DEPARTMENT OF HEALTH  & HUMAN SERVICES  
Centers for Medicare & Medicaid Services  
7500 Security Boulevard,  Mail  Stop S2-26-12  
Baltimore, Maryland    21244-1850  
 
SHO#  22-001   
RE: Promoting Continuity of  
Coverage and Distributing 
Eligibility  and Enrollment  
Workload in  Medicaid, the 
Childrens Health Insurance 
Program (CHIP), and Basic  
Health Program (BHP)  Upon  
Conclusion of the COVID-19 
Public Health Emergency  
 
March  3, 2022  
 
Dear State Health Official:  
 
The ongoing Coronavirus Disease 2019 (COVID-19) outbreak and implementation of federal  
policies to address the public health emergency (PHE) have disrupted routine Medicaid, 
Childrens Health Insurance Program (CHIP), and Basic Health Program (BHP) eligibility and  
enrollment operations.  Over the course of the PHE, states  have  made policy,  programmatic, and  
systems  changes to respond effectively to COVID-19  and qualify for the temporary Federal  
Medical  Assistance  Percentage (FMAP) increase under section 6008 of the Families First  
Coronavirus Response Act (FFCRA) (P.L. 116-127), including by satisfying a  continuous  
enrollment condition for most Medicaid beneficiaries who were enrolled in  the program as of or  
after March 18, 2020.  
 
It  has been  a top priority  for the Centers  for Medicare & Medicaid Services  (CMS)  to ensure, 
when the PHE eventually ends and states resume routine operations, including terminations of  
eligibility, that renewals of eligibility  and transitions between  coverage programs occur in  an  
orderly process that minimizes beneficiary burden and promotes continuity  of coverage.  This  
State Health Official (SHO) letter expands on the guidance released in SHO #21-002, Updated  
Guidance related to Planning for the Resumption of Normal State Medicaid, CHIP, and BHP  
Operations Upon Conclusion of the COVID-19 Public Health Emergency, published on August  
13, 2021 (August 2021 SHO), by describing  how states may distribute eligibility and  
enrollment work when states restore routine operations, mitigate churn for  eligible beneficiaries,  
and smoothly transition individuals between coverage programs, including  coverage through the 
Federally-facilitated  Marketplace or  a State-Based Marketplace  (SBM).   
 
As with previous SHO letters issued by CMS regarding the PHE, this  SHO letter is intended to  
assist states in their planning efforts whenever  the federal PHE declaration  eventually  ends and 
does not presuppose a specific time frame in which that  will occur.  The Department of Health  
and Human Services  (HHS) will determine when the federal PHE declaration will end, and CMS  
will share with states any communication released by HHS.  
 
The contents of this document do not  have the force  and effect of law and are not meant to bind the public in any way, unless  
specifically incorporated into a contract. This document is intended only to provide clarity to the  public regarding existing  
requirements under the law.   Page 2  State Health Official  
 
In addition to resuming normal eligibility  and enrollment operations, authority for other types of  
disaster relief  flexibilities will conclude  when the  PHE  eventually  ends, and states will need to  
return to regular operations across their programs.   CMS  has approved almost 1,000 disaster  
relief actions for states during the PHE, many  for  non-eligibility  and enrollment-related  
flexibilities, including section 1135 waivers to delay provider revalidations, disaster relief state  
plan amendments  (SPAs)  to extend telehealth flexibilities, and section 1915(c) Appendix Ks to 
allow  the provision of services by  family members, among many others.   
 
States  need to determine  which temporary  flexibilities  they intend to extend temporarily or 
permanently, as  allowable, and  make plans to terminate other flexibilities  after the PHE  
eventually  ends.  Guidance to support states in these planning  efforts is available in SHO #20-
004, Planning for the Resumption of Normal State Medicaid, Childrens  Health Insurance  
Program (CHIP), and Basic Health Program (BHP) Operations Upon Conclusion of the COVID-
19 Public Health Emergency (December 2020 SHO).1  This guidance, which was released on  
December 23, 2020, provides information on returning to normal operations across these  
programs, including  requirements for making temporary changes permanent and ending  
temporary authorities, as well as operational and managed care  considerations for returning to 
normal operations.  Additional information will continue to be provided to states on streamlined  
processes to temporarily  extend authorities initially  adopted through disaster relief SPAs, as well  
as to add or modify authorities needed on a temporary basis as  a state returns to normal  
operations.2   
 
