renewals in
future years, and ensures timely processing of new applications and eligibility actions within the
timelines specified in this letter. States will need to decide which flexibilities to retain and
whether to adopt new flexibilities. CMS is available to provide technical assistance to states as
they develop their unwinding operational plans.
To the extent these decisions require states to submit SPAs, updates to verification plans, or
updates to policy and procedure manuals, states should make efforts to start these processes as
soon as possible before the state implements its plans to restore routine operations. States should
also begin work as soon as possible on any necessary system changes needed to process
eligibility and enrollment actions and resume terminations of coverage for ineligible individuals
after the continuous enrollment condition expires. To the extent possible, states should make
plans to have these system changes ready, and scheduled for an off-cycle release if necessary, to
ensure they are not delayed in their ability to begin work during the unwinding period.
States that began to develop a plan to return to routine operations prior to the release of this letter
should reassess their plans and adjust how they will prioritize and distribute their workloads in
light of this guidance. CMS also released an updated Medicaid and CHIP planning tool to assist
states in their planning efforts. 6 This updated tool will take into account the new timelines to
complete pending work and help states develop an unwinding operational plan that takes into
account strategies and options to maintain coverage for eligible individuals. While CMS expects
states to develop and document their unwinding operational plans to address pending
applications, verifications, changes in circumstances, and renewals, states are not required to use
the tools developed by CMS to document their plans and, generally, will not be expected to
submit their entire unwinding operational plans to CMS for approval. However, states must
make their plans available to CMS upon request.
The perspectives and partnership of Medicaid and CHIP managed care organizations (MCOs),
providers, beneficiary advocates, and other stakeholders are critical to the resumption of
renewals and other eligibility actions in a manner that supports retention of coverage, including
the successful transition to other programs. CMS encourages states to solicit input on their
unwinding operational plans from these partners and to share their plans publicly, prior to their
implementation.
B. Timelines to Complete Eligibility and Enrollment Actions after the PHE Ends
Applications: 4 Months after the End of the PHE (with Milestones)
While states are expected to work as expeditiously as possible to process applications now, CMS
anticipates most states will have some pending applications that were received during the PHE
that will need to be completed during the unwinding period. Agencies may use a phased
approach to complete processing of these applications and resume timely and accurate
determinations of eligibility on new applications within the following timelines, measured going
forward from the end of the month in which the PHE ends:
• 2 months after the end of the month in which the PHE ends: States should complete
eligibility determinations for all pending modified adjusted gross income (MAGI) and
6 CMS previously released the Medicaid and CHIP Health Insurance Program COVID-19 Public Health Emergency Eligibility
and Enrollment Pending Actions Resolution Tool. The updated tool reflects the guidance issued in SHO #21-002 and this letter.
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other non-disability-related applications (e.g., individuals determined on the basis of
being age 65 or older) received during the PHE.
• 3 months after the end of the month in which the PHE ends: States should complete
eligibility determinations for all pending disability-related applications received during
the PHE.
• 4 months after the end of the month in which the PHE ends: States should resume
timely processing of all applications.
CMS reminds states that an application is considered to be processed timely when the agency
enrolls an eligible applicant or denies coverage for an individual whom the agency could not
determine as eligible within the application time standards described at 42 C.F.R. §§ 435.912(c),
457.340(d), and 600.320(b). The maximum time permitted under these regulations is 90 days for
individuals applying on the basis of disability and 45 days for all other applicants. Consistent
with requirements at 42 C.F.R. §§ 435.912(g), 457.340(d), and 600.320(b), agencies may not use
the application timeliness standards – or the timelines described in this letter – as a waiting
period to delay determining eligibility or as a reason for denying eligibility because the state has
not determined eligibility within the timeliness standards.
Post-Enrollment Verifications, Changes in Circumstances, and Renewals: 12 months after the
End of the PHE
In the August 2021 SHO, CMS announced that it would provide states up to 12 months after the
end of the PHE to complete renewals as well as post-enrollment verifications and
redeterminations of eligibility due to changes in beneficiary circumstances. The renewal process
includes the time states need to attempt to renew eligibility based on electronic data and other
information available to the agency; the time beneficiaries have to return the renewal form and
any required documentation; and the time needed by the agency to verify the accuracy of the
returned information, redetermine eligibility, and send appropriate notice to the beneficiary of
the agency’s decision.
Since the August 2021 SHO was released, states have raised concerns that they will be unable to
complete renewals within a 12-month unwinding period because, except for beneficiaries who
can be renewed based on information available to the state, states typically cannot complete a
renewal in the same month in which the renewal was initiated. We understand that many states
budget between 60 and 90 days to complete the full renewal process, and therefore initiate
renewals between 60 and 90 days prior to the end of a beneficiary’s eligibility period.
To account for the time needed to initiate and complete renewals, CMS will consider states to be
in compliance with the 12-month unwinding period announced in the August 2021 SHO
provided the state has initiated all renewals, as well as post-enrollment verifications and
redeterminations based on changes in circumstances, for the state’s total caseload by the last
month of the 12-month unwinding period (and completed such actions by the end of month 14).
Defining the Beginning and End of the 12-month Unwinding Period
While states will be required to initiate renewals, post-enrollment verifications, and
redeterminations for all individuals enrolled when the continuous enrollment condition expires
within 12 months, the unwinding period may vary by state but is based on the month in which
the PHE eventually ends. The unwinding period for all states must begin no later than the first
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day of the month following the month in which the PHE ends. However, states may begin their
12-month unwinding period up to two months prior to the end of the month in which the PHE
ends. This means that states that continue to comply with the continuous enrollment condition
through the end of the month in which the PHE ends may initiate renewals that may result in
termination of coverage the month after the continuous enrollment conditions ends for some
beneficiaries up to two months prior to the end of the month in which the PHE ends.
As discussed further in this letter, states must initiate a renewal of eligibility for its total caseload
during the state’s unwinding period, including for individuals who were determined ineligible
during the PHE before the state begins its unwinding period.
For example, if the PHE were to end on May 15, 2022, renewals initiated as early as April 2022
could result in terminations effective as early as June 1, 2022 (with the beneficiary’s last day of
coverage being May 31, 2022, which would be the last day the continuous enrollment condition
is in effect in this example) for beneficiaries whom the state determines no longer meet all
eligibility requirements or who do not timely return information needed by the state to complete
the renewal.
Note that the same two-month period before the state would need to initiate another renewal
would be true regardless of when the PHE eventually ends. For example, if the PHE ended on
August 15, 2022, states complying with the continuous enrollment condition could begin their
12-month unwinding period as early as July 2022, using the information gathered during a
renewal initiated in July 2022 to terminate coverage as early as September 1, 2022 for
beneficiaries whom the state determines no longer meet all eligibility requirements or who do not
timely return information needed by the state to complete the renewal. Thus, in this example
(i.e., if the PHE is extended to August 15, 2022), renewals for cases initiated prior to July 2022
that did not result in a determination of eligibility must be initiated again during the state’s 12-
month unwinding period associated with the August 15, 2022 PHE end date, consistent with the
guidance in the August 2022 SHO and this letter.
While states must initiate all pending eligibility actions (including renewals, post-enrollment
verifications, and redeterminations based on changes in circumstances) for its total caseload at
the end of the PHE within their particular 12-month unwinding period, states are expected to
complete all work initiated during their unwinding period by the end of the 14th month after the
first month of the unwinding period. For example, if the PHE ends in May 2022 and a state
begin its 12-month unwinding period ) in June 2022, the state would be required to initiate all
renewals, post-enrollment verifications, and redeterminations no later than May 2023 and
complete initiated work by the end of July 2023.
States are reminded that regardless of when a state begins its unwinding period, it must maintain
continuous enrollment of beneficiaries through the last day of the month in which the PHE ends
in order to satisfy the continuous enrollment condition necessary to receive the temporary FMAP
increase under the FFCRA for the entire quarter in which the month falls. To comply with the
continuous enrollment condition, termination of a beneficiary’s enrollment can be effective no
earlier than the first day of the month following the month in which the PHE ends, with limited
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exceptions. 7 Any state that chooses to end the continuous enrollment condition prior to the end
of the month the PHE eventually ends and no longer claim the temporary FMAP increase is still
required to follow the timelines and expectations outlined in this letter. This includes the
requirement that the state initiate a renewal for the state’s total caseload during the 12-month
period beginning in the month in which renewals initiated by the state end in termination of
beneficiaries who no longer meet eligibility requirements or did not timely return information
needed by the state to complete the renewal.
Appendix A illustrates how a state may process its unwinding related renewals, redeterminations,
and post-enrollment verifications and achieve compliance with the 12-month unwinding period.
C. Requirements for Conducting Renewals
This guidance does not change the steps states must take to complete a renewal consistent with
requirements at 42 C.F.R. §§ 435.916, 457.343, and 600.340. During the 12-month unwinding
period, all states must begin the renewal process by checking available information and data
sources to attempt to redetermine eligibility without contacting the beneficiary and requesting
documentation to obtain reliable information when eligibility cannot be renewed based on
available information, as appropriate. States must provide beneficiaries who are eligible based
on MAGI methodologies with a minimum of 30 days to return their pre-populated renewal form
and any requested information. Non-MAGI beneficiaries must be provided with a reasonable
period of time to return their renewal form and any required documentation. Renewal forms and
notices must be accessible to persons who have limited English proficiency (LEP) and persons
with disabilities consistent with §§ 435.905(b) and 457.340(e). In Medicaid, states must
determine eligibility on all bases prior to making a determination of eligibility as required at §
435.916(f)(1), including the Medicare Savings Programs. In Medicaid, a minimum of 10 days
advance notice and fair hearing rights must also be provided prior to termination or other adverse
action, in accordance with § 435.917 and 42 C.F.R. Part 431 Subpart E. Separate CHIPs must
provide sufficient notice to enable the child’s parent or other caretaker to take any appropriate
actions that may be required to allow coverage to continue without interruption consistent with §
457.340(e)(1)(iii). For individuals determined ineligible, states must assess eligibility for other
insurance affordability programs and transfer the individual’s account as appropriate in
accordance with §§ 435.916(f)(2) and 457.350(i).
States may refer to the December 2020 Center for Medicaid and CHIP Services (CMCS)
Informational Bulletin (CIB), “Medicaid and CHIP Renewal Requirements,” which is available
to assist states in meeting their obligations to make accurate redeterminations of eligibility. 8 A
description of the CIB and more information on how states may access the guidance is included
in Appendix C of this SHO letter.
D. Completing Renewals During the Post-PHE Unwinding Period
7 Consistent with 6008(b)(3) of the FFCRA and 42 C.F.R. § 433.400, states claiming the temporary 6.2 percentage point FMAP
increased authorized under FFCRA must ensure “validly enrolled” beneficiaries remain enrolled through the end of the month in
which the PHE ends unless the individual requests voluntary termination, is no longer considered to be a resident of the state, or
dies.
8 CMCS Informational Bulletin, “Medicaid and Children’s Health Insurance Program (CHIP) Renewal Requirements,”
(December 2020). Available at: https://www medicaid.gov/federal-policy-guidance/downloads/cib120420.pdf.
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While most states have continued to process eligibility and enrollment actions during the PHE,
states claiming the temporary FMAP increase authorized by section 6008 of the FFCRA have
needed to suppress terminations and other adverse actions for Medicaid beneficiaries that would
violate the continuous enrollment condition. States that have conducted renewals during the
PHE, but did not terminate Medicaid eligibility for beneficiaries who were determined not
eligible or who did not respond to requests for documentation, generally may not terminate
coverage for such beneficiaries after the continuous enrollment condition expires until the state
completes a new full renewal, as beneficiaries’ circumstances may have changed since the
completion of the renewal conducted during the PHE. This includes beneficiaries who were
receiving benefits pending the outcome of a fair hearing on or after March 18, 2020, and were
continuously enrolled during the PHE in order to comply with the continuous enrollment
condition. 9
Completing a full renewal after the continuous enrollment condition expires will ensure that: 1)
the state is collecting information from the beneficiary that allows the state to redetermine
eligibility on all bases prior to terminating coverage in accordance with 42 C.F.R. §
435.916(f)(1); 2) any adverse action is based on recently available, reliable information and that
the state is not terminating eligibility or reducing benefits unless it has sought information from
the individual in accordance with § 435.952(d); and 3) the state fulfills its obligation to complete
a renewal of eligibility.
