DEPARTMENT OF HEALTH  & HUMAN SERVICES  
Centers for Medicare & Medicaid Services  
7500 Security Boulevard,  Mail  Stop S2-26-12  
Baltimore, Maryland  21244-1850  
 
 
SHO# 23-002 
 
RE: Medicaid  Continuous  
Enrollment  Condition Changes, 
Conditions for  Receiving the  
FFCRA Temporary  FMAP  
Increase, Reporting Requirements, 
and Enforcement  Provisions  in the  
Consolidated Appropriations Act, 
2023  
 
January  27, 2023  
 
Dear State Health Official:  
 
On December 29, 2022, the Consolidated Appropriations Act, 2023 (P.L. 117-328)  (CAA, 2023)  
was enacted.1   This  state health  official (SHO) letter discusses section 5131 of subtitle D of title  
V of division FF of the CAA, 2023 (hereinafter referred to as section 5131).  This section 
makes significant changes to the continuous enrollment condition and availability of the  
temporary increase in the Federal Medical Assistance Percentage (FMAP) under section 6008 of  
the Families First Coronavirus Response Act (FFCRA) (hereinafter referred to as temporary  
FMAP increase)  and establishes new state reporting requirements and enforcement authorities  
for the  Centers  for Medicare & Medicaid Services  (CMS).  Specifically,  as  discussed in further  
detail in this letter,  section 5131:  
(1) Separates the end of the  FFCRA  continuous enrollment condition from the end of the 
COVID-19 public health emergency (COVID-19 PHE), and ends that condition on
March 31, 2023, thus  enabling states to terminate  Medicaid enrollment of individuals 
who no longer meet  Medicaid  eligibility requirements on or after April 1, 2023; 
(2) Amends the  conditions states must meet to  claim, and extends the availability of, the
temporary  FMAP increase beginning  April 1, 2023, gradually phasing down the 
increase until December  31, 2023; 
(3) Adds new reporting  requirements for all states under section 1902(tt) of the Social 
Security  Act (the Act); and 
(4) Creates new  enforcement authorities for  CMS related to the new reporting 
requirements and to state renewal activities during the  period that begins on April 1,
2023 and ends on June 30, 2024 (a time frame that will overlap with states 
unwinding periods).2 
The newly enacted CAA, 2023 does not address the end date of the COVID-19 PHE.  On 
                                                      
1  https://www.congress.gov/117/bills/hr2617/BILLS-117hr2617enr.pdf.   
2  As described in prior CMS guidance, states  will have up to 12 months to initiate, and 14 months to complete, a  
renewal for all individuals enrolled in Medicaid, CHIP, and  the Basic Health Program (BHP) following the end of  
the continuous enrollment conditionthis process  has commonly been referred to as unwinding.  
 
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 2  State Health  Official Letter  
 
January 11, 2023, the Secretary renewed the COVID-19 PHE, which is still in effect  as of the 
date of this letter.3   
 
On January 5, 2023, CMS released a Center for  Medicaid and CHIP  Services  Informational  
Bulletin  (CIB),  Key Dates Related to the Medicaid Continuous Enrollment  Condition Provisions  
in the Consolidated Appropriations Act, 2023,4 which is the first in a series  of guidance on the 
changes made by section 5131 to the continuous enrollment condition and the impact of these  
changes on prior CMS guidance.5  The January 5, 2023, CIB  relays  key dates and deliverables  
for states as they  resume  renewals and other  eligibility  and enrollment actions  following  the end 
of the continuous enrollment condition (referred to in prior guidance as the unwinding period).   
This SHO  letter is the next in this series of guidance and builds on the  guidance provided in the  
January 5, 2023, CIB.  CMS also expects to provide additional guidance on the CAA, 2023 in 
the future.  
 
CMS will be reviewing  data, state activity, and other information to ensure  all states comply  with  
federal eligibility  renewal requirements and the new  section  1902(tt)  reporting  requirements in 
preparation for and during the  states unwinding period.  States may need to make programmatic 
and operational  changes to eligibility and enrollment policies, procedures, systems, and 
operations and consider adopting alternative strategies and mitigation plans to ensure  
compliance.  CMS is available to consult with states as they prepare for  and resume renewals and  
other eligibility determinations.  States  may  contact their CMS state lead for  assistance.  
Changes to the  FFCRA Continuous  Enrollment Condition and Temporary FMAP Increase  
Section 5131(a)(2)(C) separates the  end of the  continuous enrollment condition from the end of  
the COVID-19 PHE by amending section 6008(b)(3) of the  FFCRA to end continuous Medicaid 
enrollment as a condition for claiming the temporary  FMAP increase on March 31, 2023.  This  
means that,  on or after April 1, 2023, states  claiming the temporary  FMAP  increase will no 
longer be required to maintain the enrollment of a  Medicaid beneficiary  for whom the state  
completes a renewal and  who no longer meets  Medicaid  eligibility requirements.  With  the 
changes made in section 5131, states  must end the  enrollment of ineligible  beneficiaries on or  
after April 1, 2023, after  a full renewal is conducted during the states unwinding period, no 
matter when  the COVID-19 PHE ends. 
Consistent with  the March 3, 2022, SHO #22-001, RE: Promoting Continuity of Coverage and 
Distributing  Eligibility and Enrollment  Workload in Medicaid, the Childrens Health Insurance  
Program (CHIP), and Basic Health Program  (BHP)  Upon Conclusion of the COVID-19 Public  
Health Emergency  (hereinafter SHO #22-001), and as explained in the January 5, 2023, CIB:   
                                                      
3  The Secretary renewed the COVID-19 PHE, effective January 11, 2023.  See:  
https://aspr.hhs.gov/legal/PHE/Pages/covid19-11Jan23.aspx.   
4  CMS. (January 5, 2023).  Key  Dates Related to the Medicaid Continuous Enrollment Condition Provisions in the  
Consolidated Appropriations Act, 2023  [CMCS Informational Bulletin]. Available at 
https://www.medicaid.gov/sites/default/files/2023-01/cib010523_1.pdf.   
5  CMS. (March 3, 2022).  Promoting Continuity of Coverage  and Distributing Eligibility and Enrollment Workload 
in Medicaid, the Childrens Health Insurance  Program (CHIP), and Basic Health Program (BHP) Upon 
Conclusion of the COVID-19  Public Health Emergency  [State Health Official Letter #22-001]. Available at 
https://www.medicaid.gov/federal-policy-guidance/downloads/sho22001.pdf.  
 
 
  Page 3  State Health  Official Letter  
 
  States can begin their unwinding period as early  as February 1, 2023, by initiating 
renewals  that may result in eligibility  terminations  on or after  April 1, 2023.  States  must
begin their unwinding period by  initiating  renewals  no later than April 2023.
  For states that initiate renewals prior to April 1, 2023, terminations  of Medicaid 
eligibility  may not be  effective  earlier than April 1, 2023.
  States must initiate  renewals for all individuals enrolled in Medicaid, CHIP, and BHP 
within 12 months of the beginning of the states unwinding period and must  complete
renewals for all individuals within 14 months of the beginning of the states unwinding 
period.6  
A renewal is considered initiated when the state begins the renewal process  by attempting to  
renew eligibility  on an  ex parte basis  i.e., based on available  reliable information without 
contacting the individual.  CMS encourages states  to  distribute  renewals  in  a reasonable manner  
and 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 for  several reasons discussed in  
SHO #22-001, including  to ensure states have a renewal schedule that is sustainable in future 
years.   States may refer to  SHO #22-001 (pages 14-21) for information on strategies  states may  
use to prioritize and distribute workload during the unwinding period.7 
Section 5131 also separates the end of the  temporary  FMAP increase  from the end of the  
COVID-19 PHE.  Specifically, section 5131(a) amends section 6008(a) of the FFCRA to 
continue the temporary  FMAP  increase through December 31, 2023 (instead of through the end  
of the quarter in which the  COVID-19 PHE ends),  and phases down the amount  of the FMAP  
increase beginning April  1, 2023.  Table 1 displays the amount of  the FMAP increase that will be 
available in each quarter  of calendar  year (CY) 2023, provided that the state claiming the FMAP  
increase meets  the applicable conditions in subsections (b) and (f)  of section 6008 of the FFCRA, 
as amended by section 5131 (discussed below).  If the  state meets the applicable conditions, the  
FMAP increase applies to the same match rates  to which it applied prior to the enactment of the  
CAA, 2023.8  
 
 
                                                      
6  CMS. (March 3, 2022).  Promoting Continuity of Coverage  and Distributing Eligibility and Enrollment Workload 
in Medicaid, the Childrens Health Insurance  Program (CHIP), and Basic Health Program (BHP) Upon 
Conclusion of the COVID-19  Public Health Emergency  [State Health Official Letter #22-001] (pages 7-9). 
Available at https://www.medicaid.gov/federal-policy-guidance/downloads/sho22001.pdf.   
7  CMS. (March 3, 2022). Promoting Continuity of Coverage  and Distributing Eligibility and Enrollment Workload 
in Medicaid, the Childrens Health Insurance  Program (CHIP), and Basic Health Program (BHP) Upon 
Conclusion of the COVID-19  Public Health Emergency  [State Health Official Letter #22-001] (pages 14-21).   
Available at https://www.medicaid.gov/federal-policy-guidance/downloads/sho22001.pdf.  
8  In general, the  FFCRA  FMAP  increase is available for allowable Medicaid  medical assistance expenditures  for  
which  federal matching is paid ordinarily at the state-specific FMAP defined in the first sentence of section 1905(b)  
of the  Act.  For additional guidance on  the match rates that can be temporarily increased under  section 6008 of the  
FFCRA  (as amended), see Section IV.F in:  CMS. (2021).  COVID-19 Frequently Asked Questions (FAQs) for State  
Medicaid and Childrens Health Insurance Program (CHIP) Agencies.  Available at: 
https://www.medicaid.gov/state-resource-center/downloads/covid-19-faqs.pdf.  
 
