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HHS/CMS RIN: 0938-AS55 Publication ID: Fall 2016 
Title: Eligibility Notices, Fair Hearing and Appeal Processes for Medicaid, and Other Provisions Related to Eligibility and Enrollment for Medicaid and CHIP (CMS-2334-P2) 

This proposed rule proposes to implement provisions of the Medicaid statute pertaining to Medicaid eligibility and appeals. This proposed rule continues our efforts to provide guidance to assist States in implementing Medicaid and CHIP eligibility, appeals, and enrollment changes required by the Affordable Care Act.

Agency: Department of Health and Human Services(HHS)  Priority: Other Significant 
RIN Status: Previously published in the Unified Agenda Agenda Stage of Rulemaking: Proposed Rule Stage 
Major: No  Unfunded Mandates: No 
CFR Citation: 42 CFR 430    42 CFR 431    42 CFR 433    42 CFR 435    42 CFR 457   
Legal Authority: 42 U.S.C. 1302    Pub. L. 111-148   
Legal Deadline:  None

Statement of Need:

On January 22, 2013, we published a proposed rule entitled "Essential Health Benefits in Alternative Benefit Plans, Eligibility Notices, Fair Hearing and Appeal Processes for Medicaid and Exchange Eligibility Appeals and Other Provisions Related to Eligibility and Enrollment for Exchanges, Medicaid and CHIP, and Medicaid Premiums and Cost Sharing" that proposed changes to provide states more flexibility to coordinate Medicaid and CHIP procedures related to eligibility notices, appeals, and other related administrative actions with similar procedures used by other health coverage programs authorized under the Affordable Care Act. We received a number of public comments on the proposed rule suggesting alternatives that we had not originally considered and did not propose. To give the public the opportunity to comment on those options, we are now proposing revisions related to those comments. In addition, we propose to make other corrections and modifications related to delegations of eligibility determinations and appeals, and appeals procedures. We have developed these proposals through our experiences working with states and Exchanges, and Exchange appeals entities operationalizing fair hearings.

Summary of the Legal Basis:

The Affordable Care Act extends and simplifies Medicaid eligibility. The rule proposes alternatives not included in the previously published January 22, 2013 proposed rule, based on public comments received.


The majority of Medicaid and CHIP eligibility provisions proposed in this rule serve to implement the Affordable Care Act. Therefore, alternatives considered for this rule were constrained due to the statutory provisions.

Anticipated Costs and Benefits:

While states will likely incur short-term increases in administrative costs, we do not anticipate that this proposed rule would have significant financial effects on state Medicaid programs. The extent of these initial costs will depend on current state policy and practices, as many states have already adopted the administrative simplifications addressed in the rule. In addition, the administrative simplifications proposed in this rule may lead to savings as states streamline their fair hearing processes, consistent with the processes used by the Marketplace, and implement timeliness and performance standards.


None. Delaying publication of this rule delays states from moving forward with implementing changes to Medicaid and CHIP, and aligning operations between Medicaid, CHIP and the Exchanges.

Action Date FR Cite
NPRM  11/00/2016 
Regulatory Flexibility Analysis Required: No  Government Levels Affected: State 
Federalism: No 
Included in the Regulatory Plan: Yes 
RIN Data Printed in the FR: No 
Related RINs: Split from 0938-AS27 
Agency Contact:
Judith Cash
Division Director, Division of Eligibility, Enrollment & Outreach
Department of Health and Human Services
Centers for Medicare & Medicaid Services
Center for Medicaid and CHIP Services, Mail Stop S2-01-16, 7500 Security Boulevard,
Baltimore, MD 21244
Phone:410 786-4473