Subject to the expectations relating to prioritization and distribution of pending eligibility and
enrollment work discussed in Section II of this letter, states will have considerable flexibility in
determining how best to distribute renewals over the 12-month unwinding period. Thus, while
states may not conduct a new renewal for MAGI-based beneficiaries whose eligibility was
successfully renewed during the PHE less than 12 months after such renewal, states have the
flexibility to initiate renewals at any time during the unwinding period for beneficiaries for
whom the state did not conduct a renewal during the PHE or for whom the state did not conduct
a successful renewal within the previous 12 months. Additionally, because individuals
determined ineligible during a renewal conducted during the PHE were not granted a new
eligibility period, states may initiate a new renewal for such individuals at any point during the
12-month unwinding period – i.e., the state is not required to wait for 12 months after a renewal
conducted during the PHE that resulted in a determination of ineligibility or for which a
beneficiary did not respond to a request for additional information.
Table 1 below provides guidelines for states when setting beneficiary renewal dates during the
unwinding period, based on the outcome and timing of the beneficiary’s last attempted renewal
during or prior to the PHE. CMS encourages states to use the flexibilities afforded by the unique
circumstances of the PHE and the end of the continuous enrollment condition to set a renewal
schedule that spreads renewal volume over a full 12-month period and aligns renewal dates for
9 While 42 C.F.R. § 431.230(b) grants states the option to institute recovery for benefits pending if the state’s action is sustained
by the fair hearing decision, states cannot do so if they claim the temporary FMAP increase authorized by section 6008 of the
FFCRA. An individual whose Medicaid eligibility is maintained in order to comply with the continuous enrollment condition,
which includes individuals receiving benefits pending, may not have their eligibility retroactively terminated. In order to receive
the temporary FMAP increase authorized under section 6008 of the FFCRA, states must maintain the eligibility, and benefits, of
all individuals who are enrolled or determined eligible for Medicaid as of March 18, 2020, through the end of the month in which
the public health emergency ends. Section 6008(b) of the FFCRA does not authorize recoupment of funds from any individual
whose Medicaid eligibility was continued in order to comply with the terms of section 6008(b) of the FFCRA.
Page 11 – State Health Official
individuals within households and with recertification timing for the Supplemental Nutrition
Assistance Program (SNAP) and other human services programs. Additional information on
how to implement these strategies is available in Appendix B of this letter.
Table 1. Guidelines for Establishing Renewal Dates during the 12-Month Unwinding
Period
Outcome of Last Renewal Attempted During Permissible Timing of Renewal During 12-
the Last 12 Months of PHE Month Unwinding Period
Ex parte renewal attempted but not completed. Any time (states are encouraged to consider
No further state action taken. strategies to align renewals with SNAP
recertifications or renewals for members of a
household)
Ex parte renewal attempted but not completed. Any time (states are encouraged to consider
State sent renewal form. Beneficiary strategies to align renewals with SNAP
determined ineligible or did not respond. recertifications or renewals for members of a
household)
Renewal completed based on beneficiary’s 12 months after beneficiary’s last renewal for
return of renewal form and/or additional MAGI-beneficiaries; 12 months or shorter
information. Individual continues to meet eligibility period established by the state for non-
eligibility requirements. New eligibility period MAGI beneficiaries per 42 C.F.R. § 435.916(b)
established.
Ex parte renewal attempted and successfully 12 months after beneficiary’s last renewal or
completed. New eligibility period established. 10 original renewal month, at state option, for
MAGI-beneficiaries; 12 months or shorter
eligibility period established by the state for non-
MAGI beneficiaries per 42 C.F.R. § 435.916(b)
No renewal attempted in last 12 months of Any time
PHE.
E. Acting on Changes in Circumstances during the Unwinding Period
Consistent with regulations at 42 C.F.R. §§ 435.916(d) and 457.343, states must promptly
redetermine eligibility between regular renewals of eligibility whenever they receive information
about a change in a beneficiary's circumstances that may affect eligibility. However, due to the
continuous enrollment condition, states have been unable to complete regular renewals during
the PHE for many Medicaid beneficiaries. Given how long it has been since some individuals
have been renewed, there is an increased risk that individuals who may be eligible for CHIP or
Medicaid on another basis may be terminated based on a change in circumstances related to a
single factor of eligibility. Consequently, during the unwinding period, prior to taking adverse
action based on an identified or reported beneficiary change in circumstances, states must
complete a full renewal for any beneficiary unless a renewal was completed in the 12 months
prior to the identified change. The one exception to this general rule involves beneficiaries for
whom (1) a renewal completed within the prior 12 months resulted in a determination that the
beneficiary continues to meet eligibility requirements, and (2) the state has received information
that the beneficiary’s circumstances changed after the last renewal was completed. If a state
identifies a change in circumstances during the unwinding period for an individual who has not
received a renewal in the prior 12 months, the state may choose to complete a full renewal at the
10 For beneficiaries whose eligibility is renewed during the PHE based on information available to the state without requiring
additional information from the individual (“ex parte renewal”) consistent with 42 C.F.R. § 435.916(a)(2) and (b), states continue
to have the option described in the December 2020 SHO (1) to retain the beneficiary’s initial eligibility period had the renewal
been completed timely or (2) to start a new eligibility period based on the date the ex parte renewal was completed during the
PHE. States electing to retain the eligibility period associated with the ex parte renewal completed during the PHE must do so
for all such renewals through the end of the PHE; states may not implement the option on a case-by-case basis.
The contents of this document do not have the force and effect of law and are not meant to bind the public in any way, unless
specifically incorporated into a contract. This document is intended only to provide clarity to the public regarding existing
requirements under the law.
Page 13 – State Health Official
time when the change in circumstances is identified, or the state may wait to process the new
information when it completes the beneficiary’s renewal in a subsequent month.
F. Special Considerations for CHIP and BHP
As states are aware, the continuous enrollment condition does not apply to separate CHIP
programs and BHPs. However, states have taken different approaches to processing CHIP and
BHP renewals during the PHE, and these approaches will impact how states must handle CHIP
and BHP renewals following the eventual end of the PHE. We have included several scenarios
below, highlighting where renewal processes may differ for CHIP and BHP from Medicaid.
CHIP Beneficiaries Who Became Ineligible During the PHE
As stated in the January 6, 2021, “COVID-19 Frequently Asked Questions (FAQs) for State
Medicaid and Children’s Health Insurance Program (CHIP) Agencies” (“January 2021
FAQs”), 11 states are not permitted under the CHIP state plan to extend eligibility periods for
separate CHIP enrollees who have been determined ineligible for coverage. If a state receives
information from an enrollee, processes that information, and determines the individual
ineligible for its separate CHIP, the state must process the termination and transfer the individual
to Medicaid or the Marketplace, in accordance with 42 C.F.R. § 457.350(b) and (i). States that
completed CHIP renewals during the PHE are expected to have terminated ineligible individuals
and to continue to process terminations throughout the remainder of the PHE and unwinding
period.
Similarly, as stated in the January 2021 FAQs, states are not permitted under the CHIP state plan
to extend coverage to young adults aging out of CHIP or, for pregnant individuals enrolled in
CHIP, ending their postpartum coverage period. Because this guidance was not formally
published until January 6, 2021, we recognized that some states may have continued to provide
coverage to these individuals until that date. However, we explained that states are expected to
continue to process terminations of individuals determined ineligible for a separate CHIP under
the state plan throughout the remainder of the PHE.
CMS is aware that some states, using state-only funds, have continued to cover CHIP
beneficiaries found not eligible for coverage during the PHE, including young adults aging out of
CHIP, and/or pregnant individuals ending their postpartum period, and/or children found
ineligible for coverage after a change in circumstances. States may submit a COVID-19 section
1115 demonstration application for CMS consideration requesting expenditure authority to
enable the state to claim federal financial participation (FFP) for such CHIP beneficiaries
through the end of the unwinding period, or until a redetermination is conducted during the
unwinding period. States interested in pursuing a section 1115 demonstration to receive FFP for
these individuals should contact their state lead or section 1115 demonstration project officer.
In addition, we note that states may elect to provide 12 months of extended postpartum coverage
to pregnant individuals enrolled in Medicaid and CHIP beginning April 1, 2022, under sections
9812 and 9822 of the American Rescue Plan Act of 2021 (P.L. 117-2) (ARP). States that elect
this “postpartum extension” option may consider deprioritizing renewals and redeterminations of
11 “COVID-19 Frequently Asked Questions (FAQs) for State Medicaid and Children’s Health Insurance Program (CHIP)
Agencies,” January 6, 2021, available at: https://www medicaid.gov/state-resource-center/downloads/covid-19-faqs.pdf.
Page 14 – State Health Official
eligibility for CHIP beneficiaries who are pregnant or in a postpartum period during the
unwinding period to ensure smooth implementation of the extended postpartum coverage option.
CHIP Beneficiaries Whose Renewals were Delayed during the PHE
We recognize that some states may not have been able to process CHIP renewals in accordance
with the timeliness standards of 42 C.F.R. § 457.340(d)(1) during the PHE. These states
requested and received authority through CHIP SPAs to waive the timely processing of renewals
during the PHE. As states resume processing renewals, we strongly encourage states to initiate
CHIP renewals along the same timeline as Medicaid renewals and follow the guidance in
Sections D and E above. States should incorporate CHIP eligibility and enrollment actions in
their unwinding operational plans and must restore operations consistent with the timeframes and
guidance outlined in the August 2021 SHO and this letter. This includes ensuring that states
initiate CHIP renewals no later than when the state begins its 12-month unwinding period and
complete all work initiated during the 12-month unwinding period by the end of the 14th month
once the state begins its unwinding period.
BHP Beneficiaries Whose Renewals were Delayed During the PHE
We also recognize that states that operate a BHP may not have been able to process BHP
renewals in accordance with the timeliness standards of 42 C.F.R. § 600.340 during the PHE.
These states requested and received authority through BHP Blueprint amendments to waive the
timely processing of renewals during the PHE. States that have been unable to process BHP
renewals during the PHE may follow the same processes for resuming the timely processing of
renewals for BHP as they are for Medicaid. However, we note that a state may not be able to
begin processing BHP renewals within one month of the end of the PHE if that month does not
align with when the state typically conducts BHP renewals.
For example, if the PHE ends in April 2022, but a state has elected to align renewals with the
Open Enrollment period in the Marketplace such that the state would not normally process any
BHP renewals until Fall 2022 for a new coverage year beginning January 1, 2023, the state
would not be required to change its typical renewal processing timelines. However, states can
elect to change this policy by submitting a BHP Blueprint revision, and we encourage states that
operate a BHP and currently only conduct renewals to coincide with the Marketplace Annual
Open Enrollment to consider whether to instead spread out the processing of BHP renewals
throughout the year. The 12-month unwinding period presents a unique opportunity for BHP
states to reestablish a renewal schedule that is sustainable in future years. CMS is available to
provide technical assistance to states exploring this option.
III. Prioritization and Distribution of Pending Eligibility and Enrollment Work
For states to maintain coverage for eligible individuals, complete the volume of work that will
need to be addressed in the 12-month unwinding period, and reestablish a renewal schedule that
is sustainable in future years, states will need to determine how they will prioritize and distribute
their work across the unwinding period. States should first assess the scope of their workload
and consider strategies discussed in Section V of this letter on “Strategies to Promote Continuity
of Coverage and Mitigate Churn.” States will then need to prioritize the order in which they will
initiate and complete eligibility and enrollment actions to minimize the extent to which ineligible
individuals remain enrolled, prevent inappropriate terminations of coverage for eligible
Page 15 – State Health Official
individuals, and achieve a manageable distribution of renewals in future years. Finally, states
will need to identify how they will distribute prioritized work scheduled to be initiated within the
timelines specified in this letter.
A. Adopting a Risk-Based Approach to Prioritize Work
CMS expects states to adopt a risk-based approach to prioritize pending eligibility and
enrollment actions related to post-enrollment verifications, changes in circumstances, and
renewals the state will conduct during the 12-month unwinding period. A risk-based approach
ensures states prioritize their workload in a manner that considers the need to prevent
inappropriate terminations and enables smooth program transitions for individuals no longer
eligible for Medicaid, CHIP, or a BHP. CMS also encourages states to prioritize work in a way
that will achieve an evenly-distributed renewal workload that is sustainable in future years.