Table of Contents  
 
I.   Executive Summary ............................................................................................................. 3  
II.   Restoring Routine Eligibility  and Enrollment Operations after the PHE Ends ................... 5  
III.   Prioritization and Distribution of Pending Eligibility and Enrollment Work .................... 14  
IV.   Notices and  Fair Hearings .................................................................................................. 21  
V.   Strategies to Promote Continuity of Coverage and Mitigate Churn .................................. 23  
VI.   Facilitating Transitions between Medicaid, CHIP, BHP, and the Marketplace  ................ 27  
VII.   Monitoring State Progress and Corrective Action ............................................................. 28  
VIII.   PERM or MEQC Programs  ............................................................................................... 29  
IX.   Closing  ...............................................................................................................................  29  
Appendix A: 12-Month Unwinding  Timeline  .............................................................................. 31  
Appendix B: Strategies to Promote Continuity of  Coverage  and Mitigate Churn ....................... 33  
Appendix C: Processing Returned Mail  ....................................................................................... 41  
                                                           
1  SHO #20-004, Planning for the  Resumption of Normal State Medicaid, Childrens Health Insurance Program (CHIP), and  
Basic Health Program (BHP) Operations Upon Conclusion of the COVID-19  Public Health Emergency, available at:  
https://www.medicaid.gov/sites/default/files/2020-12/sho20004.pdf.   
2  Details on extending Medicaid disaster relief SPA provisions,  either temporarily or indefinitely,  were provided during the  
February 15, 2022 All-State Medicaid and CHIP call.  Information discussed during the call is available at:  
https://www.medicaid.gov/resources-for-states/downloads/covid19allstatecall02152022.pdf.    Page 3  State Health Official  
 
Appendix D:  Related CMS Guidance ........................................................................................... 44  
    
 
I.   Executive Summary 
This SHO letter is  part of  a series of  guidance and tools  that outlines how states may address the  
large volume of pending  eligibility and enrollment actions that will need to be addressed when 
they restore  routine operations, including terminations of coverage.  This letter expands on the  
August 2021 SHO by describing how states may distribute eligibility and enrollment work in the  
post-PHE period, mitigate churn for eligible beneficiaries who lose  coverage  and later  reenroll, 
and smoothly transition individuals between coverage programs, including  coverage through  the  
Marketplace with financial subsidies.  This SHO reiterates options for states to align work on 
pending  eligibility and  enrollment actions  after the PHE eventually  ends  and provides that states  
must initiate, rather than complete, all pending actions during the 12-month unwinding period.  
In addition, this  SHO informs states that they  are  at risk of inappropriately  terminating coverage  
for eligible individuals if they plan to initiate a high volume of renewals in a given month and 
that CMS intends to collect information on all states plans to adopt strategies that will promote  
continuity of coverage  and guard against inappropriate terminations.   
A.   Background  
The ongoing COVID-19 outbreak and implementation of  federal policies to address the PHE  
have disrupted routine Medicaid, CHIP, and BHP  eligibility and enrollment operations.  
Medicaid and CHIP enrollment has grown to nearly 85 million individuals  due, in large part, to  
the continuous enrollment condition.3   It is critical to ensure, when the PHE  eventually ends, that  
renewals of eligibility occur in an orderly process  that minimizes beneficiary  burden and 
promotes continuity of coverage, including  for individuals  eligible  for other insurance  
affordability programs, and maximizes state effectiveness. 
B.   Operational Plans and Timelines to Complete Eligibility and Enrollment Actions   
As discussed in prior  guidance, states  will need to develop a comprehensive unwinding  
operational plan to restore routine operations in their Medicaid, CHIP, and BHP programs. This  
unwinding operational plan is intended to reflect how states will complete outstanding work and 
maximize uninterrupted coverage for  eligible individuals.   
CMS acknowledges that  states will have some pending applications that will need to be  
completed and will continue to receive new  applications as they  work to resume normal  
processing of renewals. This SHO permits states to use a phased approach to complete  
processing of any pending applications and resume timely and  accurate determinations of  
eligibility on all new  applications within  four months after the  eventual  end of the PHE.   
 
