Final Rule to Streamline Access to Medicaid

Introduction

On April 2, 2024, the Centers for Medicare and Medicaid Services (CMS) finalized a rule streamlining Medicaid eligibility and enrollment. The Streamlining Rule (“final rule”):

• Allows states to streamline the process for individuals living in the community to stay enrolled in Medicaid through spend-down and prospective budgeting of expenses, including home- and community-based service expenses; and
• Simplifies the processes for individuals enrolling in and staying on Medicaid

The final rule aimed to help people aged 65 and older and people with disabilities (included in a group known as the “non-MAGI” population), who have historically been left out of some efforts to simplify Medicaid processes that were put in place for the Medicaid Expansion population (referred to as the “MAGI population”).^[1] The final rule will come into effect over time, with some provisions already in effect.^[2] This issue brief summarizes the final rule’s changes to Medicaid, particularly for older adults.

In September 2023, CMS released a related final regulation focused on streamlined changes to Medicare Savings Programs^[3], and Justice in Aging summarized it in a brief entitled “Final Rule to Streamline Enrollment in Medicare Savings Programs.” Together, the September 2023 and the April 2024 final rules are referred to as the “streamlining rules.”

Table of Contents

Expanding when an individual can project costs when spending down to Medicaid eligibility

42 C.F.R. §§ 435.831; 436.831. This provision is currently in force. It is not changed by H.R. 1.

The final rule gives states the option to allow individuals living in the community to project their health and long-term care costs when determining their financial eligibility for Medicaid.^[5]

Currently, the majority of states cover a “medically needy” (also referred to as “spend down” or “share of cost”) population.^[6] As part of a medically needy group, individuals with income above the Medicaid eligibility limit can use medical expenses, nursing facility care expenses, and home and community-based services (HCBS) expenses to qualify for Medicaid.^[7] States have long had the authority to include future expenses for long-term care facility residents in determining eligibility for the medically needy population, allowing them to qualify for Medicaid prospectively.^[8]

Meanwhile, prior to the final rule, individuals residing in the community could not be determined eligible for Medicaid until they actually incurred their medical and HCBS costs. As a result, people living in the community could not immediately access care when they need it and churned on and off Medicaid, while residents in long-term care facilities had immediate access to care and continued Medicaid eligibility.

Example: Jorge has consistent HCBS expenses of $600 per month. Before the final rule became effective, his state required him to incur his HCBS and other medical expenses in order to meet the spend-down and become eligible for Medicaid. Because Jorge was $500 over-income for Medicaid eligibility and his state has a spend-down budget period of three months, Jorge was required to incur $1,500 in expenses for Medicaid-covered services before becoming eligible for Medicaid. Jorge would churn on and off Medicaid every three months: He would not qualify for Medicaid in January and February, then be enrolled in Medicaid in March. Then, he would lose Medicaid in April and May, then be re-enrolled in Medicaid in June.

Under the final rule, effective June 2024, states can now also allow individuals to count non-institutional expenses that they will incur in the future. These expenses can include:

• Reasonably constant and predictable expenses for services identified in a person-centered service plan for HCBS^[9];
• Reasonably constant and predictable expenses for prescription drugs; and
• Other reasonably constant and predictable expenses for services.

Note that this provision may be available to individuals who are not receiving HCBS.

Example (continued): Under the final rule, if Jorge’s state chooses to adopt prospective budgeting for non-institutional expenses, Jorge could stay on Medicaid continuously. He would still be responsible for the spend down amount ($500/month) but could access Medicaid immediately at the start of the spend-down budget period because he can demonstrate he will incur more than $500 in expenses each month.

Application for Medicaid

H.R. 1 delayed enforcement of some of these provisions, but states are still required or have the option to implement all of them.

The final rule made several changes to simplify the Medicaid application process.