  Page 4  State Health  Official Letter  
 
Table 1. CAA, 2023 FMAP Increase Phase Out  
2023 Calendar Overview   Temporary  FMAP Increase Available  
Q1: January 1-March 31, 2023   6.2 percentage points  
Q2: April 1-June 30, 2023   5.0 percentage points  
Q3: July 1-September 30, 2023   2.5 percentage points  
Q4: October 1-December 31, 2023   1.5 percentage points  
Conditions for Receipt  of  Temporary  FMAP Increase  
The conditions for claiming the temporary 6.2 percentage point  FMAP increase remain  
unchanged for the first quarter of CY 2023.  States claiming the temporary  FMAP increase  for  
quarter 2, 3, or 4 of CY 2023 (that is,  for any quarter in the period beginning April 1, 2023, and 
ending December 31, 2023) must continue to meet three of the  conditions  originally set forth in  
section 6008(b)  of the FFCRA  during each quarter in which the state claims the FMAP increase:  
(1)section 6008(b)(1) (related to maintenance of effort); (2) section 6008(b)(2) (related to 
premiums), with one modification made by section 5131 (discussed below); and (3) section
6008(b)(4)  (related to coverage of COVID vaccination, testing, and treatment services, without 
cost-sharing).  The applicability of these  conditions during quarters 2, 3, and 4 of CY 2023 is
discussed in this section of the  SHO.9  
Section 5131 also amended section 6008 of the  FFCRA to establish new conditions for states to 
claim the temporary  FMAP increase during quarters 2, 3, and 4 of CY 2023 under a new section 
6008(f) of the FFCRA.  States  that claim the temporary  FMAP increase during quarter 2, 3, or 4 
of CY 2023 must comply with the new FFCRA section 6008(f) conditions  for Medicaid  renewals  
that are conducted during each  quarter  for which the state claims the FMAP increase.  Guidance 
on the new  conditions established in section 6008(f) of the  FFCRA is provided later in this  SHO 
letter.  As noted above, states will continue to have 12 months to initiate their work on renewals,  
redeterminations based on changes in circumstances, and post-enrollment verifications, and 14 
months to complete this work once the states unwinding period begins, consistent with the  
guidance in  the January 5, 2023, CIB  and SHO #22-001.  
In preparation for  and during the unwinding period, CMS will review  data, state  activities, and 
other information to ensure states are complying with federal eligibility renewal requirements  
and, for states  claiming the FFCRA temporary  FMAP increase,  the applicable conditions  for 
claiming that increase.  States may need to make programmatic and operational changes to  
eligibility and enrollment policies, procedures, systems, and operations and consider adopting  
alternative strategies to ensure compliance.   States that are not compliant with federal  
redetermination requirements, regardless of whether they continue to claim the FFCRA section 
6008 FMAP increase, may  be subject to corrective action and penalties under section 1904 or  
section 1902(tt)(2)(B) of  the Act (see discussion below).  States not in compliance with all  
                                                      
9  For additional information on the  condition  under section 6008(b)(3) of the FFCRA to maintain enrollment of  
individuals effective through  March 31, 2023, see:  42 CFR   433.400,  and  CMS. (2021).  COVID-19 Frequently  
Asked Questions (FAQs) for State Medicaid and Childrens Health Insurance Program (CHIP) Agencies. Available  
at: https://www.medicaid.gov/state-resource-center/downloads/covid-19-faqs.pdf.  
 
  Page 5  State Health  Official Letter  
 
redetermination requirements may  work with CMS to develop and implement an approved 
mitigation plan.  
Maintenance of Effort Condition through December 31, 2023 
Under section 6008(b)(1) of the FFCRA, states  may  not claim the temporary  FMAP increase  for 
a quarter  if, during that quarter, they impose  eligibility standards, methodologies,  or procedures  
that are more restrictive than  those in effect  on January 1, 2020.  Section 5131 did not change  
this condition, and states  must continue to meet  it for any quarter in which they  claim the  
temporary  FMAP increase,  through December 31, 2023.  See previous  guidance in Section IV.F. 
in the  COVID-19 Frequently Asked Questions  (FAQs) for State Medicaid and Childrens Health 
Insurance Program  (CHIP) Agencies10 for additional guidance on this condition. 
Maintenance of Medicaid Premium Levels through December 31, 2023 (Modified by Section 
5131)  
Prior to the enactment of  the CAA, 2023, section  6008(b)(2) of the FFCRA  provided that  states  
could not claim the temporary  FMAP increase if they imposed  any premium with respect to an  
individual enrolled under the state plan (or a waiver of the plan) that exceeded the amount of  
such premium as of January 1, 2020.  CMS interpreted this  condition to mean that a state 
claiming the temporary  FMAP  increase could  not increase the amount of  any  premium  charged  
to an individual  enrollee  (even if that persons income increased).11  
Beginning April 1, 2023 (that is, beginning in quarter 2 of CY 2023), section 5131(a)(2)(B)  
amends section 6008(b)(2) of the FFCRA to remove the language with respect to an individual  
enrolled under such plan (or waiver).   Under the  amended section 6008(b)(2) condition, states  
claiming the temporary  FMAP increase for quarters beginning on or  after  April 1, 2023, must 
continue to ensure that the amounts in their Medicaid premium schedule do  not exceed the 
amounts  that were in place under the state plan  or any  waiver of the plan (including a section 
1115 demonstration) as of January 1, 2020.  However, beginning April 1, 2023, states  may,  
under the amended section 6008(b)(2) of the FFCRA, increase the premium amount  that is  
imposed on a given  individual  (e.g., put an individual in a higher premium band if their income  
has increased, or newly charge  an individual a premium if they are moved into an eligibility  
group that is subject to premiums)  without jeopardizing the states ability to claim the temporary  
FMAP increase,  subject to the following  three conditions:    
1)  The increase must be  consistent with the states Medicaid premium schedule.
2)  The premium schedule  amounts must not  have increased over the amounts in effect as of 
January 1, 2020.  
                                                      
10  See: CMS. (2021).  COVID-19 Frequently Asked Questions  (FAQs) for State Medicaid and Childrens Health 
Insurance Program (CHIP) Agencies. Available at: https://www.medicaid.gov/state-resource-
center/downloads/covid-19-faqs.pdf.  
11  For guidance on the condition described in section 6008(b)(2) in effect through March 31, 2023, see FAQ #II.B.9-
10, 12-13  of:  CMS. (2021).  COVID-19  Frequently Asked Questions (FAQs) for State Medicaid and Childrens  
Health Insurance Program (CHIP).  Available at: https://www.medicaid.gov/state-resource-
center/downloads/covid-19-faqs.pdf.  
 
 
  Page 6  State Health  Official Letter  
 
3)  The state must comply  with  redetermination requirements prior to resumption of 
Medicaid premiums, as  discussed  in response to Q24-25 of  the COVID-19 Public Health
Emergency Unwinding Frequently  Asked Questions for State Medicaid  and CHIP 
Agencies.12  
The state also  must  comply  with all premium requirements and limitations specified at sections  
1916 and 1916A of the  Act and 42 CFR  447.50 through 447.57;  all applicable advance notice 
and fair hearing requirements at 42 CFR  435.917 and 42 CFR  Part 431, Subpart E; public  
notice requirements at 42 CFR   447.57;  state plan amendment (SPA)  effective date 
requirements at 42 CFR  430.20; and tribal consultation requirements at  section 1902(a)(73) of  
the  Act.  CMS plans to provide additional guidance on the CAA, 2023 amendment to section 
6008(b)(2) of the FFCRA, including information about the implications of this change for state  
decisions about rescinding disaster relief SPAs.  
States may request authority under section 1902(e)(14)(A) of the Act  to  delay the resumption of  
Medicaid premiums  during the unwinding period until a full redetermination is completed for  
beneficiaries  who are subject to premiums under the State plan or a waiver, including through a 
section  1115 demonstration project.  States can  refer to SHO #22-00113 for details on how to 
request approval of section 1902(e)(14)(A)  waivers.  States may  also contact their  CMS state 
lead for more information. 
Coverage without Cost Sharing for COVID-19 Testing, Vaccines, and Treatment through 
December 31, 2023  
States claiming the temporary  FMAP increase for  any quarter  in the period beginning April 1, 
2023, and ending December 31, 2023, must continue to meet the condition in section 6008(b)(4)  
of the FFCRA, under which the state must provide coverage, without cost  sharing, for any testing  
services and  treatments for COVID-19, including  vaccines, specialized equipment, and 
therapies.14   This condition was not changed by section 5131.  However, it is  important to note 
                                                      
12  See previous  guidance regarding redetermination requirements prior to resumption of Medicaid premiums,  
including individualized notice requirements and  when a state  must obtain  updated income information before  
reinstatement, at Q24-25  of:  CMS. (2022).  COVID-19 Public Health Emergency Unwinding Frequently Asked  
Questions for State Medicaid and CHIP Agencies. Available at:  https://www.medicaid.gov/federal-policy-
guidance/downloads/covid-19-unwinding-faqs-oct-2022.pdf.  
13  CMS. (March 3, 2022).  Promoting Continuity of Coverage  and Distributing Eligibility and Enrollment Workload 
in Medicaid, the Childrens Health Insurance  Program (CHIP), and Basic Health Program (BHP) Upon 
Conclusion of the COVID-19  Public Health Emergency  [State Health Official Letter #22-001]. Available at 
https://www.medicaid.gov/federal-policy-guidance/downloads/sho22001.pdf.  
14  For information regarding implementation of this  condition,  see previous  guidance at FAQ #II.B.2, 4,14-15  of:  
CMS. (2021).  COVID-19 Frequently Asked Questions (FAQs) for State Medicaid and Childrens Health Insurance  
Program (CHIP) Agencies. Available at: https://www.medicaid.gov/state-resource-center/downloads/covid-19-
faqs.pdf. See also the discussions of  section 6008(b)(4)  of the FFCRA in the interim final rule  with request  for  
comments entitled Additional Policy and Regulatory  Revisions in  Response to the COVID-19 Public Health  
Emergency, 85 FR 71142, 71148-50 (Nov. 6, 2020) (available at:  
https://www.federalregister.gov/documents/2020/11/06/2020-24332/additional-policy-and-regulatory-revisions-in-
response-to-the-covid-19-public-health-emergency), and in  CMS. (2022).  Coverage and Reimbursement of COVID-
19 Vaccines, Vaccine Administration, and Cost-Sharing under Medicaid, the Childrens Health Insurance  Program,  
and Basic Health Program.  Available at https://www.medicaid.gov/state-resource-center/downloads/covid-19-
vaccine-toolkit.pdf.    
 