States may select among four risk-based approaches to address the backlog of pending cases.
1. Population-Based Approach: Prioritizes outstanding eligibility and enrollment actions
based on characteristics of cohorts or populations who are likely to have become eligible
for more expansive benefits or who are likely to be eligible for different coverage (e.g.,
QHP through the Marketplace). Examples of populations states may wish to prioritize
include individuals who have reported a decrease in income, individuals enrolled during
the PHE through a temporary eligibility option, or individuals who have aged out of a
group or otherwise have become categorically ineligible for the group in which they are
enrolled.
Populations whose eligibility tends to be stable, such as children, former foster youth, or
individuals dually eligible for Medicaid and Medicare, are not among the types of
populations CMS would expect states to prioritize in a population-based approach.
However, CMS encourages states to consider available options and flexibilities to
streamline enrollment and promote continuity of coverage for individuals as they
prioritize their work.
For example, states electing the extended postpartum coverage option under sections
9812 and 9822 of the ARP that implement the option during the state’s unwinding period
may choose to deprioritize renewals and redeterminations of eligibility for beneficiaries
who are pregnant or in a postpartum period when the continuous enrollment condition
expires, to ensure smooth implementation of the extended postpartum coverage option.
States may refer to the December 2021 SHO, “Improving Maternal Health and Extending
Postpartum Coverage in Medicaid and CHIP,” for more information on the state plan
option to provide 12 months of continuous postpartum coverage. 12
A population-based approach should address both the risk that ineligible individuals
remain enrolled and the risk that eligible individuals may be inappropriately terminated.
12 CMS State Health Official Letter #21-007: Improving Maternal Health and Extending Postpartum Coverage in Medicaid and
the Children’s Health Insurance Program (CHIP). December 7, 2021. Available at: https://www medicaid.gov/federal-policy-
guidance/downloads/sho21007.pdf.
Page 16 – State Health Official
However, unless authority for, or expanded eligibility under, a group expires at the end of
the PHE (e.g., as is the case for the optional COVID-19 group 13 or in the case of an
income or resource disregard adopted temporarily for the duration of the PHE), states
may not prioritize populations based solely on the Medicaid eligibility group in which
they are enrolled, de-prioritize cases based on the availability of FFP at a matching rate
that exceeds the state’s regular FMAP (e.g., states may not de-prioritize completion of
outstanding eligibility actions for individuals enrolled in the adult group) or prioritize
populations in a manner that would constitute a violation of federal law, including, but
not limited to, the Americans with Disabilities Act of 1990 (ADA), Title VI of the Civil
Rights Act of 1964, Section 504 of the Rehabilitation Act of 1973 (Section 504), the Age
Discrimination Act of 1975, and Section 1557 of the Affordable Care Act (Section 1557).
Further, compliance with these laws includes providing reasonable accommodations to
individuals with disabilities under the ADA, Section 504, and Section 1557, with
eligibility and documentation requirements, understanding program rules and notices, to
ensure they understand program rules and notices, as well as meeting other program
requirements necessary to obtain and maintain benefits.
2. Time or Age-Based Approach: Prioritizes cases based on the length of time the action has
been pending. Under a time-based approach, states can process the oldest cases first in
the 12-month unwinding period, or they may process cases by maintaining the original
month of renewal.
3. Hybrid Approach: Combined population- and time-based approaches. For example, a
state may adopt a time-based approach to prioritizing outstanding post-enrollment
verifications and changes in circumstances and a population-based approach to
prioritizing pending renewals. Alternatively, states may adopt a population-based
approach for processing the first wave of pending actions and then switch to a time-based
approach.
4. State-Developed Approach: Any other approach that meets the goals of keeping eligible
individuals enrolled, minimizes the extent ineligible individuals may remain enrolled,
achieves a sustainable renewal schedule, and meets the 12-month unwinding timeline for
addressing outstanding eligibility actions.
Regardless of how a state chooses to categorize its risk-based approach and prioritize its work,
states must ensure their risk-based approach is described in the unwinding operational plan.
B. Distributing Pending Actions Across the Unwinding Period
Once a state determines how it will prioritize its eligibility and enrollment work, we expect states
to establish a distribution schedule to initiate and process renewals and other actions over the 12-
month unwinding period. The redistribution plan should ensure that states are able to maintain
coverage for eligible individuals and manage transitions to other coverage for individuals
determined potentially eligible for enrollment in another insurance affordability program. An
13 Section 6004(a)(3) of the FFCRA added a new optional Medicaid eligibility group for uninsured individuals during the
COVID-19 PHE. This group, added at section 1902(a)(10)(A)(ii)(XXIII) of the Social Security Act, was previously referred to as
the “COVID-19 optional testing group”; the ARP expanded the coverage available to such individuals.
Page 17 – State Health Official
evenly-distributed renewal schedule will also mitigate future challenges states might experience
if they process a large volume of actions at the beginning of the unwinding period, or if they
delay beginning to process renewals until later in the unwinding period. States that do not make
plans to distribute their work during the 12-month unwinding period run the risk of errors in
processing renewals and inappropriately terminating coverage for eligible individuals, not only
during the 12-month unwinding period but also in future years as distributing this work over a
shorter period could create peaks in routine renewal volume in particular months.
In addition to the pending renewals and redeterminations that states will need to address when
the continuous enrollment condition expires, new eligibility actions also will arise during the 12-
month unwinding period (e.g., for eligible beneficiaries who experience a change in
circumstances and individuals whose enrollment or whose eligibility was renewed in the last 12
months of the PHE). States can address such new actions in accordance with the timeframes that
ordinarily would apply in accordance with 42 C.F.R. § 435.916 (i.e., in the absence of the
continuous enrollment condition). Alternatively, states can integrate such new actions into the
prioritization plan and distribution schedule developed by the state for backlogged actions
pending at the end of the continuous enrollment condition, even if doing so would result in some
delay in addressing the newly-arising actions.
C. Preventing Inappropriate Terminations
Based on our experience in working with states over the years, CMS is concerned that the
combination of several factors creates an acute risk that eligible beneficiaries will lose coverage
when states begin to process renewals and other eligibility and enrollment actions, including, the
significant increases in Medicaid and CHIP enrollment during the PHE, the disruption to
eligibility and enrollment operations, the length of time that has elapsed since state agencies had
any contact with their beneficiaries, and significant staffing shortages. While states will need to
expeditiously restore routine operations, states are obligated to ensure accurate determinations of
eligibility and are advised to take steps during the PHE to complete as much eligibility and
enrollment work as possible in order to limit the volume of actions that will need to be
completed in the 12-month unwinding period. Once states have begun to conduct renewals and
process other eligibility actions, they will need to balance how quickly they work through their
total caseload with the need to prevent errors resulting in the termination of coverage for eligible
beneficiaries and churn, as eligible individuals terminated from coverage subsequently re-apply.
In providing technical assistance to states to ensure they are able make timely and accurate
redeterminations of eligibility, we have found that states that have a more even distribution of
renewals over the course of a year are better able to maintain a workload that is sustainable in
future years, thereby enabling the state to avoid renewal backlogs and reduce risk of inaccurate
redeterminations and inappropriate terminations in future years. Based on this experience, CMS
recommends that states initiate no more than 1/9 of their total caseload of Medicaid and CHIP
renewals in a given month during the unwinding period.
We believe this target will not only mitigate the risk of inappropriate terminations and churn, but
also establish a sustainable renewal schedule by helping states avoid “renewal bulges” in some
months that increase the risk of future renewal backlogs. We believe states that distribute the
unprecedented volume of renewals that must be initiated during the 12-month unwinding period
Page 18 – State Health Official
will be more likely to avoid erroneous determinations of ineligibility and avoid coverage losses
for procedural reasons. In addition, CMS believes that initiating more than 1/9 of renewals in a
given month risks a compressed renewal workload that could put states at risk of inappropriately
shortening or extending beneficiary eligibility periods described at 42 C.F.R. §§ 435.916(a) and
(b) and 457.343 in order to manage workload in future years.
The 1/9 threshold also recognizes that there are natural fluctuations in the volume of renewals
typically processed in different months that would prevent a state from evenly distributing
renewals throughout the entire unwinding period (i.e., initiating 1/12 of a state’s total caseload
each month). For example, some states experience higher application volume during certain
periods in a given year (e.g., due to Open Enrollment or adoption of a coverage expansion). In
others, staffing levels may drop in certain months (e.g., over the winter holidays), which may
impact a state’s preferred distribution of renewals in future years. For these reasons, CMS
believes that initiating renewals for no more than 1/9 of a state’s total caseload in a given month
strikes a reasonable balance between achieving a relatively even distribution of renewals with the
need to accommodate fluctuations in the volume of work and state staff capacity that naturally
occur throughout the year.
Note that in calculating 1/9 of total caseload as of the end of the month prior to the month in
which the state’s unwinding period begins, some states may measure their total caseload based
on the total number of individuals enrolled in their programs, while others may measure total
caseload based on the total number of households with one or more household members enrolled
in the state’s programs.
CMS will require states to submit certain information, including how each state plans to
distribute renewals as well as what strategies the state is considering or has adopted to mitigate
against inappropriate coverage loss during the unwinding period. CMS will use this information
to identify states at greatest risk of inappropriate coverage losses. 14 CMS will provide states
with a form to submit summary information about their renewal distribution plans and will
follow up with states as needed to ensure that proper mitigation strategies are in place to reduce
risk of inappropriate terminations and that states’ plans will establish a sustainable workload in
future years (this form is separate from the state’s unwinding operational plan which, as
mentioned in Section II.A., states are not required to submit to CMS for approval). For more
information on the monitoring and evaluation of a state’s distribution schedule and strategies to
prevent inappropriate terminations, please see Section VII of this letter on “Monitoring State
Progress and Corrective Action.”
D. Aligning Work on Pending Actions
All beneficiaries, including limited benefit populations or groups, will require a renewal during
the 12-month unwinding period, which means there is a unique opportunity for states to align
other eligibility actions with renewals during the unwinding period to manage workload and
reestablish a renewal schedule that is sustainable in future years. The following alignment
strategies, which can support states in achieving an even distribution of work both during the 12-
14 These reports will be required under the authority in sections 1902(a)(4)(A), 1902(a)(6) and 1902(a)(75) of the Act and at 42
C.F.R. § 431.16 to ensure proper and efficient administration of the Medicaid program and section 2101(a) of the Act to promote
the administration of CHIP in an effective and efficient manner.
Page 19 – State Health Official
month unwinding period and in subsequent years, are only available during the 12-month
unwinding period. However, states may not shorten an individual’s established eligibility period
when using these strategies for the purposes of alignment. After the 12-month unwinding period
ends, states must resume timely processing of periodic renewals and redeterminations of
eligibility in accordance with 42 C.F.R. §§ 435.912, 435.916, 457.340, and 600.320 as well as
post-enrollment verifications in accordance with the verification plan described at § 435.945(j)
developed by the state. BHP states must follow the verification requirements of § 600.345 and
their certified BHP Blueprints.
Aligning Work on Verifications and Changes in Circumstances at Renewal
States may wait to complete pending post-enrollment verifications and act on changes in
circumstances reported or identified during the PHE and unwinding period for beneficiaries with
a renewal scheduled to be initiated during the 12-month unwinding period, with one exception
related to verification of citizenship or immigration status and the reasonable opportunity period
(ROP) required under 42 C.F.R. §§ 435.406 and 435.956, which allows applicants and states
additional time to complete those verification processes. This alignment strategy will create
efficiencies for states by allowing them to use information obtained at renewal to simultaneously
resolve other pending eligibility and enrollment actions and also limit the need to send multiple
requests for information to individuals to complete multiple pending actions.
As required under current regulations at 42 C.F.R. § 916(a)(2), states must ensure eligibility
notices inform beneficiaries of the basis of the eligibility determination and remind them that
they must inform the state if any of the information used to determine their eligibility is not
accurate. After the 12-month unwinding period, states must resume timely processing of post-
enrollment verifications and promptly act on changes in circumstances that occur between
renewals consistent with federal regulations.