Acceptance of Medicaid applications

42 C.F.R. § 435.907(c)(4).

The final rule emphasizes and codifies for non-MAGI populations the current requirement that state Medicaid agencies must accept all Medicaid applications, whether submitted in person, by mail, by phone, or online.^[11]

Interviews at application

42 C.F.R. § 435.907(d)

Under the final rule, after June 2027, a state would have been prohibited from requiring an interview (whether online, by phone, or in person) for anyone to enroll in Medicaid under any eligibility.^[13]

Requiring applications for other benefits

42 C.F.R. § 435.608 (rescinded by the final rule). This provision is currently in force. It is not changed by H.R. 1.

Effective June 2025, federal regulations no longer require Medicaid applicants to apply for other benefits (including retirement and disability benefits) in order to be eligible for Medicaid.^[14] States should not be requiring applicants to apply for other retirement or disability benefits in order to be eligible for Medicaid.^[15] Please note that states can still require Medicare enrollment as a condition of Medicaid eligibility. States who require Medicare enrollment are required to cover Medicare premiums and cost-sharing.^[16]

Periodic Renewal

H.R. 1 delayed enforcement of some of these provisions, but depending on the provision, states are either still required or have the option to implement them.

States must redetermine whether an individual is eligible for Medicaid through periodic renewals. The final rule streamlines this process.

Updating Addresses

42 § C.F.R. 435.919(f)

Under the final rule, by December 2025, states would have had to take a series of affirmative steps when mail is returned in order to reduce the number of people who lose Medicaid at renewal due to a change in address.^[17] 

Frequency of Renewals

42 § C.F.R. 435.916(a)

Under the final rule, by June 2027, states would have been prohibited from conducting periodic renewals more frequently than once every 12 months, unless the person is a Qualified Medicare Beneficiary.^[19] 

Table 1. State options regarding frequency of periodic renewals (taking H.R. 1 into account):

Population	Frequency of periodic renewals
Qualified Medicare Beneficiaries	A state must engage in periodic renewals every 6 to 12 months. States have the option to determine the frequency (between 6 and 12 months)[21]
Aged & Disabled and other non-MAGI enrollees	A state must engage in periodic renewals every 12 months. States have the option to engage in periodic renewals more frequently.
Expansion and other MAGI enrollees	Prior to January 2027, states must engage in periodic renewals every 12 months and are prohibited from requiring more frequent renewals.[22] Pursuant to H.R. 1, starting in January 2027, states will be required to engage in periodic renewals for the Medicaid Expansion population at least every 6 months (subject to some exemptions).[23]

Prepopulated Renewal Forms

42 C.F.R. § 435.916(b)(2)(i)

States are required to engage in an ex parte renewal process for both MAGI and non-MAGI enrollees.^[24] States are required to send a pre-populated form to the MAGI enrollee when a state cannot auto-renew using the ex parte process. Under the final rule, by June 2027, states would have been required to send a pre-populated form to non-MAGI enrollees when the state cannot auto-renew using the ex parte process.^[25]

Interviews at Renewal

42 C.F.R. § 435.916(b)(2)(iv)

Under the final rule, by June 2027, a state could no longer require an interview (whether online, by phone, or in person) for anyone to renew their Medicaid coverage. ^[28]

Change of Circumstances

42 C.F.R. § 919. H.R. 1 delayed enforcement of some of these provisions, but states are still required under previous regulations to follow almost all change of circumstances requirements.

As Medicaid enrollees experience changes such as moving, turning 65, retiring, receiving increased income, or developing a disability, their eligibility for Medicaid can change. States are currently required, under long-standing regulations, to process changes of circumstances using procedures to keep eligible individuals covered. Specifically, states are required to:

• Have procedures in place designed to ensure that beneficiaries make timely and accurate reports of any change in circumstances that may affect their eligibility.^[31]
• Anticipate changes in circumstances and act on them.^[32]
• Accept submissions about changes in circumstances by telephone, fax, in person, internet, or through other electronic means.^[33]
• Act promptly in response to submissions about changes in circumstances.^[34]
• Not terminate an individual unless there is a finding of ineligibility.^[35]

If a state finds that an individual is no longer eligible or that an individual’s benefits should be decreased, states are required to:

• Screen an individual for all types of Medicaid eligibility before decreasing or stopping benefits.^[36]
• Provide individuals with an opportunity to dispute information about change of circumstances obtained from a third party.^[37]
• Follow notice, hearing, and other requirements around an adverse action.^[38]

The requirements outlined above are based on regulations that existed before the streamlining rules and are not subject to the H.R. 1 moratorium.^[39] The final rule reorganized and clarified rules around changes in circumstances, including giving states more detailed instructions on how to implement existing regulations, described above. The intent of the final rule was not to create new requirements that states must follow when they receive information about a change in circumstances, but rather, “clarify existing requirements to ensure that states act on changes timely and in a manner that protects the coverage of beneficiaries who remain eligible (thereby, reducing unnecessary procedural terminations).”^[40]

Submitting Information and Documents

42 C.F.R. §§ 435.907(d)(1)(i); 435.916(b)(2)(i); 435.919(c)(1). H.R. 1 delayed enforcement of this provision, but states still have the option to implement it.