 
  Page 7  State Health  Official Letter  
 
that section 9811 of the  American Rescue Plan Act  of 2021 (ARP) (P.L. 117-2) amended various  
provisions of the Act to require  states  to  provide coverage, without cost sharing, of:  COVID-19 
vaccinations;  COVID-19  testing;  treatments for COVID-19, including specialized equipment and 
therapies (including preventive therapies);  and, when certain conditions are met, treatment of  
conditions that may seriously complicate the treatment  of COVID-19.  These requirements under  
section 9811 of the ARP  remain in place until the  last day of the first calendar quarter that begins  
one year  after the last day  of the COVID-19 PHE.  The requirements under section 9811 of the  
ARP  generally  overlap with, are in many circumstances broader than, and will extend longer  
than  the coverage and cost-sharing  condition under  section  6008(b)(4) of the FFCRA, and they 
apply  even if the state is not  claiming  the FFCRA temporary FMAP  increase.   CMS  therefore 
expects the CAA, 2023s amended sunset date for  section 6008(b)(4) of the  FFCRA will not  
have much  practical impact  on states coverage of these services without cost sharing.  For  
additional information, see  the June 3, 2021, CIB,15  SHO #21-003,16  SHO #21-006,17  SHO #22-
002,18 and the CMCS  COVID-19 Vaccine Toolkit.19 
Overview of New Conditions for Receipt of the Temporary  FMAP Increase in Effect April 1, 
2023, through December 31, 2023 
  
Section 5131 added a new subsection (f) to section 6008 of the FFCRA.  States claiming the  
temporary  FMAP increase for quarter 2, 3, and/or  4 of CY 2023 must  satisfy  the conditions  
under sections 6008(b)(1), 6008(b)(2), and 6008(b)(4), as  described above, in addition to the 
following  new conditions under section 6008(f) of  the  FFCRA:  
  Conduct  Medicaid  eligibility  redeterminations in accordance with all applicable  federal 
requirements, including renewal strategies authorized under section 1902(e)(14)(A) of the 
Act or other  alternative processes  and procedures  approved by CMS (section 
6008(f)(2)(A));  
  Attempt to ensure that they  have up-to-date  contact information for a  beneficiary  before 
redetermining  eligibility for  such  beneficiary (section 6008(f)(2)(B));  and 
  Undertake a good-faith effort to contact  an individual using more than one  modality prior 
to terminating their  enrollment on the basis of returned mail (section 6008(f)(2)(C)). 
 
These new  conditions apply to Medicaid  renewals  that are conducted during  any quarter during  
the period beginning April 1, 2023, and ending  December 31, 2023, in states claiming the  
temporary  FMAP increase for that quarter.  In addition to being a condition of receiving the  
                                                      
15  CMS.  (June 3, 2021).  Medicaid, Childrens Health Insurance Program (CHIP), and Basic Health Program  
(BHP) Related Provisions in the American Rescue Plan Act  of 2021  [CMCS Informational Bulletin].  Available at: 
https://www.medicaid.gov/federal-policy-guidance/downloads/cib060321.pdf   
16  CMS.  (August 30, 2021).  Medicaid and CHIP Coverage and Reimbursement of COVID-19 Testing under the  
American Rescue Plan Act  of  2021 and Medicaid Coverage  of Habilitation Services  [State Health Official Letter  
#21-003].  Available at: https://www.medicaid.gov/federal-policy-guidance/downloads/sho-21-003.pdf   
17  CMS.  (October  22, 2021).  Mandatory Medicaid and CHIP  Coverage of COVID-19-Related Treatment under the  
American Rescue Plan Act  of  2021  [State Health Official Letter  #21-006].  Available at:  
https://www.medicaid.gov/federal-policy-guidance/downloads/sho102221.pdf.  
18  CMS. (May 12, 2022).  Medicaid and CHIP Coverage of Stand-alone Vaccine Counseling  [State Health Official 
Letter #22-002]. Available at: https://www.medicaid.gov/federal-policy-guidance/downloads/sho22002.pdf.  
19  CMS. (2022).  Coverage and Reimbursement of COVID-19 Vaccines, Vaccine Administration, and Cost-Sharing 
under Medicaid, the Childrens Health Insurance Program,  and Basic Health Program. Available at 
https://www.medicaid.gov/state-resource-center/downloads/covid-19-vaccine-toolkit.pdf.   
 
  Page 8  State Health  Official Letter  
 
temporary  FMAP increase beginning  April 1, 2023, implementation of these conditions  will help  
states minimize procedural denials and reduce the  administrative burden associated with churn.  
These new  conditions and how states may comply with them  are described  in detail below.   
 
We understand that states may be  concerned about whether their plan to comply with one or  
more conditions for receiving the temporary  FMAP increase beginning April 1, 2023, is 
sufficient.  CMS is available to work with states to evaluate the sufficiency  of their plans and  
identify additional measures that states can consider to ensure satisfaction of all conditions. 
 
Compliance with Federal Renewal Requirements  
 
As indicated above, in order to claim the temporary  FMAP increase after March 31, 2023, under  
section 6008(f)(2)(A) of  the FFCRA, states  must conduct  Medicaid  redeterminations consistent  
with federal  requirements, including any renewal  strategy approved under  section 
1902(e)(14)(A) of the Act or other CMS-authorized processes  and procedures. 
  
Federal requirements related to redeterminations of eligibility  are described at 42 CFR   
435.916. Under federal regulations at  435.916, states must comply with the following  
requirements:  
   Ex Parte  Renewals:  Begin the renewal process for all beneficiaries, including both those  
whose financial eligibility  is  based on modified adjusted gross income  (MAGI) (MAGI-
based beneficiaries)  and those whose financial eligibility is not based on MAGI (non-
MAGI beneficiaries), by redetermining eligibility  without requiring information from 
the individual, if the state is able to do so based on reliable information contained in the  
individuals account or  more current  reliable information available to the  state.  This  
information may  include, but  is  not limited to, information accessed  through data sources, 
consistent with the states verification plan;   
   Renewal Form:  Provide  a renewal form  that  requests only information needed to 
determine eligibility20 when eligibility cannot be renewed on an ex parte basis.  This  
form must be pre-populated for MAGI-based  beneficiaries;   
   Reasonable Timeframe  and Modalities to Return Form:  Provide MAGI-based 
beneficiaries with a minimum of 30 days to return their pre-populated renewal form and 
any  requested information.  Provide non-MAGI beneficiaries with a reasonable period of  
time to do so.  Beneficiaries must be able to return their renewal form through any of the 
modes of submission described at  435.907(a) (online, by phone, by mail, or in-person);  
   Determine Eligibility on  All Bases:  Consider all bases of Medicaid  eligibility prior to 
determining  an individual is ineligible for Medicaid and terminating  coverage;21   
   Advance Notice and  Fair Hearing Rights:  Provide a minimum of 10 days  advance 
notice22  and fair-hearing rights prior to terminating  or reducing Medicaid eligibility, in  
                                                      
20  For example, a form that requests that a beneficiary provides their Social Security Number, citizenship or  
immigration status would  not satisfy the  requirement.  Such information is only needed once and, thus,  would not be  
needed to renew eligibility.  
21  42 CFR  435.916(f)(1) and 435.930(b).  
22  42 CFR   431.211 requires the state to send a notice at least 10 days before the date of action,  which is defined at 
  431.201 as the intended date on  which a termination, suspension, reduction, transfer or discharge becomes  
effective.  
 
 
  Page 9  State Health  Official Letter  
 
accordance with  435.917 and 42 CFR Part 431, Subpart E;   
   Assess Eligibility for Other  Insurance  Affordability  Programs (IAPs) and Transfer  
Accounts as Appropriate:  For individuals determined ineligible for Medicaid, assess  
eligibility for other  IAPs  (including CHIP, BHP, and qualified health plans  (QHPs) 
offered through a Health  Insurance Marketplace23 with advance payments of premium  
tax credits or cost-sharing reductions), and transfer the individuals  account to the  
appropriate program.  States with Marketplaces  that use the federal eligibility and  
enrollment platform are reminded that they should only transfer  accounts to the  
Marketplace for individuals about  whom the state  has sufficient information to determine  
Medicaid  and CHIP  ineligibility.  States  with Marketplaces  that use the federal eligibility  
and enrollment platform  should not transfer accounts to the Marketplace  for individuals  
whose  Medicaid  or CHIP  coverage is  terminated  for procedural reasons, such as failure to  
return a renewal form or  other requested  information needed to determine eligibility.24   
States that operate State-based  Marketplaces using their own platform  may, at state  
option, transfer accounts  to the Marketplace for  a  determination of advance payments of  
premium tax credits or cost-sharing reductions  for individuals whose coverage has  been  
terminated  from Medicaid or CHIP for procedural reasons; and  
   Reconsideration Period:  Reconsider eligibility  without  requiring a  new application for 
MAGI-based beneficiaries whose coverage is terminated for failure to return their  
renewal forms  or necessary information if the  individuals renewal form or  information is  
returned within 90 days (or longer if elected by the state) after  coverage is  terminated.  
States may, at their option, apply this policy to non-MAGI beneficiaries.  
 
In evaluating compliance with  435.916, states are directed to  the CIB, Medicaid and 
Childrens Health Insurance Program Renewal Requirements,25  released on  December 4, 2020, 
for more information on federal redetermination requirements.  
 
