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This final rule streamlines eligibility and enrollment processes for all Medicaid and Children’s Health Insurance Program (CHIP) populations and creates new enrollment pathways to maximize enrollment and retention of eligible individuals.

Statement of Need:

Since the implementation of the Affordable Care Act (ACA), CMS has made improvements in streamlining the Medicaid and CHIP application, eligibility determination, enrollment, and renewal processes. Simplifying enrollment in Medicaid and CHIP coverage is a foundational step in efforts to address health disparities for low-income individuals.  However, gaps remain in States’ ability to seamlessly process beneficiaries’ eligibility and enrollment in order to maximize coverage. This rule will provide States with the tools they need to reduce unnecessary barriers to enrollment in Medicaid and CHIP and to keep eligible beneficiaries covered.

Summary of the Legal Basis:

This rule responds to the January 28, 2021, Executive Order on Strengthening Medicaid and the Affordable Care Act.  It addresses components of title XIX and title XXI of the Social Security Act and several sections of the Patient Protection and Affordable Care Act (Pub. L. 111-148) and the Health Care and Education Reconciliation Act of 2010 (Pub. L. 111-152), which amended and revised several provisions of the Patient Protection and Affordable Care Act.

Alternatives:

In developing the policies contained in this rule, we considered numerous alternatives to the presented proposals, including maintaining existing requirements.  These alternatives will be described in the rule.

Anticipated Costs and Benefits:

The provisions in this rule will streamline Medicaid and CHIP enrollment processes and ensure that eligible beneficiaries can maintain coverage.  While states and the Federal Government may incur some initial costs to implement these changes, this rule aims to reduce administrative barriers to enrollment, which is expected to reduce administrative costs over time.  The provisions in this rule are designed to increase access to affordable health coverage, and we believe that the benefits will justify any costs.  Additionally, through clear and consistent requirements for the timely renewal of eligibility for all beneficiaries, this rule promotes program integrity, thereby protecting taxpayer funds at both the state and federal levels.  As we move toward publication, estimates of the cost and benefits of these provisions will be included in the rule.

Risks:

We anticipate that the provisions of this rule will further the administration’s goal of strengthening Medicaid and making high-quality health care accessible and affordable for every American.  At the same time, through clear and consistent requirements for conducting regular renewals of eligibility, acting on changes reported by beneficiaries and maintaining thorough recordkeeping on these activities, this rule will reduce the risk of improper payments.