Medicaid applicants and enrollees are often required to submit additional information and documents to complete their Medicaid application or renewal. Effective June 2027, the final rule would have set a minimum number of days those individuals have to return the requested information and documents to the state Medicaid agency.^[41] If an individual returned the required documents and information within that timeframe, the approval would have been dated back to the date of application.

Opportunity for Reconsideration after Denial

42 C.F.R. §§ 907(d)(1)(iii); 435.916(b)(2)(iii); 435.919(d). H.R. 1 delayed enforcement of this provision, but states still have the option to implement it.

If an individual does not return requested information within the timeframe that the state Medicaid agency sets, the final rule would have required states as of June 2027 to establish a 90-day reconsideration period from the date of denial or termination.^[42] If the individual submitted required documents and information within that reconsideration period and was ultimately found eligible, then the approval would have been required to be dated back to the time that the required information was returned to the state agency. This reconsideration period would have applied to applications, renewals, and change of circumstance.

Example at application: Padma is applying to Medicaid in a state that has adopted the 90-day reconsideration period. After submitting her application, the state Medicaid agency asked her to submit a few documents verifying her income. Padma is given 15 days to submit the documents, but she does not submit until a month later. Because she submitted required documents within 90 days of denial and showed that she was eligible, the state Medicaid agency will be required to cover Padma, effective on the date that Padma sent in the required documentation. Just as with a typical Medicaid application, Padma could also be eligible for retroactive coverage.^[44]

Example at renewal: Edna’s Medicaid agency sent her a form to fill out for her Medicaid renewal. She had 30 days to turn the form back in. Edna missed that deadline, and the Medicaid agency sent Edna a notice terminating her Medicaid coverage. Edna then sent the required information back to the Medicaid agency. The state has adopted the 90-day reconsideration period. Since Edna’s information was sent in within 90 days of the Medicaid termination and showed that she was eligible, the state Medicaid agency will be required to cover Edna, effective on the date that Edna sent in the additional information. Since the return of information is treated as a new application, Edna is entitled to retroactive coverage and will not have a gap in coverage.

State Verification of Information

H.R. 1 delayed enforcement of some of these provisions, but depending on the provision, states are still required to or have the option to implement them.

State Medicaid agencies are required to verify certain types of information in a Medicaid application or renewal before making an eligibility determination. The final rule streamlines verification of assets and citizenship.

Verification of Assets

42 C.F.R. § 435.952(c). This provision is currently in force. It is not changed by H.R. 1.

The final rule confirms states cannot require the individual to provide an exact value of assets at application or renewal.^[47] Effective June 2024, states must use a “reasonable compatibility” process instead. Under this process, the asset information an individual provides on their application is considered verified if it is within a certain percentage of trusted information obtained by the state Medicaid agency.^[48] 

Proof of Citizenship

42 C.F.R. § 435.407(a)

The final rule would have required states to accept additional sources as standalone proof of citizenship:

1. State vital records; and
2. The U.S. Department of Homeland Security (DHS) Systematic Alien Verification for Entitlements (SAVE) program^[50]

Reasonable Opportunity Periods for Citizenship or Immigration Status Verification

42 C.F.R. § 435.956(b)(4). This provision is currently in force. It is not subject to the H.R. 1 moratorium.

The final rule restricts states from limiting the number of “reasonable opportunity periods” used when verifying citizenship or immigration status.^[52]

Timely State Determination of Eligibility

42 C.F.R. § 435.912(c). H.R. 1 delayed enforcement of this provision, but states still have the option to implement it.

Currently, state Medicaid agencies are required to process applications within 45 days (unless the application is based on a disability, then it is 90 days). The final rule would have added new timeframes for states to determine eligibility at renewal and due to a change in circumstances.^[53] For example, under the final rule, states would have been required to:

• Process applications transferred from an insurance affordability program (like the Marketplace) within 90 days if the application is based on a disability; 45 days if not.
• Process a renewal by the end of the eligibility period, as long as all necessary information is submitted at least 30 days prior.
• Process a reported change of circumstances by the end of the next month if all necessary information received.