To account for the time needed to complete renewals, CMS will consider states to be in  
compliance with the 12-month unwinding period announced in the August  2021 SHO provided 
that the state has  initiated  all renewals and other outstanding eligibility  actions by the last month 
of the 12-month period. States will have  two additional months (14 months total) to complete all 
                                                           
3  Medicaid and CHIP Enrollment Snapshots (September  2021). Available at  https://wwwmedicaid.gov/medicaid/program-
information/medicaid-chip-enrollment-data/medicaid-and-chip-enrollment-trend-snapshot/indexhtml.   Page 4  State Health Official  
 
pending actions  initiated during the  12-month unwinding period.  Prior  guidance suggested all  
renewals and other  actions must be completed within the 12-month unwinding period.  
 
C.   Adopting a Risk-Based Approach and Speed of State Unwinding  
CMS expects  states to adopt a risk-based approach to prioritize pending renewals, changes in 
circumstances, and post-enrollment verifications  that the state needs to  address during the  
unwinding period.  A risk-based approach must take into consideration the  need to prevent  
inappropriate terminations and promote smooth transitions for individuals no longer  eligible  for  
Medicaid, CHIP, or a  BHP to other coverage. States may select  among  four risk-based  
approaches to address the backlog of  pending  cases: (1) Population-Based Approach prioritizing  
outstanding actions for cohorts of beneficiaries more likely to have become eligible  for  more 
expansive benefits or for  different  coverage (e.g., a Qualified Health Plan (QHP)); (2)  Time or  
Age-Based Approach prioritizing cases based on the length of time the action has been pending; 
(3) Hybrid Approach combining population- and time-based approaches;  or (4) State-Developed  
Approach meeting the  goals of keeping eligible individuals enrolled, reducing churn, 
maximizing successful transition to other coverage where appropriate, and achieving a  
sustainable renewal schedule.  This letter also outlines various alignment strategies, which can 
support states in achieving an even distribution of  work both during the 12-month unwinding  
period and in subsequent  years.  
Over the course of the 12-month unwinding period, states will need to initiate  a renewal of  every  
beneficiary enrolled in their  Medicaid  and CHIP  programs as of the end of the month prior to 
their unwinding period.   We refer in  this letter to  these beneficiaries enrolled in Medicaid and  
CHIP as of such month as the states  total caseload.   States have  flexibility to determine  
whether their total  caseload is based on the total number of individuals enrolled in the program  
or the total number of households with one or more family members enrolled in Medicaid in the  
state as of the end of the  month prior to the month in which the states unwinding period begins.  
 
States will need to distribute these renewals in a reasonable manner over the course of the 
unwinding period in order to mitigate the risk of inappropriate terminations and churn as  well as  
to ensure that the state  also resumes timely processing of new applications  during the unwinding  
period.  As this SHO  letter  explains, CMS is concerned that if states  attempt to initiate more than  
1/9 of  their total caseload  in a given month, there  will be an increased risk that state processes  
will not meet federal renewal requirements, and eligible individuals will be erroneously  
determined ineligible or lose coverage for avoidable procedural reasons.  CMS will work with  
states and provide continued technical assistance to ensure they  are able to  restore routine 
operations in a manner that promotes continuity of coverage for  eligible individuals and seamless  
coverage transitions for those who become eligible for other insurance  affordability  programs.   
D.   Facilitating Transitions  to the Marketplace  
Facilitating smooth transitions to the Marketplace  for individuals eligible for enrollment in a  
QHP will be critical to minimizing periods of uninsurance  as states identify  beneficiaries who are  
no longer eligible  for Medicaid, CHIP or a  BHP.  States are required to transfer to the 
Marketplace the electronic accounts of beneficiaries whom the state assesses as potentially  
eligible for  coverage through the Marketplace; such transfer must include  all eligibility-related  
information available to the  state.   This  SHO letter identifies strategies for states to improve  
successful transitions and enrollment in a QHP, including improving notice language  and   Page 5  State Health Official  
 