States that are unable to comply with one or more of the requirements in  435.916 may satisfy  
the condition in section 6008(f)(2)(A) of the FFCRA, as  added  by section 5131(a), by  
implementing renewal strategies authorized under  section 1902(e)(14)(A) of the Act or other  
alternative policies and procedures that CMS authorizes and approves  as sufficient  for purposes  
of satisfying  section 6008(f)(2)(A) and claiming the temporary  FMAP increase.  Depending on 
the states systems and processes, states that are unable to  comply  with all requirements set forth  
in  435.916 may need to adopt multiple alternative strategies in order to claim the temporary  
FMAP increase after March 31, 2023.  States can  refer to SHO #22-00126 or the section 
                                                      
23  Health Insurance Marketplace is a registered service mark of the U.S. Department of Health  & Human  Services.  
24  CMS. (July 25, 2016).  Coordination of Eligibility and Enrollment Between Medicaid, CHIP and the Federally  
Facilitated Marketplace (FFM or Marketplace)  [CMCS Informational Bulletin].   Available at 
https://www.medicaid.gov/federal-policy-guidance/downloads/cib072516.pdf.   
25  CMS.  (December 4, 2020).  Medicaid and Childrens Health Insurance Program (CHIP) Renewal Requirements  
[CMCS Informational Bulletin].  Available at: https://www.medicaid.gov/federal-policy-
guidance/downloads/cib120420.pdf.  
26  CMS. (March 3, 2022).  Promoting Continuity of Coverage  and Distributing Eligibility and Enrollment Workload 
in Medicaid, the Childrens Health Insurance  Program (CHIP), and Basic Health Program (BHP) Upon 
Conclusion of the COVID-19  Public Health Emergency  [State Health Official Letter #22-001].  Available at 
https://www.medicaid.gov/federal-policy-guidance/downloads/sho22001.pdf.  
 
 
  Page 10  State Health  Official Letter  
 
1902(e)(14)(A)  waivers portion of the CMS unwinding website27 for details on section 
1902(e)(14)(A)  alternative renewal strategies that  CMS can authorize and how to submit a  
request for such authorization to CMS.  States  may  also reach out to their CMS state lead for  
more information and to obtain technical assistance.  CMS is available to work with  states  that 
are unsure of whether they  meet a given regulatory renewal requirement and to  provide technical  
assistance on section 1902(e)(14)(A)  waivers or other CMS authorized alternative processes  that 
may be implemented to  satisfy section 6008(f)(2)(A) of the  FFCRA for purposes of  claiming the  
temporary  FMAP increase after March 31, 2023.  
 
We remind states that, regardless of  whether  a state is claiming the temporary  FMAP increase,  
all states  must comply with federal renewal requirements.  States that do not meet federal 
renewal requirements may  be subject to corrective action under section 1904 and, if the  
noncompliance occurs during the period that begins on April 1, 2023, and ends on June 30, 2024, 
may be subject to corrective action under section  1902(tt)(2)(B) of the Act  (added by section 
5131).  See discussion in the  Monitoring State Progress and Corrective Action  section  of this  
letter for additional information on corrective action under section 1902(tt)(2)(B) of the  Act.  
 
Up-to-Date Contact Information 
 
As a condition of claiming the temporary  FMAP increase after March 31, 2023, under section 
6008(f)(2)(B) of the  FFCRA, as added by section 5131(a), a state must  attempt to ensure that it 
has  up-to-date  contact information for each individual for whom it conducts  a renewal.28   This  
condition requires that states use  the United States Postal Service (USPS) National Change of  
Address (NCOA) database,  information maintained by  state health and human services  agencies, 
or other reliable sources  of contact information.  For purposes of compliance  with this condition, 
the types of contact information a state must attempt to update include a beneficiarys mailing  
address, phone number, and email address.  States may need to use multiple data sources and/or  
adopt multiple strategies  in order to update  all types of beneficiary  contact  information.  
 
The NCOA database information is limited to  mailing address information and does not provide  
email addresses or phone numbers.  Additionally, for  some beneficiaries,  the NCOA database 
will not provide up-to-date mailing address information, and other  state agency databases  may 
not have such contact information  either.  Therefore, to satisfy this condition, states  will need to  
take other reasonable actions in an effort  to obtain up-to-date information.  Managed care 
organizations (MCOs)  are a particularly effective source of  reliable contact information for  
beneficiaries, and  CMS strongly encourages states that contract with MCOs to work with them to 
obtain up-to-date contact information.  States  could also look to beneficiaries themselves  as a 
reliable source of  contact information and use beneficiary  outreach initiatives encouraging  
beneficiaries  to update  their  contact information.  
 
Implementing a  robust plan to obtain up-to-date contact  information for multiple modes  of 
communication will also  assist states in  meeting the returned-mail condition under section 
                                                      
27  CMS. (2022).  COVID-19 PHE Unwinding Section 1902(e)(14)(A)  Waiver Approvals.  Available at 
https://www.medicaid.gov/covid-19-phe-unwinding-section-1902e14a-waiver-approvals/index.html.  
28  As  noted above,  the conditions  in section 6008(f) of the FFCRA  apply to Medicaid renewals  that are conducted  
during any quarter during the period beginning  April 1, 2023,  and ending  December 31, 2023, in states  claiming the 
temporary  FMAP increase for  that  quarter.   
 
  Page 11  State Health  Official Letter  
 
6008(f)(2)(C) of the  FFCRA, described below, under which states must make a  good-faith effort  
to contact an individual through more than one modality prior to terminating coverage on the  
basis of returned mail.  
 
In order to comply with the up-to-date contact information condition, states should consider the  
following:  
  Sources  of  Up-to-Date Contact  Information:   States must use  the NCOA database, 
information maintained by  a state health and human services agency, or other reliable
sources of  contact information.  States have broad discretion to determine which other 
sources of  contact information are reliable for the purposes of this provision but must 
document the sources and other processes used  in their  unwinding operational plan.  For 
example, many states have implemented  beneficiary outreach  strategies using direct
phone calls, mass mailings, social media, or other mass communication strategies to 
prompt beneficiaries to provide up-to-date information themselves.  Contact information
received directly from beneficiaries in response to  an outreach campaign  could 
reasonably be considered reliable.   States have also worked with  other  entities  to obtain
up-to-date beneficiary contact  information, in addition to accessing the NCOA.  Updated
contact information received from an MCO under  contract with the  state,  for example,  is
generally considered to be a reliable source of information.  Further, states can request 
section 1902(e)(14)(A) waiver authority to update  an individuals case  record with up-to-
date contact  information from one of its MCOs without first having to confirm the change 
with the individual.
  Attempt to Ensure Up-To-Date Contact  Information:  States must attempt to ensure  they
have up-to-date contact information for each individual for whom they will conduct an
eligibility redetermination.  We interpret this  condition to mean that a state must
implement  a comprehensive plan for confirming that they have up-to-date information on
beneficiaries before their eligibility is redetermined, including  a plan that uses  reliable
data sources and adopts  other reasonable strategies  that apply broadly to the  states 
Medicaid population (e.g., routinely obtaining updated contact information from 
managed care organizations or broad outreach campaigns). 
  Timing of Attempt to Ensure Up-to-Date Contact Information:   States must have recent 
and reliable information, or have recently attempted to obtain up-to-date contact 
information  as described  immediately above, prior to initiating a  renewal  for an 
individual  to minimize the possibility that the information  in the case record has become
outdated.  For example,  CMS would consider quarterly  data matches with  NCOA or 
adoption of the section 1902(e)(14)(A)  strategy involving MCOs providing updated
contact information about a beneficiary whenever  they obtain it, to be  a recent  attempt.
  Document Strategies to Update Contact  Information in Unwinding Operational Plan: 
States  must document in their unwinding operational  plan the strategies  and processes  for 
obtaining up-to-date contact information for beneficiaries in order to demonstrate 
compliance with the condition for claiming the temporary FMAP increase  described in
section 6008(f)(2)(B) of the FFCRA.
 
 
 
 
 
 
  Page 12  State Health  Official Letter  
 
In  implementing policies and procedures to satisfy  this condition, states may  want to review  
pages 36-40 of  SHO #22-001,29 in which CMS discusses several strategies for  states to  
reestablish communication with beneficiaries, such as working with MCOs, social services  
organizations, and other  entities.  States are strongly encouraged to  implement several  strategies  
to ensure an attempt is made to obtain up-to-date contact information for  all beneficiaries, 
including  strategies that  target hard-to-reach, homeless, rural, or Tribal populations for whom  
many strategies  may be less effective.  For instance, due to limited postal delivery and broadband 
services  in Tribal communities, we encourage states to engage with the Indian Health Service 
(IHS),  Tribes and Tribal  organizations, and urban Indian organizations (collectively,  ITU) to  
help with updated contact information for Tribal  Medicaid beneficiaries, including sharing  
enrollment and renewal data with  ITUs.  We remind states that such data sharing must be  
consistent with Medicaid confidentiality  standards  under section 1902(a)(7)(A) of the  Act and 42 
CFR part 431, subpart  F, and applicable privacy laws.30 
 
Further, we remind states  that if they  have received approval under  a section 1902(e)(14)(A)  
waiver  related to updating beneficiary contact information,31 there may be  several sources of  up-
to-date contact information they  can rely on  without first confirming  a change with beneficiaries.  
The  waiver(s) could make it easier for the state to  ensure that  it has up-to-date  beneficiary  
contact information and complies  with this  condition.  We encourage states that do not currently  
have such an approved waiver to consider submitting a  request to CMS for  approval.32  
 
Contact Beneficiaries Using More Than One Modality Prior to Terminating Enrollment on the  
Basis of Returned Mail  
 
In order to claim the FFCRA temporary  FMAP increase  after March 31, 2023, states must 
comply with section 6008(f)(2)(C) of the  FFCRA, as added by section 5131(a), which provides  
that when  states receive  returned mail in response  to a redetermination of eligibility, they  must 
undertake a good-faith effort to contact an individual using more than one  modality prior to 
disenrollment on the basis of returned mail (returned-mail condition).  
  
Nothing in the CAA, 2023 changes federal  Medicaid rules regarding the steps that states are 
required to take upon receipt of returned mail.  These rules apply  regardless of whether  a state is  
conducting redeterminations during  its  unwinding period.  We remind states that there are  
                                                      
29  CMS. (March 3, 2022).  Promoting Continuity of Coverage  and Distributing Eligibility and Enrollment Workload 
in Medicaid, the Childrens Health Insurance  Program (CHIP), and Basic Health Program (BHP) Upon 
Conclusion of the COVID-19 Public  Health Emergency  [State Health Official Letter #22-001]. Available at 
https://www.medicaid.gov/federal-policy-guidance/downloads/sho22001.pdf.  
30  See Presentation: Strengthening Tribal and State Partnerships to Prepare for Unwinding  (Posted 8/30/2022)  
Available at https://www.medicaid.gov/sites/default/files/2022-08/strengthening-tribal-partner-to-prepare-
unwinding-081822.pdf.  
31  See the COVID-19 PHE Unwinding Section 1902(e)(14)(A) Waiver Approvals page  for  more information on  
these  strategies at https://www.medicaid.gov/covid-19-phe-unwinding-section-1902e14a-waiver-
approvals/index.html.  
32  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.  
 