There are many more timeframes spelled out in the final rule. These timeframes would have been effective June 2027.

Conclusion

The final rule extends several Medicaid protections to additional groups, including HCBS recipients, older enrollees, and people with disabilities. Implementation will take place over time and may face challenges due to the complexity of Medicaid rules. Though the H.R. 1 moratorium applies to many of these rules, states still have to comply with remaining requirements as noted in this brief and have the option to implement other improvements. If you are seeing issues with implementation of this rule or if your state is trying to put in place stricter rules than what are currently in effect, please contact info@justiceinaging.org.

Table 2. Medicaid Streamlining Provisions (taking into account H.R. 1)

Policy	Current Status	Regulations
Expanding when an individual can project costs when spending down to Medicaid eligibility	States have the option to allow individuals living in the community to project their health and long-term care costs when determining their financial eligibility for Medicaid.[55] This option remains in effect.	42 C.F.R. §§ 435.831 and 436.831.
Acceptance of all Medicaid applications	States are required to accept applications, whether submitted in person, by mail, by phone, or online.[56] These are long-standing requirements that remain in effect.	42 C.F.R. § 435.907(c)(4)
Interviews at application	States have the option to not require interviews for non-MAGI applicants.[57] The final rule’s prohibition of interviews for non-MAGI applicants is subject to the H.R. 1 moratorium.	42 C.F.R. § 435.907(d)
Requiring applications for other benefits	States are prohibited from requiring individuals to apply for other benefits in order to be eligible for Medicaid. (Does not apply to requirements to apply for Medicare).[58] This prohibition is in effect.	42 C.F.R. § 435.608 (rescinded by the final rule).
Updating addresses	States have the option to take additional affirmative steps to update addresses.[59] The final rule's requirement to take additional affirmative steps is subject to the H.R. 1 moratorium.	42 C.F.R. § 435.919(f)
Frequency of renewals	States have the option to limit renewals to every 12 months for non-MAGI enrollees.[60] The final rule’s requirement to limit renewals is subject to the H.R. 1 moratorium.	42 C.F.R. § 435.916(a)
Prepopulated renewal forms	States have the option to provide a prepopulated form to non-MAGI enrollees at renewal. States must engage in the ex parte renewal process for both MAGI and non-MAGI enrollees.[61] The final rule’s requirement to provide a prepopulated form to non-MAGI enrollees at renewal is subject to the H.R. 1 moratorium.	42 C.F.R. § 435.916(b)(2)(i)
Interviews at renewal	States have the option to not require interviews for non-MAGI enrollees at renewal.[62] The final rule’s prohibition of interviews at renewal is subject to the H.R. 1 moratorium.	42 C.F.R. § 435.916(b)(2)(iv).
Change of circumstances	States must act promptly in response to changes in circumstances; screen individuals for all types of Medicaid eligibility before decreasing or stopping benefits; and follow notice, hearing, and other requirements around an adverse action.[63] These long-standing regulations are still in effect; they were just redesignated in the final rule.	42 C.F.R. § 435.919
Submitting information and documents	States have the option to set a minimum number of days that an individual has to respond to requests for information and documents.[64] The final rule’s requirement for states to set a minimum number of days is subject to the H.R. 1 moratorium.	42 C.F.R. § 435.907(d)(1); 435.916(b)(2)(i); 435.919(c)(1)
Opportunity for Reconsideration after Denial	States have the option to offer a reconsideration period after denial.[65] The final rule’s requirement to set a reconsideration period is subject to the H.R. 1 moratorium, though some long-standing requirements for reconsideration periods following denial remain.	42 C.F.R. §§ 907(d)(1)(iii); 435.916(b)(2)(iii); 435.919(d)
Verification of assets	States must accept information provided by the individual regarding their assets, unless the state has access to reliable information that is not reasonably compatible with the individual’s attestation.[66] The final rule’s clarification of this requirement remains in effect.	42 C.F.R. § 435.952(c)
Proof of citizenship	States do not have the option to use DHS SAVE or state vital record data as standalone proof of citizenship. The final rule’s flexibility for states is subject to the H.R. 1 moratorium.	42 C.F.R. § 435.407(a)
Reasonable Opportunity Periods for Citizenship or Immigration Status Verification	States are prohibited from limiting the number of “reasonable opportunity periods” used when verifying citizenship or immigration status.[67] The final rule’s prohibition remains in effect.	42 C.F.R. § 435.956(b)(4).
Timely State Determination of Eligibility	States are required to process applications within 45 days (unless the application is based on a disability, then it is 90 days). States have the option of adopting timeliness standards for other actions. [68] The final rule’s strengthened timeliness standards are subject to the H.R. 1 moratorium.	42 C.F.R. § 435.912(c).