transmitting all available  contact information and  other information that the state has  for  an  
individual, regardless of the minimum technical requirements for account transfers.  
E.   Monitoring State Progress, Corrective Action, Payment Error Rate Measurement  
(PERM) or Medicaid Eligibility Quality Control (MEQC)  Programs,  and Technical  
Assistance  
This  SHO letter explains that CMS will (1) not consider eligibility  and enrollment actions  
delayed due to the PHE  as untimely  for purposes of the PERM or MEQC programs if such 
actions are initiated within the timelines detailed in the SHO letter  and completed before the end 
of the 14th month once the state begins its  12-month unwinding period; (2) release  an updated 
planning template to support state efforts to develop unwinding operational plans; (3) provide  
states with data reporting tools to monitor and evaluate state progress to complete outstanding  
work after the PHE ends; (4) monitor states progress in meeting the timelines and completing  
required  eligibility and  enrollment actions described in the letter; and (5) be available to provide  
technical assistance to states individually and through various forums.  
II.   Restoring Routine Eligibility and  Enrollment Operations  after the PHE Ends  
CMS recognizes  that states will not be  able to immediately  address the large number of pending  
eligibility  and enrollment  actions that continue to accumulate during the PHE, and states will 
need time to complete the work in a manner that prevents inappropriate terminations of  
coverage.  CMS  also  understands many  Medicaid  beneficiaries  circumstances may have 
changed and that these individuals may now be  eligible for other insurance affordability  
programs, such as CHIP, BHP, or coverage through the Marketplace with financial subsidies.  
States will need  to be able to  distribute work in a systematic way that maintains coverage for  
eligible beneficiaries, manages coverage transitions, and reestablishes  a renewal  schedule that is  
sustainable for the state agency  in future  years.    
 
A.   Developing a Plan to Address PHE-Related Eligibility and Enrollment  Work  
 
As discussed in the December 2020 SHO, states  will need to develop and document a  
comprehensive plan to restore routine operations in their  Medicaid, CHIP, and BHP  programs  
(unwinding operational plan).4   This  plan is intended to help states plan for how they will  
complete outstanding work in accordance with the timelines specified in this letter and the  
August 2021 SHO and maximize continuous coverage for  eligible  individuals.   
 
States will have a significant volume of eligibility actions to complete  once they begin the  
unwinding period, including pending applications, renewals, and redeterminations necessitated  
by changes  in beneficiary  circumstances.  Some states also will have outstanding verifications  
for individuals  determined eligible for enrollment based on self-attested information pending  
post-enrollment verification.5   States  unwinding  operational plans should include a description 
of how the state intends to address these outstanding actions in an efficient  manner  that reduces  
                                                           
4  State Health Official Letter SHO #20-004, Planning  for the Resumption of Normal State Medicaid, Childrens Health Insurance  
Program (CHIP), and Basic Health Program (BHP) Operations Upon Conclusion of the COVID-19  Public Health Emergency,  
(December 2020). Available at   https://www.medicaid.gov/federal-policy-guidance/downloads/sho20004.pdf.  
5  States have the option to enroll  individuals based on self-attested information and verify eligibility criteria post-enrollment,  
consistent with the state verification  plan.   Page 6  State Health Official  
 
erroneous loss of  coverage  for beneficiaries, ensures a sustainable distribution of renewals in 
future  years, and ensures timely  processing of new applications and eligibility actions within the  
timelines specified in this letter.  States will need to decide which flexibilities to retain and 
whether to adopt new flexibilities.   CMS  is available to provide technical assistance to states as  
they develop their unwinding operational plans.   
 
To the extent these decisions require states to submit SPAs, updates to verification plans, or  
updates to policy  and procedure manuals, states should make efforts to start these processes as  
soon as possible before the state implements its plans to restore  routine operations. States should 
also begin work as soon as possible  on any necessary system changes needed to process  
eligibility and  enrollment actions and  resume terminations of coverage for  ineligible individuals  
after the continuous enrollment condition expires.  To the extent possible, states should make  
plans to have these system changes ready, and scheduled for  an off-cycle release if necessary, to 
ensure they  are not delayed in their ability to begin work during the unwinding period.  
 
States that began  to develop a plan to return to routine operations  prior to the release of this letter  
should reassess their plans and adjust how they will prioritize and distribute  their  workloads in 
light of this guidance.   CMS  also released  an updated Medicaid and CHIP planning tool to assist  
states in their planning  efforts.6  This updated tool will  take into account the new timelines to  
complete pending work and help states develop an unwinding operational plan that takes into 
account strategies and options to maintain coverage for eligible individuals.  While CMS expects  
states to develop and document their unwinding  operational plans to address pending  
applications, verifications, changes in circumstances, and renewals, states  are not required to use  
the tools developed by CMS to document their plans and, generally, will not be expected to 
submit their  entire unwinding operational plans to CMS for approval.  However, states must 
make their plans available to CMS upon request.  
 
The perspectives and partnership of Medicaid and CHIP managed care organizations  (MCOs), 
providers, beneficiary  advocates, and other  stakeholders  are critical to the resumption of  
renewals and other  eligibility  actions in a manner that supports  retention  of coverage, including  
the successful transition to other programs.  CMS encourages states  to solicit input on their  
unwinding operational plans from these partners  and to share their plans publicly, prior to their  
implementation. 
 