 
  Page 13  State Health  Official Letter  
 
generally three types of beneficiary mail that could be returned to the Medicaid agency: (1) mail  
with an in-state forwarding address; (2) mail with an out-of-state forwarding address; and (3)  
mail that does not include a forwarding address.   States must continue to follow existing  
requirements for processing each of these types of  returned mail including confirming whether  
the address information on the piece of  returned mail is complete and consistent with the address  
information the state has  on file.33 
  
The new returned-mail condition under  section 6008(f)(2)(C) of the  FFCRA  applies specifically  
to situations in which the state sends a notice to a  beneficiary, instructing them to return a  
renewal form.   For the purposes of meeting this returned mail condition, we define a  good faith 
effort to contact an individual using more than one modality to mean: (1) the state has a process  
in place to obtain up-to-date mailing addresses  and additional contact information (i.e., telephone  
numbers, email addresses) for all beneficiaries; and (2) the state attempts to reach  an individual 
whose mail is returned through  at least two modalities using the most up-to-date contact  
information the state has  for the individual, which could include a  forwarding address if one is  
provided on the returned mail.  
 
States also should consider the following:  
  Up-to-Date Contact Information:  The requirement to obtain up-to-date contact 
information for purposes  of complying with the returned mail condition will be satisfied 
if the state has met the condition described in section 6008(f)(2)(B) of the  FFCRA to
attempt to obtain an up-to-date mailing  address, phone number, and email address for all 
beneficiaries due for a renewal.   In addition to the data sources described in section 
6008(f)(2)(B) of the  FFCRA, MCOs  are a particularly  effective source of reliable contact 
information for beneficiaries, and CMS strongly encourages states that contract with
MCOs to work with them to obtain up-to-date contact information. 
  Permissible Modalities:   States have discretion in the types of modalities they  rely upon
to satisfy the returned mail condition.  Such modalities may include  mail,  telephone,
email, text messaging, communication through an online portal, or other commonly 
available electronic means.34  
 
The returned-mail condition under section 6008(f)(2)(C) of the  FFCRA  applies whenever  
beneficiary mail is returned to the state agency  in response to a redetermination of eligibility, 
thus prompting  states to process the  returned mail and  requiring states to make a good faith effort  
to attempt to contact the beneficiary using more than one modality.  States should follow these  
steps to meet the returned mail condition of attempting to make a  good  faith effort to contact the 
beneficiary through two  modalities.  
  Returned Mail has Complete  Information:   Generally, when beneficiary mail is  returned,
states must ensure that the mail was sent to the intended address by comparing the 
                                                      
33  For a detailed discussion on the requirements for processing returned mail, see  Appendix C of:  CMS.  (March  
2022).  Promoting Continuity  of Coverage and Distributing Eligibility and Enrollment Workload in Medicaid, the  
Childrens Health Insurance  Program (CHIP), and Basic  Health Program (BHP) Upon Conclusion of the COVID-
19 Public Health Emergency  [State Health Official Letter  #22-001].  Available at 
https://www.medicaid.gov/federal-policy-guidance/downloads/sho22001.pdf.  
34  Phone calls and text  messages, initiated either directly by the  state agency or through a  state contractor or partner,  
must be compliant with Federal communications laws  such  as the Telephone Consumer Protection Act.   For more  
information, see: https://www.fcc.gov/document/fcc-provides-guidance-enable-critical-health-care-coverage-calls.  
 
  Page 14  State Health  Official Letter  
 
completeness and accuracy of the address on the returned mail against the information in 
the beneficiarys record.  If the address listed on the original mailing contains an error or  
is missing information, such as an apartment number, the state must resend the returned 
notice to a completed address.  If the subsequent  mailing to the beneficiarys  correct  
address is not returned, the state is no longer required to take additional steps to meet the  
returned mail condition by  attempting to contact the beneficiary using an  additional 
modality.  If the subsequent mailing to a  corrected  address is returned, the state would 
proceed  as indicated below based on whether the returned mail has a forwarding address  
or not. 
   Returned Mail with No Forwarding Address:  When  a state receives returned mail with  
no forwarding  address, it must attempt to contact the beneficiary through two modalities, 
including by phone, email, text, or other available modalities.   If the state only has one 
other mode of contact available, such as only an  email address, the state must attempt to  
contact the beneficiary using that one modality; in this instance, the state will be  
compliant with the returned mail condition provided that it has complied with the up-to-
date contact information condition.  Similarly, if the state has no other modalities  
available to contact the beneficiary, the state similarly  will be compliant with the returned  
mail condition if it has satisfied the up-to-date  contact information condition.   
   Returned Mail  with a Forwarding Address:  
  States are not required to send the returned mail to the forwarding address, but  
doing so would represent one attempt to contact the beneficiary for purposes of  
the returned mail condition.  
  If the beneficiarys returned mail contains a forwarding address,  and the state 
sends the original mailing to the forwarding  address,35 except as noted below, the 
state would need to attempt to contact the beneficiary through at least one other  
modality, if available, to comply with the returned mail condition.  If the state has  
no other modalities available to contact the beneficiary, the state  will be  
compliant with the returned mail condition if it has  satisfied the condition to 
obtain up-to-date contact information from all beneficiaries.   Importantly, if the 
notice is mailed to the forwarding address and is not returned to the state, the  
returned mail condition no longer  applies  because the original mailing has been  
completed and is no longer considered to be returned.  Under these circumstances,  
no additional outreach is  required.  
  If a state is  unable to or does not send the correspondence to the forwarding 
address, the state must attempt to contact the beneficiary through two modalities,  
if available, prior to termination.   If the state only  has one other mode of contact  
available, such as only  an email address, the state must make a good faith effort to 
contact the beneficiary using that one modality.  If the state does not send the  
notice to the forwarding  address and does not have two other modes  of contact,  
the state will need to document in their unwinding operational plan why it is  
unable to send notices to a forwarding address.  
   Lack of Alternative Contact  Information:  A state  that has satisfied the condition  
described in section 6008(f)(2)(B) of the  FFCRA to attempt to obtain up-to-date contact  
information for other modalities but was not able to obtain such alternative  contact  
                                                      
35  States  may request section 1902(e)(14)(A)  waiver authority  to update a beneficiarys address information  from the 
USPS  without first reaching out to confirm the change  with the individual.  
 
  Page 15  State Health  Official Letter  
 
information for a  given beneficiary will not violate the returned mail condition due to not  
reaching out to the beneficiary through another modality as long as the state has taken the 
steps outlined above to reach the individual by mail (i.e., resending the notice to a  
corrected address, if applicable, and sending the notice to a forwarding address, if  
provided and the state is  able to do so).   For example, if after  complying with the  
condition described in section 6008(f)(2)(B), the only contact information available to the  
state is the address  in  the individuals case record, and the state does not have a phone  
number, email address or other means to contact the individual, the state would be in  
compliance with section 6008(f)(2)(C).  If a  state  has documented in its unwinding  
operational plan why  it is unable to mail  a notice to a forwarding address and has no 
other modalities available, the state has  complied with the returned mail condition.   
   Document Returned Mail Policies in Unwinding Operational Plan:   States  must document  
in their unwinding operational plans  their  process for  undertaking a good-faith effort to  
contact individuals using more than one modality  prior to disenrollment on the basis of  
returned mail.  States must also document their inability to send mail to a forwarding  
address, if applicable.  
 
Attempting to reach beneficiaries through other modalities after beneficiary mail is returned  in 
response to a redetermination of eligibility  is necessary  to satisfy the returned mail condition, 
and it  may also  help reduce procedural denials and churn.  In addition, MCOs are  an important  
tool for conducting outreach to individuals when a state is not able to reach a beneficiary.  CMS  
strongly encourages states that contract with MCOs to work with them on other avenues to reach  
and support eligible beneficiaries in maintaining coverage through Medicaid or the  
Marketplace.36   To ensure beneficiaries are able to  complete the renewal process, states should  
ensure that, if they successfully contact an individual after  receiving beneficiary returned mail,  
the beneficiary receives any necessary renewal forms at their correct address and has sufficient  
time to return the renewal form and complete the renewal process.  
Additional Considerations and Process for Claiming the Temporary  FMAP Increase  
 
State Attestation of Compliance  
  
As  discussed above, states may claim  federal financial participation (FFP)  associated with  the 
temporary  FMAP  increase under section 6008 of the FFCRA, as amended by section 5131(a), 
after March 31, 2023, only  if they  meet the conditions  described in subsections 6008(b)(1), (2), 
(4), and 6008(f).  While states are ineligible for the temporary  FMAP increase unless they meet 
these conditions, CMS will not require that states submit a demonstration of compliance prior to  
drawing FFP associated  with the temporary  FMAP  increase.  Each state should be aware that  
when it draws  FFP associated  with  the temporary  FMAP  increase in the  Payment Management  
System (PMS), it is attesting that:   
(1)  It is eligible for the temporary  FMAP increase;  
(2)  The expenditures for which it is drawing  FFP are those for which the temporary  FMAP  
increase  is applicable;  and   
                                                      
36  For a detailed discussion on engaging managed care plans, see:  CMS. (January 2023).  Strategic Approaches to 
Engaging Managed Care Plans to Maximize Continuity of Coverage as States Resume Normal Eligibility and 
Enrollment Operations.   Available at:  https://www.medicaid.gov/resources-for-states/downloads/health-plan-
strategy.pdf.  
 
  Page 16  State Health  Official Letter  
 
(3)  It meets the applicable  conditions in section 6008(b) and (f) of the  FFCRA  for claiming  
the temporary  FMAP  increase.  
 