Endnotes

1. The Affordable Care Act (ACA) ushered in a set of streamlined processes for a subset of Medicaid enrollees. This subset of Medicaid enrollees is often called “MAGI” because their eligibility is based on a modified adjusted gross income (MAGI) standard. Many of the ACA’s streamlining changes did not apply to “non-MAGI” applicants and enrollees, including older adults and people with disabilities. The final Streamlining Rule extends many of these ACA changes to non-MAGI individuals, including interviews, 12-month continuous eligibility, and pre-populated forms at renewal. ↑

2. For a table outlining applicability dates, see the final rule at 89 FR 22,836. ↑

3. Note that both streamlining rules affect Medicare Savings Programs, as Medicare Savings Program enrollees are part of the “non-MAGI” group. ↑

4. Public Law 119-21, to Provide for Reconciliation Pursuant to Title II of H. Con. Res. 14. Sections 71101, 71102 address the streamlining rules. ↑

5. Codified at 42 C.F.R. §§ 435.831 and 436.831. For discussion, see the proposed rule at 87 FR 54,776 and the final rule at 89 FR 22,784. ↑

6. KFF, “Medicaid Eligibility through the Medically Needy Pathway” (2022). ↑

7. For more information on Medicaid spend-down, see KFF, “Medicaid Financial Eligibility in Pathways Based on Old Age or Disability in 2022: Findings from a 50-State Survey,” (July 2022). ↑

8. As long as these prospective expenses are reasonably constant and predictable.  ↑

9. Including service plans as part of 1915(c), 1915(j), 1915(k) or 1915(i) authorities. ↑

10. Final rule at 89 FR 22,785 (“We agree that many of the services identified by commenters could be reasonably constant and predictable. However, we decline to individually evaluate each service identified against that standard here. Under the final Rule, discretion is left to each State to evaluate whether, and under what circumstances, a given service is considered reasonably constant and predictable.”) ↑

11. Codified at 42 C.F.R. § 435.907(c)(4). For discussion, see the proposed rule at 87 FR 54,780 and the final rule at 89 FR 22,792. ↑

12. This is a long-standing policy for both MAGI and non-MAGI populations. Before the final rule, the MAGI requirement existed at 42 C.F.R. § 435.907(a). The non-MAGI requirement exists in CMS guidance. The final rule moved the MAGI requirement to 42 C.F.R. § 435.907(c)(4) and included the non-MAGI requirement. ↑

13. Interviews at application were already prohibited for MAGI individuals by 42 C.F.R. § 435.907(d). The final rule amended 42 C.F.R. § 435.907(d) to extend the interview prohibition non-MAGI individuals. For discussion, including the clarification that phone and video interviews are prohibited. see the proposed rule at 87 FR 54,782 and the final rule at 89 FR 22,794. ↑

14. This final rule applied to both MAGI and non-MAGI populations. See 42 C.F.R. § 435.608 (which was deleted, effective June 2025). For discussion, see the proposed rule at 87 FR 54,802 and the final rule at 89 FR 22,825. ↑

15. Final rule at 89 FR 22,827 (“Eliminating § 435.608 will only prohibit states from requiring that Medicaid applicants and beneficiaries, as a condition of their Medicaid eligibility, apply for other benefits for which they may be entitled.”) ↑

16. Final rule at 89 FR 22,826. States are permitted to require Medicare application as a condition for Medicaid enrollment because they are relying on New York State Department of Social Services v. Dublino, not 42 C.F.R. § 435.608. With regards to the requirement to apply for Medicare, “a state must agree to pay any premiums and cost-sharing (except those applicable under Part D) that such individuals would otherwise incur based on their Medicare enrollment.” Final rule at 89 FR 22,827. ↑