B.   Timelines to Complete Eligibility and  Enrollment Actions after the PHE  Ends  
 
Applications: 4 Months after the  End of the PHE  (with Milestones)   
While states  are expected to work as expeditiously as possible to process applications now, CMS  
anticipates most states will have some pending applications that were received during the PHE  
that will need to be completed  during the unwinding period. Agencies may use a phased  
approach to complete processing of these applications and resume timely and accurate 
determinations of eligibility on new  applications within the following  timelines, measured  going 
forward  from the  end of the month in which the PHE ends:  
   2 months  after the end of the month in which the  PHE  ends: States should complete  
eligibility determinations for all pending  modified adjusted gross income (MAGI) and 
                                                           
6  CMS  previously released the Medicaid and CHIP Health Insurance Program COVID-19  Public Health Emergency Eligibility  
and Enrollment Pending Actions  Resolution Tool.  The updated tool  reflects  the guidance issued in SHO #21-002 and  this letter.   Page 7  State Health Official  
 
other non-disability-related applications (e.g., individuals determined on the basis of  
being age 65 or older) received during the PHE.  
   3 months  after the end of the month in which the  PHE  ends: States should complete 
eligibility determinations for all pending disability-related applications received during  
the PHE.  
   4 months  after the end of the month in which the  PHE  ends: States should resume 
timely processing of all applications.  
 
CMS reminds states that an application is considered to be processed timely when the agency  
enrolls an eligible applicant or denies coverage for an individual whom the agency  could not  
determine as  eligible within the application time standards described at 42 C.F.R.  435.912(c), 
457.340(d), and 600.320(b).  The maximum time permitted under these  regulations is 90 days for  
individuals applying on the basis of disability and 45 days  for all other  applicants.  Consistent  
with  requirements at 42 C.F.R.  435.912(g), 457.340(d), and 600.320(b), agencies may not use 
the application timeliness standards   or the timelines described in this letter   as a waiting  
period to delay determining eligibility or  as a reason for denying eligibility because the state has  
not determined eligibility within the  timeliness standards.  
 
Post-Enrollment Verifications,  Changes in Circumstances, and Renewals: 12 months  after the  
End of the PHE  
In the  August 2021 SHO, CMS announced that it would provide states up to 12 months after the  
end of the  PHE to  complete  renewals as well as post-enrollment verifications and 
redeterminations of eligibility due to  changes in beneficiary circumstances.  The renewal process  
includes  the time states need to attempt to renew eligibility based on  electronic data and other  
information available to the agency; the time  beneficiaries have to return the renewal form  and  
any  required documentation; and  the time needed  by the agency to verify the accuracy of the 
returned information, redetermine eligibility, and send appropriate notice to the beneficiary of  
the agencys decision.   
 
Since the August 2021 SHO was released, states  have raised concerns that  they will be unable to  
complete renewals within a 12-month unwinding  period because, except for beneficiaries who  
can be renewed based on information available to  the state, states typically  cannot complete a  
renewal in the same month in which the renewal  was initiated.   We understand that  many states  
budget between 60 and 90 days to complete the full renewal process, and therefore  initiate  
renewals between 60 and 90 days prior to the end of  a beneficiarys  eligibility period.    
 
To account for the time needed to initiate and  complete renewals,  CMS  will consider states to be  
in compliance with the 12-month unwinding period announced in the August 2021 SHO  
provided the state has  initiated all renewals, as well as post-enrollment verifications and 
redeterminations based on changes in circumstances,  for the states total caseload  by the last 
month of the 12-month unwinding period (and completed  such actions by the end of month 14).   
 
Defining the Beginning and End of the 12-month Unwinding Period   
While states  will be required to initiate renewals, post-enrollment verifications, and 
redeterminations for all individuals enrolled when the continuous enrollment condition expires  
within 12 months, the unwinding period may vary by state but is based on the month in which 
the PHE eventually ends. The unwinding period for all states must begin no later  than the first  Page 8  State Health Official  
 
day of the month following the month in which the  PHE ends.  However, states may begin their  
12-month unwinding period up to two months prior to the end of the month in which the PHE  
ends.  This  means that states  that continue to comply with the continuous enrollment condition 
through the  end of the month in which the PHE ends  may initiate renewals that may result in  
termination of coverage the month after the  continuous enrollment conditions ends  for some  
beneficiaries up to two months prior to the end of the month in which the PHE ends.  
As discussed further in this letter, states must initiate a renewal of  eligibility for its total caseload  
during the states unwinding period, including for  individuals  who were determined ineligible 
during the PHE before the state begins its unwinding period.   
 