To minimize the need for separate review, avoid state burden, and expedite providing  federal  
matching funds  to states,  CMS will  indicate in each  grant award letter  it sends to states  that, by 
drawing down the funds, the state is  attesting that it  is in compliance with all federal 
requirements, including  that the state meets all applicable conditions for receiving the temporary  
FMAP increase, subject to expenditure review.   This is the  same  process states have been  using  
to draw  FFP  associated  with the temporary  FMAP increase under  FFCRA section 6008 since the 
temporary  FMAP increase  became available.   
 
Further, CMS intends to engage states to provide technical  assistance regarding compliance and, 
as necessary,  will request additional information to assess compliance.  States may propose  
additional  strategies and  mitigation plans to  achieve compliance  with section 6008(f)(2) of the  
FFCRA for purposes of  claiming  the temporary FMAP  increase.  For example,  we understand 
that many states  face challenges in conducting  ex parte  renewals for some or all of  their  
populations.  These states  can adopt alternative strategies,  such as  section 1902(e)(14)(A) waiver 
strategies, including using  the Supplemental Nutrition Assistance Program  (SNAP)-based  
income  enrollment strategy, in order to satisfy the conditions described in section 6008(f)(2) of  
the FFCRA.  As noted above, states can  refer to SHO #22-001 or the section 1902(e)(14)(A)  
waivers portion of the CMS unwinding website for details on section 1902(e)(14)(A)  alternative  
renewal strategies that CMS can authorize and how to submit a request for  such authorization to 
CMS.   
 
CMS is also considering  additional strategies to support states  seeking to adopt alternative CMS-
approved strategies  to satisfy the  conditions in section 6008(f)(2) of the FFCRA needed to claim  
the temporary  FMAP increase between April 1, 2023, and December 31, 2023.  States interested  
in using any alternative strategies  should contact their CMS state lead.   
 
If CMS determines that a state that drew down FFP associated with the temporary  FMAP  
increase did not satisfy the conditions  under section 6008(b) and (f) of the  FFCRA, as modified 
by section 5131, during  a quarter in which those  conditions applied, the state will be required to  
return  the FFP associated  with  the temporary  FMAP  increase  for any quarter when it did not  
qualify.  
  
Process for Claiming FFP Associated with the Temporary  FMAP  Increase  
 
Qualifying  states can  claim the FFP associated with the temporary  FMAP  increase  for qualifying  
expenditures on a quarterly basis using the  Form CMS-64 submission in the automated Medicaid 
Budget and Expenditure  System (MBES).37  States should ensure that their quarterly  and, if  
applicable, supplemental  budget request on the  Form CMS-37 for the relevant period clearly  
indicates whether the state is requesting FFP associated with the  temporary  FMAP  increase and 
the amount of FFP.  CMS  will  ensure that the MBES and Medicaid and CHIP  Financial System  
                                                      
37  In addition to the attestation outlined above  within the grant award, states certify on the Form CMS-64 that they 
are claiming expenditures under the Medicaid program  (and  as applicable, under  CHIP)  only if the expenditures  are 
allowable in accordance with  applicable implementing  federal, state, and local statutes, regulations, policies, and the 
state plan.  
 
  Page 17  State Health  Official Letter  
 
(MACFin) are updated to enable state reporting, as applicable.  
 
Beginning April 1, 2023, the temporary  FMAP  increase is available for  each quarters  qualifying  
medical assistance expenditures until (and including)  December 31, 2023, for  states  that have 
met conditions in section 6008(b) and the new section 6008(f) of the FFCRA (discussed above).  
States should follow existing federal policy  regarding the particular match  rates that are  available 
for a given quarter.  Per  45 CFR  95.13(b), the applicable FMAP is based on date of payment, 
not date of service, for  current quarter original expenditures.  The FMAP applicable to  
expenditures for all prior  period adjustments should be the FMAP at which the original  
expenditure was claimed,  consistent with 45 CFR  95.13(b).  States  must report overpayments  
and collections at the same match rate at which the expenditures were originally claimed,  
including when the original rate incorporated the  FFCRA  FMAP increase.   Therefore, if  a 
Medicaid expenditure was claimed using the FFCRA  FMAP  increase, the  returned  federal share 
of any recoveries associated with that expenditure would reflect that same FMAP increase.  
Consistent with existing requirements at 42 CFR  433.32(a), states must  document expenditures  
to ensure a  clear  audit trail, including by isolating  expenditures that are matched at increased  
FMAPs.  CMS will conduct oversight to ensure  that  state expenditures are allowable and  
accurate, including with respect to the matching rate claimed.   
Please note that  under  the timely claims filing requirement at section 1132 of the Act and 45 
CFR part 95 subpart A, states must claim federal  Medicaid matching funds for qualifying  
expenditures  within  the two-year  time limit unless they meet one of the  four exceptions (see 45  
CFR   95.19). 
Reporting Requirements  
States  regularly  provide  a variety of data about  Medicaid and CHIP  applications, enrollment, and 
call-center activity  through the submission of the  Medicaid and CHIP Eligibility  and Enrollment 
Performance  Indicator data  and  the Transformed Medicaid  Statistical Information  System (T-
MSIS)  data,  as well as  other reporting mechanisms.  SHO #22-001 announced that states would 
be required to submit additional data through a new reporting tool as they restore routine  
eligibility and enrollment operations, including  resuming renewals, after the Medicaid  
continuous enrollment condition ends.  In March 2022, CMS released a new  Unwinding  
Eligibility and Enrollment Data Reporting Template (Unwinding Data Report)38  that states  
will use to submit a baseline data report and ongoing monthly  reports during  a states unwinding  
period.39   States that operate a State-based  Marketplace (SBM) with its own  eligibility and  
enrollment platform also  submit  QHP and BHP  enrollment metrics  (State-based Marketplace 
(SBM)  Priority Metrics)  to CMS, as required under  45 CFR 155.1200(a)(3).  CMS anticipates  
                                                      
38  The Unwinding Data Report and Unwinding Data Report Specifications are available at  
www.Medicaid.gov/unwinding. States  will submit their baseline and  monthly Unwinding Data Reports through the  
same portal used to submit Performance Indicator data,  which is available at  https://sdis.medicaid.gov/user/login.  
39  For an explanation that states must submit baseline unwinding data by February 8, 2023,  March 8, 2023, or April  
8, 2023,  depending on  when a  state initiates renewals,  see: CMS. (2023).  Key Dates Related to Medicaid Continuous  
Enrollment Condition Provisions in the Consolidated Appropriations Act, 2023  [CMCS Informational Bulletin].  
Available at: https://www.medicaid.gov/federal-policy-guidance/downloads/cib010523.pdf.  
 
  Page 18  State Health  Official Letter  
 
that SBMs with their own eligibility and  enrollment platforms will use these existing reports to  
submit monthly data during a states unwinding period.  
New section 1902(tt)(1)  of the Act, as  added by section 5131(b), requires that, during the period 
that begins on April 1, 2023, and ends on June 30, 2024, states submit to CMS, and CMS makes  
public, certain monthly data about  activities related  to  eligibility  determinations and 
redeterminations conducted during that same period.  CMS  currently  believes  that all the data  
states must report under these new  reporting requirements are included in existing data sources, 
including the unwinding  data report  and SBM priority metrics.  As such, CMS does not  
anticipate that states will need to submit a separate report (or  additional reporting) to CMS to 
comply with section 1902(tt)(1) of the  Act.  Rather, CMS anticipates that states  will be able to  
submit the data metrics required under section 1902(tt)(1) through the appropriate existing CMS  
data reporting tool.  CMS reserves the  right to add reporting metrics, if needed, in the future.  As  
needed, CMS will provide states additional  guidance and information on the data specifications  
for metrics reported to satisfy the reporting requirements under section 1902(tt)(1) of the  Act.  
While CMS currently believes that states can meet the reporting requirements in section  
1902(tt)(1) of the  Act through existing reports and reporting tools, the timing of  certain state  
reporting  may need to change to  satisfy  the timeline  under section 1902(tt)(1) of the Act.  
Specifically, states will need to submit monthly  unwinding data reports through June 30, 2024.  
This timeline reflects a  change from previous  guidance regarding unwinding data, as some states  
may submit monthly unwinding data  for a period that exceeds 14 months, depending on when 
the state initiates its first batch of renewals.40   
As noted, with regard to the reporting of data under section 1902(tt)(1)(D), CMS anticipates that 
states with Marketplaces  that operate their  own eligibility and  enrollment platform will use  
existing reports to satisfy this requirement.   Additionally, for states with Marketplaces that  use 
the Federal eligibility and enrollment platform, CMS expects to report the required data on  
behalf of states, to the  extent possible.  CMS therefore does not  anticipate that states with  
Marketplaces that use the  Federal eligibility and  enrollment platform will need to report any  
additional data to satisfy  this requirement.  
CMS will publish all data that is reported to comply with section 1902(tt)(1) of the Act. 
However, for  a number of reasons, Medicaid and CHIP data sent to Marketplaces that use the  
Federal eligibility and  enrollment platform41 do not, on their own, specify  when an individuals  
account has been transferred to the Marketplace because that person is not eligible for, or is  
losing, Medicaid or CHIP coverage.  CMS intends to explore using additional data sources to 
determine and report which account transfers to Marketplaces that use the  Federal eligibility and  
enrollment platform result from Medicaid or CHIP redeterminations.  To publish data that  
identifies which of these account transfers  result from Medicaid or CHIP redeterminations, CMS  
might have to make estimates based on several administrative data sets, which limits both the  
                                                      
40  CMS. (March 3, 2022).  Promoting Continuity of Coverage  and Distributing Eligibility and Enrollment Workload 
in Medicaid, the Childrens Health Insurance  Program (CHIP), and Basic Health Program (BHP) Upon 
Conclusion of  the COVID-19  Public Health Emergency  [State Health Official Letter #22-001]. Available at 
https://www.medicaid.gov/federal-policy-guidance/downloads/sho22001.pdf.   
41  All Marketplaces that use the  Federal eligibility and enrollment platform  have  eligibility systems  that  are not  
integrated  with Medicaid or CHIP.  
 