Individuals whose Medicaid benefits have been maintained during an ROP have not had an
eligibility determination completed pending verification of U.S. citizenship or satisfactory
immigration status; rather, they are receiving benefits pending a determination of eligibility that
rests on the verification of their status. Therefore, states will need to review the verification and
ROP process applied during the PHE in order to determine the appropriate action for individuals
whose citizenship or verification status was not completed during the PHE but whose enrollment
has been maintained under an ROP to comply with the continuous enrollment condition. If a
state did not send an individual notice to initiate an ROP during the PHE, or delayed or otherwise
did not complete the regular verification of satisfactory immigration status or U.S. citizenship
process as required under §§ 435.406 and 435.956, the agency must send the required notice
after the PHE ends and provide the 90-day ROP for the individual to provide any needed
documentation and the state to complete its verification process in accordance with §§ 435.406,
435.407, and 435.956. We note that the ROP begins on the date the beneficiary receives notice
of such opportunity from the agency, in accordance with § 435.956(b)(2)(i).
Even if a state has provided a fully compliant notice and ROP to all affected beneficiaries but
some beneficiaries have not resolved their citizenship or immigration status inconsistency during
the PHE, we encourage states to attempt to reverify eligibility for these beneficiaries before the
state’s unwinding period begins. This may be necessary in order to provide the due process
protections, including advance notice of termination and fair hearing rights, for these individuals.
Page 20 – State Health Official
States may extend the ROP period during this additional verification in certain situations.
Specifically, for individuals who have attested to satisfactory immigration status, states may
attempt to re-verify immigration status again after the continuous enrollment condition expires,
as § 435.956(b)(2)(ii)(B) allows states to provide for a reasonable extension of the ROP for
individuals attesting to satisfactory immigration status and who are making a good faith effort to
obtain any necessary documentation, or if the state needs more time to verify the individual’s
status or assist the individual in obtaining documents needed to verify their status. For
individuals who have attested to U.S. citizenship status, states may re-verify their US citizenship
during the unwinding period through a COVID-19 1115 demonstration, which would provide for
an extension of the ROP beyond the 90-day timeframe required under section 1902(ee) of the
Social Security Act (the Act). CMS is available to provide technical assistance to states
interested in pursuing this approach.
After the continuous enrollment condition expires, the state can terminate individuals who still
have not provided needed documentation of citizenship or immigration status during a fully
compliant ROP and for whom the state is not able to verify their status, as long as the state
provides a minimum of 10 days advance notice of termination and fair hearing rights consistent
with § 435.917 and 42 C.F.R. Part 431, Subpart E.
Aligning Renewals with SNAP Recertification
For beneficiaries also enrolled in SNAP, states may schedule their Medicaid renewals to coincide
with the individual’s SNAP recertification, provided such recertification occurs within the 12-
month unwinding period. This strategy not only may achieve greater administrative efficiencies
for states but also can minimize the burden for individuals.
Aligning Renewals for all Individuals in a Household
States may choose to align work on renewals for all members in a household during the 12-
month unwinding period. This strategy will minimize beneficiary burden by allowing families to
receive one request for information from the state. It also will help to align renewals for all
members of a household in future years.
CMS reminds states that, while states may process renewals for an entire household at the same
time, redeterminations of eligibility are made on an individual basis. Thus, a state may not
terminate coverage for one member whose eligibility is verified with information available to the
state because the state was not able to verify eligibility for another member in the household.
For example, a family of four (two parents and two children) is enrolled in Medicaid through
different eligibility groups. The parents are enrolled in the adult group and the two children are
enrolled in the children’s group. The state chooses to align work on renewals for the entire
family during the 12-month unwinding period. The state initiates the renewal by checking
available data. The state has sufficient income and other information to determine eligibility
continues for the two children, but the income data obtained by the state indicates that the
parents’ income exceeds the standard for the adult group. The state sends the family a pre-
populated renewal form and provides a minimum of 30 days for the family to return the renewal
form. The family does not return the renewal form. Because the state does not have sufficient
information to renew eligibility for the parents, it must send advance notice of termination
related to their coverage. However, the state may not terminate coverage for the children and
must begin a new 12-month eligibility period for them.
Page 21 – State Health Official
Aligning Renewals for Individuals Who Missed Their Medicare Initial Enrollment Period
Some individuals who have retained Medicaid coverage during the PHE may have become
eligible for Medicare since March 2020 but have not signed up for Medicare during their
Medicare initial enrollment period because they continue to be covered by Medicaid and may
think they do not need Medicare coverage at this time. An individual’s Medicare initial
enrollment period is the 7-month period that starts three months before an individual is first
eligible to enroll in Medicare.
Unless the individual is eligible for a special enrollment period, individuals who miss their
Medicare initial enrollment period may only sign up for Medicare during the Medicare general
enrollment period, which runs from January 1 to March 31 each year. Those individuals may
also have to pay a monthly late enrollment penalty. However, certain Medicaid enrolled
individuals may obtain Medicare coverage at other times of the year through their state’s
Medicare buy-in process.
A Medicare-eligible beneficiary who misses their Medicare initial enrollment period, is not
enrolled into Medicare through the state’s buy-in process, and loses their Medicaid eligibility
outside of the Medicare general enrollment period (i.e., after the state resumes regular
terminations), may experience a gap in coverage before their Medicare coverage begins. Such
individuals also may incur late enrollment penalties once they do enroll in Medicare.
States may leverage available data matching processes to help identify beneficiaries who may
have become eligible for Medicare during the PHE. 15 To minimize disruptions in coverage and
to avoid imposition of late enrollment penalties, CMS encourages states to attempt to identify
these beneficiaries and to reach out to advise them to enroll in Medicare during their initial
enrollment period or during the current Medicare general enrollment period (before March 31,
2022), whichever applies. States should refer these individuals to their local State Health
Insurance Assistance Program (SHIP) for counseling. Additionally, states should consider the
timing of the next Medicare general enrollment period in scheduling renewals during the
unwinding period for individuals who may be Medicare eligible, in order to facilitate seamless
coverage transitions and avoid gaps in coverage by scheduling these individuals’ renewals to
coincide with the Medicare general enrollment period.
IV. Notices and Fair Hearings
A. Notices
Whenever a Medicaid or CHIP agency makes a decision affecting a beneficiary’s eligibility, the
state generally must send the beneficiary a notice at least 10 days prior to the date of action
(defined at 42 C.F.R. § 431.201 as “the intended date on which a termination, suspension,
reduction, transfer or discharge becomes effective”) of the agency’s decision. This advance
15 CMCS Informational Bulletin, “Strategies to Streamline Transitions for Medicare-eligible Beneficiaries Who Newly Qualify
for Medicare,” (June 2017). Available at https://www medicaid.gov/federal-policy-guidance/downloads/cib060717.pdf. The 2021
MAPD State User Guide is available at https://www.cms.gov/Research-Statistics-Data-and-Systems/CMS-Information-
Technology/mapdhelpdesk/MAPD-State-User-Guide.
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notice must include certain information, including the beneficiary’s right to a Medicaid fair
hearing, as described at 42 C.F.R. § 435.917 and 42 C.F.R. Part 431, Subpart E, or a CHIP
review, as described at 42 C.F.R. §§ 457.340(e) and 457.1120-1190.
States must provide beneficiaries with advance notice of any action resulting from an eligibility
determination conducted during the unwinding period. This requirement applies even in cases
where the unwinding period eligibility determination yields the same action as a determination
conducted during the PHE, and for which the state previously provided notice, as it is important
for beneficiaries to have accurate and up-to-date information regarding the specific end date for
their Medicaid and CHIP eligibility. Regulations at 42 C.F.R. §§ 431.210(a) and
457.340(e)(1)(ii)(A) require the notice to include the effective date of the action.
As a reminder, states may need to revise timeframes for individuals to request a fair hearing.
During the PHE, CMS approved section 1135 waiver authority to provide many states with the
flexibility to allow applicants or beneficiaries more than 90 days to request a fair hearing.
Following the end of the PHE, states using this flexibility may either revert back to the time
provided for individuals to request a fair hearing prior to the grant of section 1135 authority or
may modify their policy to provide another reasonable time period not to exceed 90 days, in
accordance with federal regulations (42 C.F.R. § 431.221(d)), which does not require a
submission of a SPA. As discussed in the December 2020 SHO, the state must provide
individuals the amount of time the individual was informed they have to request a fair hearing
following an adverse action after the PHE ends, even if the state stops providing the additional
time allowed during the PHE going forward.
For additional information regarding notice requirements for the end of flexibilities and
authorities granted to states during the PHE, see the December 2020 SHO.
B. Medicaid Fair Hearings and CHIP Reviews
Typically, a state Medicaid or CHIP agency must provide an individual the opportunity to have a
Medicaid fair hearing or a CHIP review when an individual believes the state has taken an action
erroneously, including suspensions, terminations, or reductions of eligibility or when the state
has denied the individual’s claim for eligibility (42 C.F.R. §§ 431.220(a) and 457.1120). One
exception is that states are not required to provide a Medicaid fair hearing or a CHIP review
when the action is due to a change in law or policy, such as the end of eligibility that was
authorized only during the PHE (e.g., the extension of eligibility to non-residents temporarily
residing in the state due to the PHE) (see 42 C.F.R. §§ 431.220(b) and 457.1130(c)). However, a
beneficiary always has the right to request a Medicaid fair hearing or a CHIP review to contest
that the eligibility determination was wrong on another basis under existing authority. In
Medicaid, beneficiaries also have the right to continue to receive benefits pending the fair
hearing decision when the individual requests the fair hearing prior to the date of the action in
accordance with 42 C.F.R. § 431.230.
During the PHE, a number of states were granted a regulatory concurrence that allowed a state to
take more than 90 days to take final administrative action on Medicaid fair hearing requests due
to an emergency beyond the state’s control (42 C.F.R. § 431.244(f)(4)(i)(B)). All states,
including those granted this regulatory concurrence, are expected to begin processing fair
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hearing requests timely when the continuous enrollment condition ends (see 42 C.F.R. §
431.244(f)(1)-(3)). However, we understand that some states are concerned that the volume of
fair hearings may increase dramatically and exceed the state’s capacity to adjudicate all fair
hearing requests within the regulatory time limits.
For states that encounter such challenges in their fair hearing process, CMS will consider
providing authority under section 1902(e)(14) of the Act to provide the state with additional time
to take final action provided that certain beneficiary protections are provided. For more
information on the section 1902(e)(14) waiver opportunity, see section V.A. below. The CHIP
review regulations require states to complete the reviews of eligibility and enrollment matters in
a “reasonable amount of time” (42 C.F.R. § 457.1160(a)). CMS interpreted that regulation to
contain sufficient flexibility for states to take additional time to complete CHIP reviews during
the PHE, and thus did not find it necessary to grant states explicit authority to do so. Following
the end of the PHE, states will need to continue completing reviews within a reasonable
timeframe as described at 42 CFR § 457.1160(a).
As states restore routine eligibility and enrollment practices, including eligibility terminations,
states may see a return to a normal or higher than normal volume of fair hearing requests. As
states develop their unwinding operational plans, they should consider the volume of requests
their fair hearing programs can process in a timely fashion and take the anticipated volume of
requests and the state’s operational capacity into account as they determine how to distribute
pending actions across the unwinding period. Just as some states may have been unable to hold
in-person fair hearings and reviews during the PHE or had reduced the number of in-person
hearings, states may modify certain fair hearing and review processes without the need for
additional state plan authority to avoid and reduce backlogs of fair hearings. States may hold fair
hearings and reviews by telephone or video, as long as the state is providing access to the fair
hearing process in accordance with 42 C.F.R. Part 431 subpart E (including providing access to
individuals with disabilities and those who have LEP) and 42 C.F.R. § 457.1140(d). States may
also explore establishing or expanding an informal resolution process to resolve fair hearing
requests prior to holding a fair hearing, an option which is available to states without additional
state plan authority.
CMS plans to post on Medicaid.gov a resource document with additional strategies that states
may want to consider to help manage the anticipated increase in fair hearing requests and is
available to provide technical assistance to states related to fair hearing processes generally, and
specifically regarding timeframes after the PHE eventually ends.