17. Codified at 42 C.F.R. § 435.919(f). For discussion, see the proposed rule at 87 FR 54,791 and the final rule at 89 FR 22,809. ↑

18. Please note that historically, state access to Medicaid managed care data has been limited, meaning that managed care plans often have more up-to-date addresses than states do. Many states pursued temporary waiver authority under section 1902(e)(14)(A) of the Social Security Act to gain access to that address data during the COVID-19 pandemic public health emergency. While H.R. 1 puts a moratorium on the state requirement to use managed care data to update addresses, there may still be avenues for states seeking enrollee addresses from managed care plans. For example, Section 71103 of H.R. 1 appears to give states additional leeway for gathering enrollee addresses from managed care plans (in the context of anti-fraud action). ↑

19. Codified at 42 C.F.R. § 435.916(a)(1). For discussion, see the proposed rule at 87 FR 54,781 and the final rule at 89 FR 22,792. According to CMS, at least six states – Minnesota, New Hampshire, Texas, Utah, Washington, and West Virginia – conducted renewals more frequently than 12 months. Final rule at 89 FR 22,845. QMB enrollees may not have periodic renewals more often than every six months. 42 C.F.R. § 435.916(a)(1). In the proposed rule, CMS explained that Section 1902(e)(8) of the Social Security Act allowed states to renew QMB enrollees as frequently as every six months, though the agency urged states to adopt a 12-month renewal cycle for QMB. Proposed rule at 87 FR 54,782. Note that, even if periodic renewal will occur on an annual basis, spend-down budget periods can be much shorter (from one to six months). Final rule at 89 FR 22,794. ↑

20. Section 71107 of H.R. 1 ↑

21. 42 U.S.C. § 1396a(e)(8) ↑

22. 42 C.F.R. § 435.916(a)(1). ↑

23. Section 71107 of H.R. 1 ↑

24. Before the final rule, the requirement to engage in ex parte processes for MAGI and non-MAGI enrollees was found in 42 C.F.R. §§ 435.916(a)(2) and 435.916(b). After the rule, it was found at 42 C.F.R. § 435.916(b)(1). ↑

25. Codified at 42 C.F.R. § 435.916(b)(2)(i). For discussion, see the proposed rule at 87 FR 54,782 and the final rule at 89 FR 22,792. Ex parte refers to a requirement (already in place before the final rule) that states use all available information to see if a Medicaid enrollee (MAGI or non-MAGI) remains eligible for Medicaid during a periodic renewal before reaching out to the Medicaid enrollee. 42 C.F.R. § 435.916. ↑

26. Prior to the final rule, this requirement to send a pre-populated form to MAGI enrollees when the ex parte process did not result in a finding of eligibility was at 42 C.F.R. § 435.916(a)(3). After the rule, it was found at 42 C.F.R. § 435.916(b)(2)(a) and included non-MAGI enrollees. ↑

27. Prior to the Rule, 42 C.F.R. § 435.916(b) specified that states had the choice to send a pre-populated form to non-MAGI enrollees during re-determination when the ex parte process did not result in a finding of eligibility. ↑

28. Codified at 42 C.F.R. § 435.916(b)(2)(iv). For discussion, see the proposed rule at 87 FR 54,782 and the final rule at 89 FR 22,794. This was already an existing requirement for MAGI population to not engage in interviews at renewal, located before the final rule at 42 C.F.R. § 435.916(a)(3)(C)(iv). The final rule redesignated this requirement to 42 C.F.R. § 435.916(b)(2)(iv) and expanded the interview prohibition to non-MAGI individuals. For discussion, including the clarification that phone and video interviews are prohibited, see the final rule at 89 FR 22,794.↑

29. Final rule at 89 FR 22,793. For information on which states have adopted streamlining provisions already, see KFF State Health Facts, “Actions to Align Non-MAGI with MAGI Renewal Policies”. ↑

30. Final rule at 89 FR 22,845. ↑

31. Prior to the final rule, this requirement was found at 42 C.F.R. § 435.916(c). The final rule moved it to 42 C.F.R. § 435.919(a)(1). ↑