For example, if the PHE  were to end on May 15, 2022, renewals initiated as early  as  April 2022 
could result in terminations effective  as early as  June 1, 2022 (with the beneficiarys last day of  
coverage being May 31, 2022, which would be the last day the continuous  enrollment condition 
is in effect in this example) for beneficiaries whom the state determines no longer meet all  
eligibility requirements or who do not  timely  return information needed by  the state to complete  
the renewal.     
 
Note that the same two-month period before the  state would need to initiate another renewal  
would be true regardless  of when the PHE  eventually  ends.  For example, if the PHE ended on 
August 15, 2022, states  complying with the continuous enrollment condition could begin their  
12-month unwinding period as early  as July 2022, using the information gathered during  a 
renewal  initiated in July  2022 to terminate  coverage as early as September  1, 2022 for 
beneficiaries whom the state determines no longer meet all eligibility  requirements or who do not 
timely return information needed by the state to complete the renewal.  Thus, in this example  
(i.e., if the PHE is extended to August 15, 2022), renewals for cases  initiated prior to July 2022 
that did not result in a determination of eligibility  must be initiated  again  during the states 12-
month unwinding period associated with the August 15, 2022 PHE end date, consistent with the  
guidance in the August 2022 SHO and this letter.   
 
While states must initiate all pending  eligibility actions (including renewals, post-enrollment 
verifications, and redeterminations based on changes in circumstances)  for its total caseload  at  
the end of the PHE within their particular 12-month unwinding period, states are  expected to 
complete all work initiated during their unwinding period by the end of the 14th month after the  
first month of the unwinding period.  For  example, if the PHE ends in May 2022 and a state 
begin its 12-month unwinding period ) in June 2022, the state would be required to initiate all 
renewals, post-enrollment verifications, and redeterminations no later than May 2023 and 
complete initiated work by the  end of July 2023.   
 
States are reminded that regardless of  when a state begins its unwinding period, it must  maintain  
continuous  enrollment of beneficiaries through the last day of the month in which the PHE ends  
in order to satisfy the continuous enrollment condition necessary  to receive the temporary  FMAP  
increase under the  FFCRA for the entire quarter in which the month falls.  To comply with the  
continuous enrollment condition, termination of a beneficiarys enrollment can be effective no  
earlier than the first day  of the month following the month in which the PHE ends, with limited   Page 9  State Health Official  
 
exceptions.7 Any state that chooses to end the continuous enrollment condition prior to the end 
of the month the PHE  eventually  ends and no longer claim the  temporary  FMAP increase  is still 
required to follow the timelines and expectations outlined in this letter.  This includes the  
requirement that the state initiate a renewal for the states total caseload during the 12-month 
period beginning in the  month in which renewals initiated by the state  end in termination of  
beneficiaries who no longer meet  eligibility requirements or did not timely return information  
needed by the state to complete the renewal.  
 
Appendix A  illustrates how a state may process its  unwinding related renewals, redeterminations, 
and post-enrollment verifications and achieve compliance with the 12-month unwinding period. 
 
C.   Requirements  for  Conducting Renewals    
 
This guidance does not  change the steps states must take to complete a renewal consistent with  
requirements at 42 C.F.R.  435.916, 457.343, and 600.340.  During the 12-month unwinding  
period, all states must begin the renewal process by  checking available information and data 
sources to attempt to redetermine eligibility without contacting the beneficiary and requesting  
documentation to obtain reliable information when eligibility cannot be renewed based on 
available information, as  appropriate.  States must provide beneficiaries  who are eligible based  
on MAGI methodologies  with  a minimum of 30 days to return their pre-populated renewal form  
and any requested information.  Non-MAGI beneficiaries must be provided  with a reasonable 
period of time to return their renewal form and any  required documentation.  Renewal forms and 
notices must be accessible to persons who have  limited English proficiency  (LEP)  and persons  
with disabilities consistent with   435.905(b) and 457.340(e).  In Medicaid, states must  
determine eligibility on all bases prior to making  a determination of eligibility as required at  
435.916(f)(1), including  the Medicare Savings Programs.  In Medicaid, a minimum of 10 days  
advance notice and fair hearing rights must also be provided prior to termination or other adverse  
action, in accordance with   435.917 and 42 C.F.R. Part 431 Subpart E.  Separate CHIPs must  
provide sufficient notice  to enable the childs parent or other caretaker to take any appropriate  
actions that may be required to allow coverage to continue without interruption consistent with  
457.340(e)(1)(iii).  For individuals determined ineligible, states must assess  eligibility for other  
insurance  affordability programs and transfer the individuals account as  appropriate in 
accordance with   435.916(f)(2) and 457.350(i).  
 