V. Strategies to Promote Continuity of Coverage and Mitigate Churn
A. Temporary 1902(e)(14)(A) Waiver Unwinding Strategies to Promote Continuity of
Coverage and Mitigate Churn in Medicaid
As states prepare to restore routine operations, CMS has worked closely with state agencies and
other stakeholders to identify ways to efficiently enroll eligible individuals, and reduce churn. In
order to support states facing significant operational issues and streamline the renewal or fair
hearing processes to protect otherwise eligible beneficiaries at risk of inappropriately losing
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coverage during the unwinding period, CMS will allow for the limited use of section
1902(e)(14)(A) authority.
Section 1902(e)(14)(A) of the Act, added by section 2002 of the Affordable Care Act, allows for
waivers “as are necessary to ensure that states establish income and eligibility determination
systems that protect beneficiaries.” Since 2013, CMS has granted section 1902(e)(14)(A) waiver
authority to protect beneficiaries’ access to coverage by providing administrative relief to many
states facing operational issues (e.g., backlogs and application processing delays), navigating
serious challenges with eligibility systems, and facilitating the enrollment of newly eligible
individuals.
To protect beneficiaries in addressing the challenges states may face as they transition to routine
operations during the unwinding period, CMS has determined that states may seek approval to
use this authority in a time-limited manner to implement the five specific targeted strategies
outlined below. These strategies can efficiently facilitate the renewal process by limiting the
need for requests for additional information from beneficiaries, thus leading to fewer procedural
terminations and reducing state administrative burdens during this transition period. The
strategy to address states’ significant operational challenges in the fair hearing process can
protect the due process rights and maintain coverage of individuals pending the outcome of a fair
hearing, reducing loss of coverage and state administrative burden during this transition period.
1. Renewal for Individuals Based on SNAP Eligibility: Consistent with guidance for
implementing Strategy 3 in SHO letter #13-003 16 and revised parameters in SHO letter
#15-001 17, states may use this authority to renew Medicaid eligibility for SNAP
participants without conducting a separate MAGI-based income redetermination. An
approved section 1902(e)(14)(A) waiver request would allow states to rely on SNAP data
for renewals for individuals under 65 years of age, despite the differences in household
composition and income-counting rules, when necessary to protect beneficiaries in the
face of systems limitations. Please note that a state can permanently leverage SNAP
information for renewal, by pursuing the facilitated enrollment strategies described in
Appendix B.
2. Ex Parte Renewal for Individuals with No Income and No Data Returned: CMS may
grant section 1902(e)(14)(A) authority to temporarily permit renewals, on an ex parte
basis, for households whose attestation of zero-dollar income was verified within the last
twelve months, at the initial application or the previous renewal, when no information is
received/returned from a financial data source at renewal. In order to complete the ex
parte renewal, the state must take appropriate steps to review the non-financial
components of eligibility consistent with the requirements at 42 C.F.R. §§ 435.916 and
435.956. CMS reminds states that the renewal notice also must instruct beneficiaries to
inform the agency if any of the information used to make the eligibility determination is
inaccurate.
16 State Health Official letter #13-003, “Facilitating Medicaid and CHIP Enrollment and Renewals in 2014,” May 17, 2013.
Available at: https://www medicaid.gov/federal-policy-guidance/downloads/sho-13-003.pdf.
17 State Health Official letter #15-001, “Policy Options for Using SNAP to Determine Medicaid Eligibility and an Update on
Targeted Enrollment Strategies,” August 31, 2015. Available at: https://www.medicaid.gov/federal-policy-
guidance/downloads/sho-15-001.pdf.
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3. Facilitating Renewal for Individuals with No Asset Verification System (AVS) Data
Returned within a Reasonable Timeframe: Under this approach, CMS may grant states
authority under section 1902(e)(14)(A) of the Act to permit renewals of beneficiaries for
whom no information is returned by the AVS within a reasonable timeframe.
In accordance with regulations at 42 C.F.R. § 435.916, states must attempt to make an ex
parte determination at renewal and check income data sources at renewal, consistent with
its verification plan. Additionally, section 1940 of the Act requires that states verify
assets using the state’s AVS for individuals excepted from MAGI-based methodologies
and subject to an asset test. While states are required to comply with these requirements,
the state may establish a reasonable time frame for AVS information to be returned.
Currently, if the AVS does not return information within the timeframe established by the
state, the state must attempt to redetermine eligibility in accordance with its verification
process, which may include requesting additional information and documentation or
obtaining a new attestation of assets from the individual by sending the beneficiary a
renewal form requesting the additional information. Time-limited authority granted
under this approach would allow a state to assume there has been no change in resources
that are verified through the AVS when no information is returned within a reasonable
timeframe, and therefore complete the renewal process without any further verification of
the assets that are verified through the AVS.
4. Partnering with Managed Care Plans to Update Beneficiary Contact Information: States
generally are required to contact the beneficiary to confirm the accuracy of updated
contact information received from a health plan and to provide a reasonable period for the
beneficiary to dispute the information provided by the plan, prior to updating the
beneficiary record (see “Overview of Strategic Approach to Engaging Managed Care
Plans to Maximize Continuity of Coverage as States Resume Normal Eligibility and
Enrollment Operations - February 2022 Update”). However, CMS recognizes that some
states may have system or operational limitation that prevent the state for doing so. CMS
may grant section 1902(e)(14)(A) authority to temporarily permit such states to accept
updated enrollee contact information from managed care plans without additional
confirmation with the individual where doing so would serve to protect beneficiaries in
the aggregate. Under this temporary waiver authority, states may treat updated contact
information received from the plan as reliable and update the beneficiary record with the
new contact information without first sending a notice to the address on file with the
state.
5. Extended Timeframe to Take Final Administrative Action on Fair Hearing Requests:
CMS may grant states authority under section 1902(e)(14)(A) to temporarily extend the
timeframe to take final administrative action on fair hearing requests. In order to use this
option in a manner that protects beneficiaries, states would be required to provide
benefits pending the outcome of a fair hearing decision (including reinstating benefits
pursuant to 42 C.F.R. § 431.231), regardless of whether or not a beneficiary has
requested a fair hearing prior to the date of the adverse action, and to forgo recoupment
from beneficiaries if the fair hearing ultimately upheld the agency’s determination.
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While we have outlined five targeted strategies requiring approval under section 1902(e)(14)(A)
of the Act, CMS may consider other 1902(e)(14)(A) waiver renewal strategy requests that impact
the state’s ability to process renewals, including flexibilities that address streamlining application
processing in order to maximize state resources or enrollment strategies for other populations to
promote continuity of coverage.
However, CMS will not approve 1902(e)(14)(A) waiver requests unrelated to the state’s
unwinding period or requests that fail to protect beneficiaries. For example, states may not use
the authority to extend beneficiary eligibility periods beyond the unwinding period. In addition,
CMS will not approve requests to shorten eligibility periods or bypass renewal or fair hearing
requirements that minimize beneficiary burden and ensure eligible individuals remain enrolled
(e.g., eliminating the requirement to complete ex parte renewals), as such requests would not
serve to protect beneficiaries, as required by section 1902(e)(14)(A) of the Act.
To request authority to implement one or more of these strategies, states can request such waiver
authority under section 1902(e)(14)(A) of the Act on a time-limited basis during the unwinding
period. CMS is available to provide technical assistance and can provide sample language the
state can use to craft a letter requesting the waiver authority. States interested in one or more of
the temporary waiver authorities described above should contact their CMS State Lead.
B. State Plan and Operational Strategies to Promote Continuity of Coverage and Mitigate
Churn
As states develop their plans to complete pending eligibility and enrollment actions, they should
also consider strategies that will help eligible individuals maintain coverage, prevent churning on
and off of coverage, and mitigate procedural denials based on the absence of a returned renewal
form or other information needed by the state to complete a redetermination of eligibility. These
strategies may include:
• State plan options, such as:
• continuous eligibility for children
• 12 months continuous postpartum coverage (beginning April 2022)
• express lane eligibility for children
• Options to streamline renewals, such as:
• expanding the number and type of data sources used to attempt an ex parte
renewal
• aligning MAGI and non-MAGI renewal policies
• Improving communications and outreach to beneficiaries, such as by:
• updating contact information
• partnering with health plans
• establishing processes to address returned beneficiary mail
o using multiple modalities to reach individuals (e.g., mail, email, text)18
18 CMS is working with other federal partners to examine potential statutory constraints around the use of text messaging. We
will pass along additional information as it becomes available.
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As part of their unwinding operational planning, states should assess their readiness to complete
eligibility and enrollment actions and adopt policy options and operational strategies that will
address situations in which eligible beneficiaries may be at risk of losing coverage and create
efficiencies for states to address the volume of work during the unwinding period. States should
ensure that their eligibility and enrollment workforce is aware of any new strategies that are
adopted through memorandums, updated internal procedures and policy manuals, formal
trainings, or other methods of communication. States may refer to Appendix B and the
November 2021 tool, “Strategies States and U.S. Territories Can Adopt to Maintain Coverage of
Eligible Individuals as they Return to Normal Operations," for examples of strategies that
promote continuity of coverage and mitigate churn and additional guidance on how states may
implement them. 19
VI. Facilitating Transitions between Medicaid, CHIP, BHP, and the Marketplace
In completing renewals once the continuous enrollment condition expires, states are likely to
identify many beneficiaries who are no longer eligible for Medicaid, CHIP, or coverage through
a BHP. Many of these individuals will likely be eligible for enrollment in a QHP through the
Marketplace with significant financial assistance. Facilitating smooth transitions to the
Marketplace for these beneficiaries will be critical to ensuring that such eligible individuals do
not become uninsured.
Regardless of whether a state has an SBM that operates its own eligibility and enrollment
platform or a Marketplace that relies on the federal eligibility and enrollment platform to
complete eligibility determinations for coverage in a QHP, state Medicaid, CHIP, and BHP
agencies are required to have an agreement with the relevant Marketplace and, consistent with
the requirements at 42 C.F.R. §§ 435.1200, 457.350, and 600.330, have a coordinated process to
send electronic accounts and other information to the Marketplace, to receive electronic accounts
and other information from the Marketplace, and to ensure prompt determinations of eligibility
and enrollment in the appropriate program. As noted above, for individuals determined by the
agency as not eligible for Medicaid, CHIP, or BHP following a renewal or redetermination of
eligibility, the agency must promptly assess the individual’s potential eligibility for Marketplace
coverage and timely transfer the individual’s electronic account to the Marketplace. The account
must include all of the information collected and generated by the state regarding the individual’s
Medicaid, CHIP, and/or BHP eligibility.
Medicaid and CHIP agencies may have insufficient information to assess an individual as
potentially eligible for Advanced Premium Tax Credits or Cost-Sharing Reductions through the
Marketplace, as such assessment requires application of different financial methodologies,
evaluation of access to or enrollment in employer-sponsored or other forms of coverage, and, in
some cases, non-citizen eligibility criteria. States are not required to conduct individual
assessments but instead may implement a streamlined approach that will reduce the
administrative burden for states and ensure timely transfer of individuals potentially eligible for
QHP enrollment. States can treat anyone who is determined ineligible for Medicaid or CHIP as
potentially eligible for QHP enrollment, other than individuals whose coverage was denied or
19 “Strategies States and the U.S. Territories Can Adopt to Maintain Coverage of Eligible Individuals as They Return to Normal
Operations,” (November 2021). Available at: https://www medicaid.gov/state-resource-center/downloads/strategies-for-covrg-of-
indiv.pdf.
Page 28 – State Health Official
terminated for a procedural reason (e.g., failing to complete the renewal process) and individuals
who do not attest to U.S. citizenship or a lawfully present non-citizen status. BHP agencies
should continue to follow the requirements related to coordination with other insurance
affordability programs under § 600.330.