32. Prior to the final rule, this requirement was found at 42 C.F.R. § 435.916(d)(2). The final rule moved it (with a small modification for the state to act at “an appropriate time” rather than at “the appropriate time”) to 42 C.F.R. § 435.919(b)(6). ↑

33. Prior to the final rule, this requirement was found at 42 C.F.R. § 435.916(c). The final rule moved it to 42 C.F.R. § 435.919(a)(2). ↑

34. Prior to the final rule, this requirement was found at 42 C.F.R. § 435.916(d). The final rule moved it to 42 C.F.R. § 435.919(b). ↑

35. 42 C.F.R. § 435.930(b). See discussion at the final rule at 89 FR 22,798. ↑

36. Slide 8 of CMS, Medicaid and CHIP Renewals and Redeterminations (June 2021) (”The Medicaid agency must also continue to furnish Medicaid coverage to beneficiaries who have returned their documentation/renewal form prior to the end of their eligibility period unless and until they are determined to be ineligible”) (citing 42 C.F.R. § 435.930(b)). See also 42 C.F.R. § 435.916(f)(1) (redesignated by the final rule to 42 C.F.R. § 435.916(d)). ↑

37. Prior to the final rule, this requirement was found at 42 C.F.R. § 435.952(d). The final rule kept 42 C.F.R § 435.952(d) and added 42 C.F.R. § 435.919(b)(4). For discussion, see the final rule at 89 FR 22,800. ↑

38. See, e.g., 42 C.F.R. §§ 435.952(d) and 431.201. ↑

39. Many regulations that existed prior to the streamlining rules were redesignated to 42 C.F.R. § 435.919 by the streamlining rule. ↑

40. Final rule at 89 FR 22,796. ↑

41. Codified at 42 C.F.R. §§ 435.907(d)(1)(i) (setting 15 days as the minimum number that a state must allow a person to return information and documents at application); 435.916(b)(2)(i) (setting 30 days as the minimum number of days at the periodic redetermination); and 435.919(c)(1) (setting 30 days as the minimum number of days for a change in circumstance). For discussion, see the proposed rule at 87 FR 54,782 and the final rule at 89 FR 22,792 and 22,799. A table is available at the final rule at 89 FR 22,802 ↑

42. Codified at 42 C.F.R. §§ 435.907(d)(1)(iii); 435.916(b)(2)(iii); and 435.919(d). For discussion, see the proposed rule at 87 FR 54,782 and the final rule at 89 FR 22,792 and 22,796. The 90-day reconsideration period was already required for MAGI individuals at renewal. This requirement was found at 42 C.F.R. § 435.916(a)(3)(iii) before the final rule, and was redesignated (with revisions) by the final rule at 42 C.F.R. § 435.916(b)(2)(iii). ↑

43. See the final rule at 89 FR 22,800 (”… we note that treating additional information received during the 90-day reconsideration period as a new application entitles eligible individuals to up to 3 months of retroactive coverage under Medicaid consistent with § 435.915.”). Also see the final rule at 89 FR 22,804. ↑

44. The retroactive period will be shortened from 90 days to one month (for expansion populations) and two months (for other Medicaid eligibility groups) starting January 2027. ↑

45. For a list of states that have taken action to streamline (including the use of reconsideration periods), see KFF State Health Facts, “Actions to Align Non-MAGI with MAGI Renewal Policies”. Note that KFF does not specify whether the 90-day reconsideration period is for application, renewal, or change in circumstances. ↑

46. See, e.g., CMS letter to Massachusetts (September 5, 2023) (CMS’ approval of Massachusetts’ 1902(e)(14) waiver request to make the effective date the date of termination (rather than the date documents were returned)). These 1902(e)(14) waivers are especially helpful in states that have waived the 90-day retroactive coverage requirement. Note that, to date, CMS has only approved 1902(e)(14) waivers in the context of an emergency, such as the COVID-19 Public Health Emergency and that these waivers are time-limited. See CMS, COVID-19 PHE Unwinding Section 1902(e)(14)(A) Waiver Approvals. There may be an option to make (e)(14) waiver flexibility permanent through the submission of a state plan amendment. See CMCS Informational Bulletin re. Extension of Temporary Unwinding-Related Flexibilities (May 9, 2024).↑

47. Codified at 42 C.F.R. § 435.952(c). For discussion, see the proposed rule at 87 FR 54,778 and the final rule at 89 FR 22,788. ↑