  Page 19  State Health  Official Letter  
 
accuracy  and timeliness of public reporting.  Working within these constraints, CMS expects to 
make these account transfer data public as expeditiously as possible.  
In  Table 2, CMS identifies each  reporting element  under section 1902(tt)(1)  of the Act  and the  
data source that  CMS  anticipates that  states (or the Marketplaces that use the Federal platform)  
will use to satisfy each element.  
Table 2. Reporting  Elements Under Section 1902(tt)(1) for the  Period from April 1, 2023, 
through June 30, 2024, and Corresponding  Data Sources   
 
  Reporting  Element    Data Source   
Apply to All States   
1   Total number of  Medicaid and  CHIP   Unwinding Data Report, Monthly Metric  
beneficiaries for  whom a renewal was   442  
initiated  
2   Total number of  Medicaid and CHIP   Unwinding Data Report, Monthly Metric  
beneficiaries  whose  Medicaid or CHIP   5a   
coverage is  renewed   
3   Of the  Medicaid and CHIP beneficiaries   Unwinding Data Report, Monthly Metric  
whose  Medicaid or CHIP coverage is   5a(1)  
renewed, those whose coverage is renewed  
on an  ex-parte  basis  
4   Total  number of  individuals  whose coverage   Unwinding Data  Report, Monthly Metric  
for Medicaid or CHIP  was terminated   5b and Unwinding Data Report, Monthly  
Metric 5c  
5   Total number of  individuals  whose coverage   Unwinding Data Report, Monthly Metric  
for Medicaid or CHIP  was  terminated for   5c  
procedural reasons   
6   Total number of  beneficiaries who were  T-MSIS, CHIP-CODE43  
enrolled in a separate CHIP  
7   For each  state call center, total call center   Medicaid and CHIP Eligibility  and 
volume    Enrollment Performance,  Indicator 144  
8   For each  state call center, average wait times   Medicaid and CHIP Eligibility  and 
Enrollment Performance,  Indicator 2  
 
9   For each  state call center, average  Medicaid and CHIP Eligibility  and 
abandonment rate    Enrollment Performance,  Indicator 3  
                                                      
42  Unwinding Data Report Specifications are available at:  https://www.medicaid.gov/sites/default/files/2022-
12/unwinding-data-specifications-dec-2022.pdf.   
43  The  T-MSIS Data Dictionary  is available at: https://www.medicaid.gov/medicaid/data-
systems/macbis/transformed-medicaid-statistical-information-system-t-msis/t-msis-data-dictionary/index.html.  
44  The Performance Indicator Data Dictionary is available on the Performance Indicator Technical  Assistance page 
at: https://www.medicaid.gov/medicaid/national-medicaid-chip-program-information/medicaid-chip-enrollment-
data/performance-indicator-technical-assistance/index.html.   
 
  Page 20  State Health  Official Letter  
 
  Reporting  Element    Data Source   
Apply to  Marketplaces that use the Federal eligibility and enrollment platform (Non-
Integrated Eligibility System)   
10   Total number of individuals  whose accounts   Marketplaces  that use  the  Federal  
are received at the Marketplace  from the   eligibility and  enrollment  platform 
state Medicaid/CHIP agency  due to a  (Federally-facilitated Marketplaces  and  
Medicaid/CHIP  redetermination   State-based Marketplaces on the Federal  
platform); states do not need to report  
11   In the  accounts  received  at the Marketplace   Marketplaces  that use  the Federal  
due to a Medicaid/CHIP  redetermination, the  eligibility and  enrollment  platform 
number of individuals who apply  for and are   (Federally-facilitated Marketplaces  and  
determined eligible for  a QHP   State-based Marketplaces on the Federal  
platform); states do not need to report    
12   In the  accounts  received  at the Marketplace   Marketplaces  that use the Federal  
due to a Medicaid/CHIP  redetermination  and  eligibility and  enrollment  platform 
who apply  for and are determined eligible   (Federally-facilitated Marketplaces  and  
for a QHP, the number of individuals who  State-based Marketplaces on the Federal  
select a plan   platform); states do not need to report   
Apply to  SBMs with their own platforms that use a Non-Integrated Eligibility System  
13   Number of individuals  whose accounts  are  SBM Priority Metrics,   
received  by the SBM  or BHP   Monthly Metrics 7a  and 7b 
 
14   Number of  individuals  whose accounts  are   SBM Priority Metrics,  
received  by the SBM  or BHP  and are   Monthly Metric 9a  and 172a  
determined eligible for  a QHP  or BHP  
 
15   Number of individuals whose accounts  are   SBM Priority Metrics,  
received  by the SBM or  BHP  and are  Monthly Metric 1a  and 169a  
determined eligible for  a QHP or a BHP  who 
make a QHP  plan selection or are  enrolled in 
a BHP  
Apply to  SBMs with Integrated Eligibility System   
16   Number of individuals who are determined  SBM Priority Metrics,  
eligible for a QHP  or  a BHP    Monthly Metric 9a  and 172a  
17   SBMs with  Integrated Eligibility System:  SBM Priority Metrics,  
Number of individuals who are determined  Monthly Metric 1a  and 169a  
eligible for a QHP  or BHP  and make a QHP  
plan selection  or are enrolled in a BHP   
As noted in SHO #22-001, states may be expected to report additional data  and/or report  
information more frequently in cases  where additional CMS oversight or enforcement is needed, 
such as when  reported data indicate states are not meeting the timelines to initiate and  complete 
 
  Page 21  State Health  Official Letter  
 
renewals for total caseload during the unwinding period.  CMS is available to provide technical  
assistance to ensure states understand metric data specifications and  are able to fulfill statutory  
reporting requirements.  
Monitoring State  Progress and Corrective Action  
In SHO #22-001, CMS announced that it will monitor states  compliance with  reporting  required 
data and meeting timelines relating to initiating  and completing  required  eligibility and  
enrollment actions during the states unwinding period.  Where  reported data or other  
information indicates  that states are not meeting unwinding timelines in SHO #22-001 and 
subsequent guidance, or in circumstances where data or other information demonstrate other  
potential compliance issues  including potential erroneous disenrollment of eligible  
beneficiaries  states may  be  expected to report additional data, including  the states unwinding  
operational plan, and/or report information more frequently.45  As explained in SHO #22-001, 
states that do not  resolve  their pending  eligibility  and enrollment actions within the timelines  
specified may be required to submit a corrective  action plan (CAP) to CMS outlining strategies  
and a timeline to come into compliance with federal requirements.  
 
In addition to enforcement and oversight authorities CMS already has under existing laws and 
regulations, section  1902(tt)(2)  of the Act  (added  by section 5131(b)) includes  new  enforcement  
mechanisms  for CMS to apply if  CMS determines  that a state is  not  in compliance with the  
reporting requirements in section  1902(tt)(1) of the Act, or if CMS determines that a state is non-
compliant  with  federal  eligibility redetermination  requirements during the  period that begins on 
April 1, 2023 and ends on June 30, 2024.  Specifically:  
   FMAP Reduction for  Failure to  Comply with Section 1902(tt)(1) Reporting 
Requirements:  If a  state does not satisfy the  reporting requirements in section 1902(tt)(1) 
of the Act during any  fiscal quarter that occurs during the period that begins on July 1, 
2023, and ends on June 30, 2024, the FMAP  determined for the  state for the quarter  
under section 1905(b) shall be reduced by the number of percentage points (not to 
exceed 1 percentage point) equal to the product of  0.25 percentage points and the  
number of fiscal quarters during such period for which the state has failed to satisfy such 
requirements.  CMS  will apply  FMAP reductions using MBES and intends  to provide 
more information in future  guidance regarding the FMAP reduction process. 
   Corrective Action for Failure to Comply with Section 1902(tt)(1) Reporting 
Requirements  or Federal  Eligibility Redetermination Requirements:  If a state  has been  
determined by CMS  to be out of compliance  with the reporting requirements in section 
1902(tt)(1) and/or  federal  eligibility redetermination requirements during the period that  
begins on April 1, 2023, and ends on June 30, 2024, CMS may  require the  state to submit 
and implement a CAP.  Under section 1902(tt)(2)(B)  of the Act, not later than 14 days  
                                                      
45  For explanation that  unwinding operational plans  must be made available to CMS upon request, see both:  CMS.  
(December 22, 2020).  Planning for the Resumption of Normal State Medicaid, Childrens  Health Insurance  
Program (CHIP), and Basic  Health Program (BHP) Operations Upon Conclusion of the  COVID-19 Public Health 
Emergency  [State Health Official Letter  #20-004], and CMS. (March 3, 2022).  Promoting Continuity of Coverage  
and Distributing Eligibility and Enrollment Workload in Medicaid, the Childrens Health Insurance Program  
(CHIP), and Basic Health Program (BHP) Upon Conclusion of the COVID-19 Public Health Emergency  [State  
Health Official Letter  #22-001].  These guidance documents  are available at https://www.medicaid.gov/federal-
policy-guidance/downloads/sho20004.pdf  and  https://www.medicaid.gov/federal-policy-
guidance/downloads/sho22001.pdf.  
 