States are also encouraged to implement additional approaches that may help with transitions to
and enrollment in a QHP. While most appropriate for states served by a Marketplace that relies
on the federal eligibility and enrollment platform or those in which the state
Medicaid/CHIP/BHP and Marketplace systems are not integrated, the following strategies may
be helpful for all states to consider. States can:
• Improve eligibility determination notice language for individuals found ineligible for
Medicaid/CHIP/BHP so that they are aware that the Medicaid/CHIP/BHP agency will be
transferring their application to the Marketplace and that the Marketplace will be sending
them a notice with information on applying for coverage and financial assistance through
the Marketplace;
• Transmit all available contact information provided on the application or contained in the
beneficiary record for individuals on the application, including email addresses, phone
numbers, and beneficiary communication preferences, to the Marketplace. The Medicaid
Enterprise State Systems Officer assigned to each state will follow up with states’
technical teams to discuss any missing contact information from accounts that are
transferred to the Marketplace and will offer technical assistance as necessary to ensure
that accounts are transferred with complete contact information as quickly as feasible;
• Transmit all eligibility information the state has on an individual in the account transfer
to the Marketplace. Consider including notice language to beneficiaries that includes
contact information for Navigator and assister programs which can help them with the
transition to the Marketplace; and
• Work with community-based organizations that comprise the Administration for
Community Living (ACL)’s aging and disability networks, including Area Agencies on
Aging (AAAs), Centers for Independent Living (CILs), and Protection and Advocacy
organizations (P&As), as well as beneficiary advocates to ensure consumers get
information and assistance they need to navigate this transition.
For more information, states may refer to the July 2016 CIB, “Coordination of Eligibility and
Enrollment Between Medicaid, CHIP and the Federally Facilitated Marketplace (FFM or
“Marketplace”),” which is available to assist states in meeting their obligations to coordinate
eligibility and enrollment among insurance affordability programs and the account transfer
process. 20
VII. Monitoring State Progress and Corrective Action
CMS will monitor states’ progress in meeting the timelines and completing required eligibility
and enrollment actions described in this letter. Under the authority in sections 1902(a)(6) and
1902(a)(75) of the Act and 42 C.F.R. § 431.16, all states will be expected to submit data
20 CMCS Informational Bulletin, “Coordination of Eligibility and Enrollment Between Medicaid, CHIP and the Federally
Facilitated Marketplace (FFM or “Marketplace”),” (July 2016). Available at: https://www medicaid.gov/federal-policy-
guidance/downloads/cib072516.pdf.
Page 29 – State Health Official
demonstrating progress in completing pending applications and initiating the state’s total
caseload of renewals, along with the disposition of renewals. States will be required to submit
baseline data to CMS and report additional data on a monthly basis, for a minimum of 14
months. Where reported data indicate that states are not meeting timelines described in this
letter, or in circumstances where data demonstrate other potential compliance issues, including
potential erroneous disenrollments of eligible beneficiaries, states may be expected to report
additional data and/or report information more frequently. CMS will identify the data elements
to be reported and provide a reporting template for states to use.
In addition, states that do not resolve their pending eligibility and enrollment actions within the
timelines specified may be required to separately submit a corrective action plan to CMS
outlining strategies and a timeline to come into compliance with federal requirements.
VIII. PERM or MEQC Programs
CMS will not consider eligibility and enrollment actions that are delayed due to the PHE as
untimely for purposes of the PERM or MEQC programs if such actions are initiated within the
timelines detailed in this letter and completed before the end of the 14th month once the state
begins its unwinding period. States with an approved section 1902(e)(14)(A) waiver, that are
compliant with the parameters outlined in Section V.A. of this SHO letter, shall be not be
considered in violation of Medicaid statute and regulations for purposes of PERM and MEQC
reviews.
IX. Closing
CMS shares states’ goal of ensuring that eligible individuals remain enrolled in Medicaid, CHIP,
and/or BHP coverage and that individuals who are no longer eligible are able to transition
seamlessly to other coverage options for which they are eligible, including Marketplace
coverage. CMS also remains interested in hearing state and stakeholder feedback and concerns
as states plan for the eventual end of the PHE and the continuous enrollment condition, and the
return to routine operations. We are committed to providing states with updated guidance and
resources, as appropriate, as well as ongoing technical assistance necessary for states to complete
eligibility and enrollment work as described in this letter. Please submit any additional requests
for technical assistance to your CMS State Lead.
Sincerely,
Daniel Tsai
Deputy Administrator and Director
Cc:
National Association of Medicaid Directors
National Academy for State Health Policy
Page 30 – State Health Official
National Governors Association
American Public Human Services Association
Association of State and Territorial Health Officials
Council of State Governments
National Conference of State Legislatures
Academy Health
National Association of State Alcohol and Drug Abuse Directors
Appendix A: 12-Month Unwinding Timeline
Note: The options in this graphic are illustrative of when a state may begin its 12-month unwinding period when the PHE eventually ends and
are based on a state with a 75-day renewal processing timeline for a cohort of individuals. There will be variation depending on individual
state renewal processing timelines.
The contents of this document do not have the force and effect of law and are not meant to bind the public in any way, unless specifically incorporated into a contract. This document is
intended only to provide clarity to the public regarding existing requirements under the law.
Page 32 – State Health Official
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Appendix B: Strategies to Promote Continuity of Coverage and Mitigate Churn
States will need to consider strategies that ensure eligible individuals remain enrolled and allow
states to efficiently complete outstanding work. As states develop their unwinding operational
plans, they should identify where there is a risk that eligible individuals may lose coverage in
their current and planned processes and adopt strategies that mitigate particular risks in the state.
The following are examples of strategies states may adopt to promote continuous coverage and
reestablish communications with beneficiaries.
A. Promote Continuous Coverage for Eligible Individuals
Provide Continuous Eligibility to Maintain Coverage for Eligible Individuals
Under continuous eligibility, beneficiaries retain eligibility for a period, up to 12 months, elected
by the state. A beneficiary for whom continuous eligibility applies generally retains eligibility,
regardless of changes in circumstances, for the duration of the continuous eligibility period
elected by the state. Adopting continuous eligibility for some or all populations can ease the
burden on states during the unwinding period by relieving the state of any need to conduct a
redetermination based on changes in circumstances after a beneficiary has been renewed for
coverage during the unwinding period, until the next regularly-scheduled renewal. This would
ensure that the state would only need to take action on the beneficiary’s case once during the
unwinding period.
Under 42 C.F.R. §§ 435.926 and 457.342, a state may provide up to 12 months of continuous
eligibility in Medicaid and CHIP for children who are under age 19 or under a younger age
specified by the state. This option provides the state with the authority generally to not act on
changes in circumstances for children during the continuous eligibility period. 21 States
implementing continuous eligibility in Medicaid must apply the policy to all children under the
age specified by the state who are eligible under all mandatory and optional categorically needy
groups under Section 1902(a)(10)(A) of the Act.
Action: To elect this option, states must submit a SPA.
States can adopt income and resource disregards under the authority of section 1902(r)(2) of the
Act to provide continuous eligibility for most adult beneficiaries enrolled on the basis of being
age 65 or older, living with a disability or blindness, or need for long-term care services and
supports. States that would like to provide continuous eligibility for MAGI-based adult
beneficiaries may consider submitting a section 1115 demonstration waiver application.
Action: States interested in pursuing a section 1902(r)(2) disregard for individuals eligible on a
non-MAGI basis must submit a SPA. States interested in pursuing a section 1115 demonstration
to provide continuous eligibility should contact their state lead or section 1115 demonstration
project officer.
21 There are several exceptions specified in the regulations to this general rule, in which states are expected to act on changes in a
child’s circumstances, including children turning age 19, changes in state residency, death, or voluntary termination, and, for
children enrolled in CHIP, becoming eligible for Medicaid.
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Extend Postpartum Coverage in Medicaid and CHIP
Sections 9812 and 9822 of the ARP give states a new option to provide 12-months of extended
postpartum coverage to individuals who were enrolled in Medicaid or CHIP while pregnant.
Individuals eligible for extended postpartum coverage are entitled to continuous eligibility
despite changes in circumstances that would otherwise affect eligibility during the extended
postpartum period. States may adopt this option beginning April 1, 2022, and, as noted earlier in
this letter, states may wish to deprioritize work on actions for pregnant and postpartum
individuals during the 12-month unwinding period until the extended postpartum coverage
option becomes effective and the state has taken steps to adopt it. States may refer to SHO #21-
007 “Improving Maternal Health and Extending Postpartum Coverage in Medicaid and CHIP,”
for more information on implementing this option. 22
Action: To elect this option, states must submit a Medicaid and CHIP SPA.
Maximize Success of Ex Parte Renewals Through Use of Expanded Data Sources
States must attempt to renew eligibility based on available information (ex parte renewal) for all
beneficiaries as required at 42 C.F.R. § 435.916(a)(2) and (b). States may expand the number
and type of data sources used during the ex parte process as well as create a data source
hierarchy to prioritize sources that provide the most recent and reliable data. States can also
adopt policies during the unwinding period (or longer) to maximize the use of the ex parte
renewal processes and increase the rate at which beneficiaries’ eligibility may be renewed using
information available to the state and without requiring a renewal form or other documentation
from beneficiaries. For example, states may rely on information in the case record which the
state determines is highly unlikely to change, especially for particular populations (such as
income for children eligible for coverage under section 1902(e)(3) of the Act (“Katie Beckett
group”) without regard to their parents’ income, beneficiaries dually eligible for Medicare and
Medicaid, or beneficiaries over a specified age), as reliable information even if the state requires
documentation of income not verified electronically from other beneficiaries. States pursuing
this option may need to update their verification plan.
Action: No SPA is needed, but updated verification plans for MAGI-based determinations must
be submitted to CMS.
Adopt MAGI Renewal Policies for Non-MAGI Renewals to Minimize Beneficiary Burden
States that currently renew eligibility more frequently than once every 12 months for some or all
of their non-MAGI beneficiaries may elect to renew eligibility for some or all of their non-
MAGI populations only once every 12 months. Extending the renewal timeframe may also
support other state priorities, such as increasing access to home and community-based services,
by reducing the frequency in which beneficiaries must respond to state requests.
Action: To elect this option, states must submit a SPA.
Under 42 C.F.R. § 435.916(b), states may also adopt renewal procedures required for MAGI
beneficiaries under § 435.916(a)(3) for non-MAGI beneficiaries. Such procedures include using
22 CMS State Health Official Letter #21-007, “Improving Maternal Health and Extending Postpartum Coverage in Medicaid and
the Children’s Health Insurance Program (CHIP),” December 7, 2021. Available at: https://www medicaid.gov/federal-policy-
guidance/downloads/sho21007.pdf.
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a pre-populated renewal form for beneficiaries whose renewal cannot be completed using only
information available to the state; providing a minimum of 30 days for beneficiaries to respond;
and providing a reconsideration period for beneficiaries whose eligibility is terminated at
renewal for failure to return their renewal form or other required information, but who
subsequently do so after their eligibility is terminated, without requiring the submission of a new
full application.
Action: States may need to submit a SPA for CMS approval to implement these options or
update internal procedures.
Use Information from Other Programs like SNAP and Temporary Assistance for Needy Families
(TANF) to Renew Eligibility
States have several options to leverage information from programs like SNAP or TANF to verify
eligibility and facilitate renewals in a manner that minimizes beneficiary burden. Some of these
options will require states to submit a SPA. As noted in Section V.A. of this SHO letter, states
may also use a temporary 1902(e)(14)(A) waiver. Under the Express Lane Eligibility authority
at sections 1902(e)(13) and 2107(e)(1) of the Act, states are permitted to rely on findings from an
entity designated by the state to determine whether a child satisfies one or more factors of
eligibility for Medicaid or CHIP, including income. States may also adopt the facilitated
enrollment SPA option for adults and children. This option allows states to rely on income
determinations made by another program if the state is certain the individual would be income-
eligible using MAGI-based methods. Both the Express Lane Eligibility and facilitated
enrollment SPA options may be used at application, renewal, or both. States interested in these
options may refer to the SHO #10-003, “Express Lane Eligibility” 23 and the SHO #15-001
“Policy Options for Using SNAP to Determine Medicaid Eligibility and an Update on Targeted
Enrollment Strategies” for additional guidance. 24
States may also use verified information from other state and federal programs to verify the
financial eligibility of an individual. For example, SNAP wage or other income data captured in
an integrated eligibility and enrollment system may be used to verify continued eligibility at
renewal or a redetermination based on a change in circumstances.
Action: States electing to use other program information as a reliable data source should update
their verification plans. Changes made to MAGI verifications plans must be submitted to CMS.
Modify or Suspend Periodic Data Matching
States can improve coverage retention and reduce churn between regular renewals by suspending
periodic data matching or modifying the approach by reducing the frequency with which
periodic data matches are conducted. This strategy will avoid or reduce the administrative
burden associated with redeterminations between regular renewals during the 12-month
unwinding period, including the need to process new applications submitted by beneficiaries
terminated because they did not respond to a mid-year request for additional information.