48. The asset information is also considered verified if the electronic source and the application amount are both below the eligibility threshold. 42 C.F.R. § 435.952, effective June 2024. ↑

49. CMS Informational Bulletin re: Ensuring Timely and Accurate Medicaid and CHIP Eligibility Determinations at Application (May 9, 2024) (slide 30). ↑

50. Codified at C.F.R. § 435.407. For discussion, see the proposed rule at 87 FR 54,779 and the final rule at 89 FR 22,788. The final rule also would have required states to engage in a data match with state vital statistics records if it is “available and effective”. ↑

51. CBPP. Medicaid Eligibility and Enrollment Rules Law Framework for Program Improvements States Can Still Adopt, Despite Moratorium (Sep. 24, 2025). ↑

52. Codified at 42 C.F.R. § 435.956(b)(4). ↑

53. Codified at 42 C.F.R. § 435.907(c). For discussion, see the proposed rule at 87 FR 54,783 and the final rule at 89 FR 22,792 and 22,801. See the final rule at 89 FR 22,802 for a detailed table with new timeframes for states to follow when making eligibility determinations. ↑

54. Final rule at 22,804 (“Finally, although we are not making changes to the existing 45 and 90 calendar day application timeliness standards at § 435.912(c)(3), we clarify that these standards represent the maximum amount of time a state may take to complete an eligibility determination.”) ↑

55. 42 C.F.R. §§ 435.831 and 436.831. These regulations are not subject to the H.R. 1 moratorium.↑

56. This is a long-standing policy for both MAGI and non-MAGI populations. Before the final rule, the MAGI requirement existed at 42 C.F.R. § 435.907(a). The non-MAGI requirement exists in CMS guidance. The final rule moved the MAGI requirement to 42 C.F.R. § 435.907(c)(4) and included the non-MAGI requirement. ↑

57. Interviews at application were already prohibited for MAGI individuals by 42 C.F.R. § 435.907(d). The final rule amended 42 C.F.R. § 435.907(d) to extend the interview prohibition non-MAGI individuals. For discussion, including the clarification that phone and video interviews are prohibited. see the proposed rule at 87 FR 54,782 and the final rule at 89 FR 22,794. ↑

58. 42 C.F.R. § 435.608 (rescinded by the streamlining rule). The removal of 42 C.F.R. § 435.608 was not subject to the H.R. 1 moratorium. ↑

59. 42 C.F.R. § 435.919(f), which is subject to the H.R. 1 moratorium. ↑

60. 42 § C.F.R. 435.916(a), which is subject to the H.R. 1 moratorium. ↑

61. Prior to the final rule, this requirement to send a pre-populated form to MAGI enrollees when the ex parte process did not result in a finding of eligibility was at 42 C.F.R. § 435.916(a)(3). After the final rule, it was found at 42 C.F.R. § 435.916(b)(2)(a) and included non-MAGI enrollees. ↑

62. Codified at 42 C.F.R. § 435.916(b)(2)(iv). This was already an existing requirement for MAGI population to not engage in interviews at renewal, located before the rule at 42 C.F.R. § 435.916(a)(3)(C)(iv). The rule redesignated this requirement to 42 C.F.R. § 435.916(b)(2)(iv) and expanded the interview prohibition to non-MAGI individuals; this change is subject to the H.R. 1 moratorium. ↑

63. 42 C.F.R. § 435.919, which is subject to the H.R. 1 moratorium. For regulations in place before the rule, see the section ”Change of Circumstances” in this brief. ↑

64. 42 C.F.R. §§ 435.907(d)(1)(i); 435.916(b)(2)(i); 435.919(c)(1). These regulations are subject to the H.R. 1 moratorium. ↑

65. 42 C.F.R. §§ 907(d)(1)(iii); 435.916(b)(2)(iii); 435.919(d). These regulations are subject to the H.R. 1 moratorium. ↑

66. 42 C.F.R. § 435.952(c). This regulation is not subject to the H.R. 1 moratorium. ↑

67. 42 C.F.R. § 435.956(b)(4). This regulation is not subject to the H.R. 1 moratorium. ↑

68. 42 C.F.R. § 435.912(c). This regulation is subject to the H.R. 1 moratorium. ↑