  Page 22  State Health  Official Letter  
 
after receiving  a written  notice  that the state is out of compliance, the  state  must  submit a  
CAP to CMS.  The state must receive CMS approval for its proposed CAP not  later than  
21 days  after submitting it to CMS.  The state must initiate implementation  of the plan  
not  later than 14 days  after CMS approves it.  
   Suspension of Terminations  for Procedural Reasons  and Civil Monetary Penalties:  If a  
state fails to submit or implement an approved CAP  in accordance  with the  timelines and  
requirements described above, CMS may require a state under section 1902(tt)(2) to 
suspend some or all terminations of Medicaid eligibility  that are for procedural reasons  
until the state takes  appropriate corrective action  (as determined by CMS), and/or  may  
impose  on that state  a civil money penalty of not  more than $100,000 for  each day  that 
the  state is not in compliance.  
Implications for  Optional COVID-19 Group, Waivers Approved Under Section  
1902(e)(14)(A) of the Act, and Other  Authorities  
Even though section 5131 does not  address when  the COVID-19 PHE will  end, the changes in  
the CAA, 2023 could have  implications for certain COVID-19 PHE-related flexibilities and  
authorities.  We outline below  certain  implications  that  the changes made by  section 5131  may 
have for state  redeterminations for the optional COVID-19 group and for  waivers already  
approved under section 1902(e)(14)(A) of the  Act  that states intended to have in place when the  
continuous enrollment condition ends.  Certain other COVID-19 PHE related flexibilities  can  
remain in effect  for the duration of the COVID-19 PHE, including, but not limited to, Medicaid  
and CHIP  section  1135 waivers and disaster SPAs.  As a reminder, the requirements under  
sections 9811 and 9821 of  the ARP  apply until the last day of the first calendar quarter that 
begins one year after the COVID-19 PHE ends.  These  ARP  requirements include providing  
coverage, without cost sharing, of:  COVID-19 vaccinations;  COVID-19 testing;  treatments for  
COVID-19, including specialized equipment and therapies (including preventive therapies);  and, 
when certain conditions are met, treatment of conditions that may seriously  complicate the  
treatment of COVID-19.  The CAA, 2023 generally  does not impact  authorities tied to the end of  
the COVID-19 PHE (e.g., 1135 waivers, disaster relief SPAs). 
Optional COVID-19 Group 
Section 6004(a)(3) of the FFCRA created a new optional COVID-19 Medicaid eligibility  group 
at section  1902(a)(10)(A)(ii)(XXIII) of the  Act.  Section 9811(a)(2) of the  ARP amended the  
language following section 1902(a)(10)(G) of the  Act describing the  coverage that must be 
provided to the optional COVID-19 eligibility  group.  Federal authority for this eligibility  group  
expires on the last day of the  COVID-19 PHE.  States that adopted the optional COVID-19 
group may  continue to provide coverage  to  this  eligibility  group while the  COVID-19 PHE is in  
effect.  While federal authority for the optional COVID-19 group was not  amended in the  CAA, 
2023, the changes made  by the CAA, 2023 make  it possible for the continuous enrollment  
condition to  expire  before the end of the  COVID-19 PHE, which will have implications for  
redeterminations of eligibility for beneficiaries enrolled in the optional COVID-19 group.  
If the COVID-19 PHE  ends after the  continuous enrollment condition ends, states that opt to  
continue covering the optional COVID-19 eligibility group after the  continuous enrollment  
condition ends on March 31, 2023, will need to establish a process to initiate renewals for  
 
  Page 23  State Health  Official Letter  
 
individuals enrolled in the group following the end of the continuous enrollment condition.  
CMS recognizes that states that adopted a streamlined enrollment process outside of  their  
eligibility system to implement the optional COVID-19 group (e.g., using  a separate application 
to facilitate enrollment)  may face operational challenges initiating  renewals during unwinding  
and may not have sufficient information to complete a full renewal of eligibility, including  
assessing  all other bases  of eligibility.  These states may choose to deprioritize redeterminations  
for this group during the  unwinding period while they  work to establish such a process.  CMS is 
available to provide technical assistance if needed.  
When the COVID-19 PHE ends  (or earlier if the state initiates a regular renewal for beneficiaries  
in the optional COVID-19 group after the state begins its unwinding period and before the end of  
the COVID-19 PHE), states must redetermine  eligibility on all bases for beneficiaries who  are  
enrolled in the optional COVID-19 group and sunset the eligibility  group.  Guidance to assist  
states  with  meeting  the  requirements to redetermine eligibility on  all bases  when authority for the  
group expires  can be  found in the Ending Coverage in the  Optional COVID-19 Group Preparing  
States for the End of the Public Health Emergency  slide  deck.46   States  are reminded that they  
must stop claiming FFP for services provided to individuals enrolled in this group once the  
COVID-19 PHE ends.   
CMS will provide states that adopted the optional  COVID-19 group with additional guidance on 
redetermining eligibility  for these beneficiaries during the unwinding period if the  COVID-19 
PHE remains in effect.  States that opt to end coverage for this  optional eligibility  group before 
the COVID-19 PHE ends  may submit a SPA to CMS.  See the May 11, 2021, all-state call  slides 
for additional information.47   
Section 1902(e)(14)(A)  Waiver Effective Dates  
 
To support states facing significant operational issues with income and eligibility determination  
systems and to protect eligible beneficiaries from inappropriate  coverage losses during the  
unwinding period, CMS has granted more than 40 states section 1902(e)(14)(A)  waivers to 
support unwinding efforts.  The effective and/or expiration date of many of these approved 
waivers  is linked to the end of the  COVID-19 PHE.  Given that the  CAA, 2023 has de-linked the  
end of the continuous enrollment condition and the  start of the unwinding  period from the end of  
the COVID-19 PHE, the effective dates  of section  1902(e)(14)(A) waivers granted for the  
purpose of assisting states in their unwinding efforts may no longer  align with  states  unwinding  
timelines.  To minimize  administrative burden on states as they begin their unwinding process, 
CMS is providing the following  guidance to allow states to implement  modified effective dates,  
without needing to submit  a revised request to CMS.  States should, however, document any  
change in the effective date of a section 1902(e)(14)(A) waiver in their  records  and maintain a 
copy of this guidance.  
   Approved section 1902(e)(14)(A) waivers with a start date tied to the  COVID-19 PHE:  
Some states elected to make a section 1902(e)(14)(A) waiver  effective in the month the  
                                                      
46  CMS.  (October 2022).  Ending Coverage in the Optional COVID-19 Group Preparing States for the End of the  
Public Health Emergency.  Available at https://www.medicaid.gov/resources-for-states/downloads/ending-covrg-
optnl-covid-grp-guidance.pdf.  
47  CMS. (May 11, 2021).  All State Medicaid and CHIP Call.  Available at 
https://www.medicaid.gov/sites/default/files/2021-05/allstatecall-20210511.pdf.   
 
  Page 24  State Health  Official Letter  
 
COVID-19 PHE ends or  the month following the  end of the  COVID-19 PHE.  These 
states can now use the date of the end of the continuous enrollment condition (March 31, 
2023) in lieu of the end date of the COVID-19 PHE.  For example, if a state received  
CMS approval to begin a  section 1902(e)(14)(A)  waiver in the month after the end of the  
COVID-19 PHE, the states new start date would be the month after the end of the  
continuous enrollment provision (i.e., April 1, 2023).  
   Approved section  1902(e)(14)(A) waivers  with an expiration date tied to the  COVID-19 
PHE:   Some states have section  1902(e)(14)(A) waivers that  expire a certain number of  
months after the  COVID-19 PHE ends.  These states can now  replace  the date that the 
COVID-19 PHE ends with the date that the continuous enrollment conditions ends  
(March 31, 2023) for purposes of these  waivers.  For example, if a states  approved 
section  1902(e)(14)(A) waiver ends 14 months after the month that the  COVID-19 PHE  
ends, the state can elect to change the end date to 14 months  after the end of the 
continuous enrollment condition (i.e., May 31, 2024).  
   Approved section  1902(e)(14)(A) waivers  with an effective and/or  expiration date tied to  
the states unwinding period:   Some states have waivers that are effective when their  
state-specific unwinding  period begins.  Additionally, some states have waivers that  end 
12 months or longer  after the state-specific unwinding period, as defined in SHO #22-
001. These dates do not  need to be adjusted as a result of the  CAA, 2023.  
 
ARP Section 9817 Maintenance of Effort Requirements  
 
Section  9817 of the ARP provides qualifying states with a temporary 10 percentage point FMAP  
increase for  certain Medicaid  home and community-based services (HCBS) expenditures  
provided between April  1, 2021 and March 31, 2022.  Under ARP section 9817, states must  use 
the federal funds attributable to the increased FMAP to supplement, not supplant, state funds  
expended for Medicaid HCBS in effect as of April 1, 2021.  As discussed in SMD #21-00348 and 
SMD #22-002,49  states are expected to demonstrate compliance with  this requirement by  
maintaining  HCBS eligibility,  covered services, and payment rates  until the  state funds  
equivalent to the amount of federal funds attributable to the increased FMAP are fully expended.  
 
The CAA, 2023 did not change ARP section 9817, including the conditions  related to receiving  
that FMAP increase.  However, as discussed in SMD #21-003, the conditions for the FMAP  
increase under ARP section 9817 do not supersede other statutory or regulatory  requirements  
that apply to section 1915(c) waivers, or other requirements under other provisions authorizing  
HCBS.  As a result, if states have implemented temporary changes to HCBS eligibility, covered  
services, and/or payment  rates, states are expected  to retain those changes for as long  as  
allowable under those authorities (e.g., according  to the end date approved under an Appendix K  
but no later than 6 months  after the COVID-19 PHE ends), but CMS will not apply penalties or  
non-compliance  restrictions on the receipt of the increased FMAP once the authority for those  
                                                      
48  CMS.  (May 13, 2021).  Implementation of American Rescue Plan Act of  2021 Section 9817: Additional Support  
for Medicaid Home and Community-Based Services during the COVID-19 Emergency  [State Medicaid Director  
Letter  #21-003].  Available at:  https://www.medicaid.gov/federal-policy-guidance/downloads/smd21003.pdf.  
49  CMS. (June 3, 2022).  Updated Reporting Requirements and Extension of Deadline to Fully Expend State Funds  
Under American Rescue Plan Act of 2021 Section 9817  [State Medicaid Director Letter #22-002].  Available at: 
https://www.medicaid.gov/federal-policy-guidance/downloads/smd22002.pdf.  
 
  Page 25  State Health  Official Letter  
 
temporary changes has  expired or if the state needs to implement changes to comply with other  
federal statutory or regulatory  requirements.  
 
 Closing  
 
As states restore routine eligibility  and enrollment operations, CMS shares  states goals  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  (if they are  eligible for those other  coverage options), including Marketplace coverage.   
We are committed to providing states with updated guidance and resources, as appropriate, as  
well as ongoing technical assistance, to better  enable  states to  proceed with eligibility and  
enrollment work in a manner that is  consistent with  the changes  made under the CAA, 2023, as  
described in this letter.   For additional information and resources, states  are  encouraged to review  
guidance and other information posted to the  Medicaid.gov/Unwinding  page.   States may  also  
submit technical assistance questions directly to CMSUnwindingSupport@cms.hhs.gov.  
 
Sincerely,   
 
Daniel Tsai  
Deputy  Administrator and Director  
 
Cc:   
 
National Association of  Medicaid Directors   
National Academy for State Health Policy   
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