23 CMS State Health Official Letter # 10-003, “Express Lane Eligibility Option,” February 4, 2020. Available at
https://www.medicaid.gov/sites/default/files/Federal-Policy-Guidance/downloads/SHO10003.PDF.
24 CMS State Health Official Letter # 15-001, “Policy Options for Using SNAP to Determine Medicaid Eligibility and an Update
on Targeted Enrollment Strategies,” August 31, 2015. Available at https://www medicaid.gov/federal-policy-
guidance/downloads/sho-15-001.pdf.
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Action: States need to update their verification plans in order to suspend or reduce the frequency
of periodic data matches. Changes made to MAGI verifications plans must be submitted to
CMS.
Extend Beneficiary Response Times
States are strongly encouraged to review their policies regarding the amount of time beneficiaries
are given to provide requested information and to provide additional time as appropriate.
Extending the timeframe for beneficiaries to respond to requests for information will minimize
the risk that beneficiaries lose coverage for procedural reasons. As discussed in the “Medicaid
and CHIP Renewal Requirements” CIB, we believe it would be reasonable for states to allow
beneficiaries 30 days to respond and provide any necessary information needed to verify
eligibility. 25
Action: Update internal state procedures; states do not need to submit a SPA for CMS approval
to implement this option.
Offer a Reconsideration Period for Coverage Losses following Changes in Circumstances
States may offer a minimum 90-day reconsideration period, similar to the reconsideration period
provided for MAGI beneficiaries at renewal under 42 C.F.R. §§ 435.916(a)(3)(iii) and 457.343,
for beneficiaries whose eligibility has been terminated for failure to respond to a request for
information needed to redetermine eligibility following a change in circumstances, if the
individual subsequently returns the needed information. Offering a reconsideration period
allows states to reconsider an individual’s eligibility without requiring the individual to fill out a
new application. The required information returned within the reconsideration period serves as
an application. If adopted, a determination or denial of eligibility based on the returned
information must be made consistent with timeliness standards specified in § 435.912 or §
457.340(d), as applicable. In Medicaid, retroactive eligibility would be available, consistent with
§ 435.915(a), to provide coverage for up to three months prior to the date the information was
returned. States would also need to ensure they collect any additional information from the
individual that is not available to the state but required at application, such as a signature.
Action: Update internal state procedures; states do not need to submit a SPA for CMS approval
to implement this option.
B. Reestablish Communication and Conducting Outreach with Beneficiaries
CMS recognizes that states may have had minimal or no contact with many beneficiaries for an
extended period, as many have not experienced a periodic renewal of eligibility in several years
due to the continuous enrollment condition. There is an inherent risk that eligible individuals will
lose coverage after the continuous enrollment condition expires because they have a new address
or other contact information, which has not been updated with the state. Further, beneficiaries
may not understand that renewals of eligibility are resuming, or know when their renewal may
occur during the 12-month unwinding period. States will need to employ a variety of strategies
25 CMCS Informational Bulletin, “Medicaid and Children’s Health Insurance Program (CHIP) Renewal Requirements,”
(December 2020). Available at: https://www medicaid.gov/federal-policy-guidance/downloads/cib120420.pdf.
Page 37 – State Health Official
to reestablish communication with beneficiaries and engage in outreach efforts to ensure eligible
individuals maintain coverage.
Update Beneficiary Contact Information
All states should take steps during the PHE to update beneficiary contact information to prevent
coverage losses for eligible individuals and remind beneficiaries that they may report updated
information online, by phone, by mail, or in person. Maintaining complete and accurate contact
information is critical to ensuring beneficiaries get renewal forms and program information
timely in order to promote retention of coverage or facilitate seamless coverage transitions to
BHP or the Marketplace, as appropriate. States can begin sending reminders to beneficiaries to
update their contact information and identify individuals for whom the state may have outdated
information.
States are also encouraged to work with MCOs to establish a process to engage in outreach to
beneficiaries to update their contact information and use information made available to the
Medicaid agency by MCOs and/or establish processes to receive updated information on an
ongoing basis from MCOs. When updated address information is received by the state from
managed care plans, states may update the beneficiary record with the new address, provided that
it is an in-state address and provided that the state sends a notice to the address on file with the
state and provides the individual with a reasonable period of time to verify the accuracy of the
new contact information. States are also encouraged to contact the beneficiary through other
modalities, such as via telephone, electronic notice, email, or text message, and to send
information to the new address, where feasible. If the beneficiary does not respond to the
mailing to verify the accuracy of the contact information provided by the managed care plan or if
the beneficiary responds to the outreach through the other modalities and confirms the new
address on file with the MCO, the state may update the beneficiary record with the new contact
information from the managed care plan. Critically, states should ensure that managed care
plans only provide updated contact information received directly from or verified by the
beneficiary, and not from a third party or other source. Information provided from such sources
is not considered reliable. For strategies centered on working with MCOs, states may refer to the
“Overview of Strategic approach to Engaging Managed Care Plans to Maximize Continuity of
Coverage as States Resume Normal Eligibility and Enrollment Operations” resource available on
Medicaid.gov. 26 As noted in Section V.A. of this SHO letter, states may also request temporary
authority under section 1902(e)(14)(A) of the Act if systems or operational limitations prevent
them from sending the beneficiary a notice to the address on file prior to updating the
beneficiary’s record with new contact information provided by an MCO.
States are strongly encouraged to establish linkages with the U.S. Postal Service (USPS)
National Change of Address (NCOA) database as they prepare to return to normal operations.
The NCOA is a set of data that includes the permanent change-of-address records maintained by
the USPS. Every time an individual or family moves and submits a change-of-address form to
their local post office, their new address is recorded in the NCOA database. States can establish
agreements with USPS to gain access to the NCOA database in order to utilize these address
26 “Overview of Strategic approach to Engaging Managed Care Plans to Maximize Continuity of Coverage as States Resume
Normal Eligibility and Enrollment Operations,” (December 2021). Available at
https://www.medicaid.gov/sites/default/files/2021-12/health-plan-strategy-12062021.pdf.
Page 38 – State Health Official
changes. States are also encouraged to leverage address information received from USPS when
mail is returned to the state with an in-state forwarding address. 27 Under USPS forwarding mail,
an individual can elect to have their mail forwarded to their new address. To mitigate against
errors, USPS implements controls, which include charging a fee by credit card to validate online
change of address (COA) requests, requiring individuals submitting a hardcopy COA request to
verify that they understand an unauthorized COA order is a federal offense, and sending two
confirmation letters (to the new and old address) to authenticate the order.
Given the increased likelihood of individuals moving during the PHE, leveraging the NCOA and
USPS in-state forwarding address information provides states with a streamlined tool to improve
address accuracy and locate beneficiaries who would otherwise be at risk for a procedural
termination during the unwinding period. State agencies may treat information obtained from
the NCOA and USPS returned mail with an in-state forwarding address as reliable and update
the beneficiary record with the new contact information, provided that the state conducts the
following outreach.
When updated address information is received by the state from NCOA or from USPS returned
mail with an in-state forwarding address, states must send a notice to the address on file with the
state and provide the individual with a reasonable period of time to verify the accuracy of the
new contact information. States are also encouraged to contact the beneficiary through other
modalities, such as via telephone, electronic notice, email, or text message, and to send
information to the new address, where feasible. If the beneficiary does not respond to verify the
accuracy of the contact information provided by NCOA or from USPS returned mail or if the
beneficiary responds to the outreach through the other modalities and confirms the new address,
the state may update the beneficiary record with the new contact information. States pursuing
this option need to update their verification plan and may use the “Other” electronic data section
to indicate how the state will use NCOA. Please refer to Appendix C of this section for a
detailed discussion on processing returned mail, including mail returned with an out-of-state or
with no forwarding address.
Use Multiple Modalities to Reach Beneficiaries
While beneficiaries must be able to communicate with the state agency and return eligibility and
enrollment information online, by phone, by mail, or in person, often states rely entirely on mail
to facilitate communication with beneficiaries. States are required to communicate with
beneficiaries through electronic notices pursuant to an individual’s election under 42 C.F.R.
§ 435.918 and are encouraged to explore and adopt consumer communication and outreach
strategies through a variety of modalities, including phone and text messaging. States are also
encouraged to pursue using additional methods of outreach beyond mail to follow up in specific
situations such as when there are outstanding requests for information, incomplete renewal
forms, or returned mail.
Update Notices and Other Consumer Facing Messages
States are encouraged to review existing applicant and beneficiary notices and communications
and make modifications needed to effectively convey key messages in plain language, consistent
with 42 C.F.R. §§ 435.905 and 435.917(a). Notices must provide clear instructions on how to
27 Please refer to Appendix C of this section for additional information on processing returned beneficiary mail.
Page 39 – State Health Official
complete renewal forms or respond to requests for information as well as explain what
information is needed for the state to determine eligibility. Notices should advise beneficiaries
to keep their contact information up-to-date.
Review Communication Strategies for Individuals who have LEP and People with Disabilities.
States are reminded that program information on Medicaid and CHIP must be provided in plain
language and in a manner that is accessible to individuals who have LEP and for people with
disabilities, as required at 42 C.F.R. §§ 435.905(b) and 457.110(a). Applicants and beneficiaries
with LEP must be able to access information about Medicaid and CHIP, including through use of
oral interpretation and written translation. States should ensure that written notices, applications,
and renewal forms are translated into multiple languages and that such information is otherwise
available to individuals through oral interpretation (see §§ 435.206(e), 435.907(g), 435.916(g),
435.917(a), 435.956(b), and 457.340(e)). States may consider providing qualified oral
interpretation by hiring qualified bilingual staff who speak frequently spoken non-English
languages within the state’s population (e.g., Spanish), partnering with community-based
organizations with qualified interpretation services, and providing qualified interpreters by
telephone, consistent with 42 C.F.R. § 435.901 and 45 C.F.R. Part 92. Language services needed
by individuals who have LEP must be provided free of charge in accordance with 42 C.F.R. §§
435.905(b)(3) and 457.110(a). States must inform individuals who have LEP how to access the
language services that are available, including through use of taglines (i.e., a short statement
written in non-English languages that indicate the availability of language assistance services
free of charge). 28
To provide people with disabilities accessible information, states must take appropriate steps to
ensure that communications with applicants, beneficiaries and members of the public are as
effective as communications with others. This includes providing appropriate auxiliary aids and
services at no cost to qualified individuals with disabilities where necessary to afford an equal
opportunity to participate in, and enjoy the benefits of, a service, program, or activity, in
accordance with 42 C.F.R. § 435.905(b), federal law and implementing regulations. 29
For additional detail on providing accessible information to individuals with LEP and people
with disabilities, see 45 C.F.R. Part 92.
Utilize MCOs and Stakeholders to Conduct Outreach
Close collaboration between states and contracted managed care entities, social service
organizations, and other stakeholders can help ensure eligible individuals retain coverage in
Medicaid and CHIP and ease transitions for individuals eligible for coverage through the
Marketplace. States are strongly encouraged to engage with their contracted managed care
entities as they develop their unwinding operational plans and identify clear roles and ways in
which health plans can assist with outreach and enrollment efforts. States are encouraged to
28 See also Title VI of the Civil Rights Act of 1964 and its implementing regulations at 45 C.F.R. Part 80, and Section 1557 of the
Affordable Care Act and its implementing regulations at 45 C.F.R. Part 92.
29 See Section 504 of the Rehabilitation Act of 1973 and HHS’s implementing regulations at 45 C.F.R. Part 84, Title II of the
Americans with Disabilities Act and DOJ’s implementing regulations at 28 C.F.R. Part 35, specifically 28 C.F.R. § 35.160, and
Section 1557 of the Affordable Care Act and its implementing regulations at 45 C.F.R. Part 92.
Page 40 – State Health Official
provide contracted managed care entities with a monthly list of individuals who are due for
renewal to allow health plans to provide secondary outreach to ensure individuals complete the
renewal process. This will be especially useful during the 12-month unwinding period as states
are redistributing renewals and beneficiaries and health plans may not otherwise know which
cohort of individuals is due for renewal in each month.
Engage Other Stakeholders
States are also strongly encouraged to engage with other key stakeholders (e.g., providers,
beneficiary advocacy groups) and with the Indian Health Service, Tribes and Tribal
organizations, and urban Indian organizations (ITUs) located in your state on an ongoing basis.
Communicating with stakeholders and ITUs regularly will help identify opportunities to leverage
their support with assisting beneficiaries in updating eligibility information and ensure that they
understand the need to respond to states’ notices and complete the renewal process.
C. Consider Additional Strategies
CMS has identified several additional policies and operational strategies to streamline workflow,
strengthen renewal processes to ensure eligible beneficiaries remain enrolled in coverage and
facilitate coverage transitions between programs, and enhance oversight of eligibility and
enrollment operations. These strategies are listed in the November 2021 tool, “Strategies States
and the U.S. Territories Can Adopt to Maintain Coverage for Eligible Individuals as They Return
to Normal Operations.” 30 States are strongly encouraged to review available strategies described
in this letter as well as the November 2021 tool and take any steps needed to ensure that those
strategies the state wants to implement are in place before the state begins its unwinding period.
30 “Strategies States and the U.S. Territories Can Adopt to Maintain Coverage of Eligible Individuals as They Return to Normal
Operations,” November 2021. Available at: https://www medicaid.gov/state-resource-center/downloads/strategies-for-covrg-of-
indiv.pdf.
Appendix C: Processing Returned Mail
States should take steps during the PHE to establish procedures and update policy manuals to
ensure that staff know the specific actions they should take in response to returned beneficiary
mail, as depicted in Graphic 1, below. States are encouraged to create a specialized and
dedicated unit (either centralized or within each region/county) for processing returned mail from
the USPS.
Receipt of returned mail indicates a potential change in circumstances that may impact eligibility
(i.e., state residency). However, returned mail does not necessarily mean a move out of state or
that a beneficiary is ineligible. At the same time, if a state does not obtain updated contact
information when mail is returned, beneficiaries are at high risk for procedural termination. For
all returned beneficiary mail, states are strongly encouraged to attempt to contact the beneficiary
by mail and send notices to both the current address on file and the forwarding address, if one is
provided, requesting that the beneficiary confirm the new address provided by USPS. States also
are strongly encouraged to attempt to contact the beneficiary using one or more other modalities,
such as by phone, electronic notice, email, or text messaging as permissible. If a state is unable
to locate the beneficiary by mail or by using another modality, states should check data sources
for updated address information (e.g., MCOs, the state agency that administers SNAP or TANF,
the Department of Motor Vehicles records, or the USPS NCOA database). More information on
state flexibilities to update addresses based on MCO and NCOA data is included in Appendix B
of this SHO letter (See Appendix B, Section B. “Reestablish Communication and Conducting
Outreach with Beneficiaries”).
If the state’s attempts to locate the beneficiary to confirm the contact information are
unsuccessful, the action states need to take upon receipt of returned mail will depend on whether
the USPS has provided a new in-state address, a new out-of-state address, or no new address on
the returned mail. States must take steps to locate beneficiaries who may have moved prior to
taking any adverse action. Mail returned with an in-state forwarding address is not an indication
of a change affecting eligibility. Nonetheless, it is important for the state to confirm the accuracy
of the information to ensure future ability to contact the beneficiary. Because this is a change
that does not affect eligibility, states are strongly encouraged to verify the information by
sending notice by mail to the current address and also to the forwarding address and attempt to
contact the beneficiary using one or more other modalities. States may accept the USPS in-state
forwarding address and update the beneficiary’s record provided that the state first sends a notice
to the current address on file confirming the accuracy of the information. A state may not
terminate coverage if the state does not receive a response to the request for confirmation of an
in-state address change, even if the state does not update the beneficiary’s record with the new
in-state address.
When a beneficiary’s mail is returned to the state agency with an out-of-state address, the state
must send notice and attempt to contact the beneficiary to confirm the accuracy of the
information and verify continued state residency. Because the out-of-state address may be an
indication of a change in residency, the state must send notice consistent with the beneficiary’s
elected format, either electronically or by mail, to the current address the state has on file,
requesting that the beneficiary confirm the address and state residency. States are strongly
encouraged also to send notice to the out-of-state forwarding address and/or other address
provided by a third party, attempt to locate the beneficiary using other electronic or telephonic
The contents of this document do not have the force and effect of law and are not meant to bind the public in any way, unless
specifically incorporated into a contract. This document is intended only to provide clarity to the public regarding existing
requirements under the law.
Page 42 – State Health Official
modalities, and by checking third-party data sources for more recent address information. If the
beneficiary does not respond with the requested information, or the information provided does
not establish the beneficiary’s continued state residency, the state must provide advance notice of
termination or other adverse action and fair hearing rights consistent with 42 C.F.R. §§ 431.206-
214.
We encourage states attempt to locate beneficiaries whose mail is returned to the state agency
without a forwarding address consistent with the steps described above prior to discontinuing
coverage based on a determination that a beneficiary’s whereabouts are unknown. If a
beneficiary cannot be located, and there is no forwarding address, the state may terminate
eligibility in accordance with regulations at 42 C.F.R. part 431, subpart E. If a beneficiary’s
whereabouts become known prior to the beneficiary’s originally-scheduled renewal date, the
state must reinstate coverage in accordance with regulations at § 431.231(d).
Graphic 1. Agency Action Required by Three Types of Returned Mail
The contents of this document do not have the force and effect of law and are not meant to bind the public in any way, unless specifically incorporated into a contract. This document is
intended only to provide clarity to the public regarding existing requirements under the law.
Appendix D: Related CMS Guidance
Guidance Related to Returning to Routine Operations after the PHE Ends
• State Health Official Letter (SHO) #20-004, “Planning for the Resumption of
Normal State Medicaid, Children’s Health Insurance Program (CHIP), and Basic
Health Program (BHP) Operations Upon Conclusion of the COVID-19 Public
Health Emergency” (“December 2020 SHO”): Provides guidance to states on planning
for the eventual return to regular operations, including ending temporary authorities when
the PHE concludes, making temporary changes permanent in certain circumstances,
procedures for ending coverage and policies authorized under expiring FFCRA
provisions, and addressing pending eligibility and enrollment actions that developed
during the PHE.
States may access the December 2020 SHO at https://www.medicaid.gov/federal-policy-
guidance/downloads/sho20004.pdf.
• State Health Official Letter (SHO) #21-002, “Updated Guidance Related to
Planning for the Resumption of Normal State Medicaid, Children’s Health
Insurance Program (CHIP), and Basic Health Program Operations Upon
Conclusion of the COVID-19 Public Health Emergency (“August 2021 SHO”):
Updates guidance in the December 2020 SHO to provide states 12-months after the PHE
ends to complete pending eligibility and enrollment work and ensures states renew
eligibility for all beneficiaries prior to taking any adverse action.
States may access the August 2021 SHO at https://www.medicaid.gov/federal-policy-
guidance/downloads/sho-21-002.pdf.
Medicaid and CHIP Renewal and Account Transfer Requirements
• CMCS Informational Bulletin (CIB), “Medicaid and CHIP Renewal Requirements”
(“Renewal CIB”): Reminds states about current federal requirements and expectations
codified in existing regulations at 42 C.F.R. §§ 435.916 and 457.343 for completing
redeterminations of eligibility for Medicaid and CHIP beneficiaries. These requirements
are intended to ease the administrative burden on states and beneficiaries by limiting
requests for information to information needed to determine eligibility, ensuring
beneficiary eligibility is assessed on all bases before determining an individual is
ineligible and promoting seamless transitions of coverage, and minimizing the churn of
beneficiaries on and off Medicaid and CHIP coverage for procedural reasons.
States may access the Renewal CIB at https://www.medicaid.gov/federal-policy-
guidance/downloads/cib120420.pdf.
• CMCS Informational Bulletin Coordination of Eligibility and Enrollment Between
Medicaid, CHIP, and the Federally Facilitated Marketplace (FFM or
“Marketplace”) (“Account Transfer CIB”): Reminds states about federal requirements
related to coordination of eligibility and enrollment among insurance affordability
programs and the account transfer process. These requirements are intended to ensure
determinations of eligibility and enrollment in the appropriate program are made
promptly and without delay.
The contents of this document do not have the force and effect of law and are not meant to bind the public in any way, unless
specifically incorporated into a contract. This document is intended only to provide clarity to the public regarding existing
requirements under the law.
Page 45 – State Health Official
States may access the Account Transfer CIB at https://www.medicaid.gov/federal-policy-
guidance/downloads/cib072516.pdf.
Strategies to Promote Continuity of Coverage and Prevent Inappropriate Terminations
• Overview of Strategic Approach to Engaging Managed Care Plans to Maximize
Continuity of Coverage as States Resume Normal Eligibility and Enrollment
Operations: Provides states strategies to work with health plans to update beneficiary
contact information, conduct outreach, support individuals enrolled in Medicaid during
renewal and assist individuals transitioning to the Marketplace.
States may access the “Overview of Strategic approach to Engaging Managed Care Plans
to Maximize Continuity of Coverage as States Resume Normal Eligibility and
Enrollment Operations” resource at https://www.medicaid.gov/sites/default/files/2021-
12/health-plan-strategy-12062021.pdf.
• Strategies States and the U.S. Territories Can Adopt to Maintain Coverage of
Eligible Individuals as They Return to Normal Operations: Provides states a list of
policy and operational strategies that states can implement to support unwinding
activities at the end of the COVID-19 PHE in order to ensure continuous coverage for
eligible beneficiaries and facilitate coverage transitions for individuals eligible for other
forms of coverage.
States may access the “Strategies States and the U.S. Territories Can Adopt to Maintain
Coverage of Eligible Individuals as They Return to Normal Operations” tool at
https://www.medicaid.gov/state-resource-center/downloads/strategies-for-covrg-of-
indiv.pdf.
• Medicaid and CHIP Coverage Learning Collaborative: Ensuring Continuity of
Coverage and Preventing Inappropriate Terminations for Eligible Medicaid and
CHIP Beneficiaries Part 1 (“Preventing Inappropriate Terminations of Coverage Part 1
deck”): Provides guidance and strategies for states to address workflow processes,
leverage other program data and strengthen consumer outreach and communication to
promote continuity of coverage.
States may access the Preventing Inappropriate Terminations of Coverage Part 1 deck at
https://www.medicaid.gov/state-resource-center/downloads/mac-learning-
collaboratives/ensrng-contnty-cvrg-prvntng-inprprte-trmntns-part-1.pdf.
• Medicaid and CHIP Coverage Learning Collaborative: Ensuring Continuity of
Coverage and Preventing Inappropriate Terminations for Eligible Medicaid and
CHIP Beneficiaries Part 2 (“Preventing Inappropriate Terminations of Coverage Part 2
deck”): Provides guidance and strategies for states to maintain communication with
beneficiaries and address returned mail.
Page 46 – State Health Official
States may access the Preventing Inappropriate Terminations of Coverage Part 2 deck at
https://www.medicaid.gov/state-resource-center/downloads/mac-learning-
collaboratives/ensrng-contnty-cvrg-prvntng-inprprte-trmntns-part-2.pdf.
• Medicaid and CHIP Coverage Learning Collaborative: Connecting Kids to
Coverage: State Outreach, Enrollment and Retention Strategies. Highlights effective
and practical strategies to improve state outreach, enrollment, and renewal activities.
States may access “Connecting Kids to Coverage: State Outreach, Enrollment, and
Retention Strategies” at https://www.medicaid.gov/state-resource-center/downloads/kids-
coverg-outreach-enrolmnt-retention-strategies.pdf.
Tools for Effective Communication of Eligibility Determinations
• Medicaid and CHIP continuous Coverage Unwinding Phase 1: Plan & Educate
(Unwinding Communications Toolkit): Provides important information to help inform
people with Medicaid and CHIP about steps they need to take to renew coverage.
States may access the Unwinding Communications Toolkit at
https://www.medicaid.gov/resources-for-states/downloads/unwinding-comms-toolkit.pdf.
• Effective Communication of Eligibility Determinations: Provides states a set of tools
to assist in the development of key messages, including model notices.
States may access the Effective Communication of Eligibility Determinations tools at
https://www.medicaid.gov/resources-for-states/mac-learning-collaboratives/expanding-
coverage-under-medicaid-and-chip/index.html.
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