States may refer to the December 2020 Center  for  Medicaid and CHIP Services (CMCS)  
Informational Bulletin  (CIB), Medicaid and CHIP  Renewal Requirements, which is available 
to assist states in meeting their obligations to make accurate redeterminations of eligibility.8   A 
description of the CIB and more information on how states  may access the guidance is included  
in Appendix C  of  this SHO  letter.   
  
D.  Completing Renewals  During the Post-PHE Unwinding Period  
 
                                                           
7  Consistent with 6008(b)(3) of the FFCRA and 42 C.F.R.   433.400, states claiming the temporary 6.2 percentage point  FMAP  
increased authorized  under  FFCRA  must ensure validly enrolled  beneficiaries remain enrolled through the end of the month in 
which the  PHE ends unless the individual requests voluntary termination,  is no longer  considered to be  a  resident of  the  state, or 
dies.  
8  CMCS Informational Bulletin,  Medicaid and Childrens Health Insurance Program (CHIP) Renewal Requirements,  
(December  2020). Available at: https://wwwmedicaid.gov/federal-policy-guidance/downloads/cib120420.pdf.   Page 10  State Health Official  
 
While  most states have continued to process eligibility  and enrollment actions during the PHE, 
states  claiming the temporary  FMAP increase authorized by section 6008 of the FFCRA  have 
needed to suppress terminations and other  adverse actions for Medicaid beneficiaries that would  
violate the continuous enrollment condition. States  that have conducted renewals during the  
PHE, but  did not terminate  Medicaid eligibility for beneficiaries who  were determined not  
eligible or who did not respond to requests for documentation, generally may  not terminate  
coverage for such beneficiaries after  the  continuous enrollment condition expires  until the state  
completes a new  full renewal, as beneficiaries  circumstances may have changed since the 
completion of the renewal conducted during the PHE.  This  includes  beneficiaries who were 
receiving benefits pending the outcome of a fair hearing on or  after March 18, 2020, and were  
continuously enrolled during the PHE in order to comply with the continuous enrollment  
condition.9    
 
Completing a full renewal after the  continuous enrollment condition expires  will ensure that:  1) 
the state is collecting information from the beneficiary that allows the state to redetermine  
eligibility on all bases prior to terminating  coverage in accordance with  42 C.F.R.  
435.916(f)(1); 2) any adverse action is based on recently  available, reliable  information and that 
the state is not terminating eligibility or  reducing benefits unless it has sought information from 
the individual in accordance with  435.952(d);  and 3) the state fulfills its obligation to complete  
a renewal of  eligibility.    
 
Subject to the expectations relating to prioritization and distribution of pending eligibility and 
enrollment work discussed in Section  II of this letter, states will have  considerable  flexibility in  
determining how best to distribute renewals over the 12-month unwinding  period.  Thus, while  
states may not  conduct a new renewal for MAGI-based beneficiaries whose eligibility  was  
successfully renewed during the PHE less than 12 months after such renewal, states have  the 
flexibility to initiate renewals  at any time during the unwinding period for  beneficiaries for  
whom the state did not conduct a renewal during the PHE or for whom the  state did not conduct  
a successful renewal within the previous 12 months.  Additionally, because individuals  
determined ineligible during a renewal conducted during the PHE  were not  granted a new  
eligibility period, states  may initiate  a new  renewal  for such individuals at  any point during the  
12-month unwinding period  i.e., the state is not required to wait for 12 months after a renewal  
conducted during the PHE that resulted in a determination of ineligibility  or for which a  
beneficiary did not respond to a request for additional information.   
 
Table 1 below provides guidelines for states when setting beneficiary  renewal dates during the 
unwinding period, based on the outcome and timing of the beneficiarys last attempted renewal 
during or prior to the PHE.  CMS encourages states to use the flexibilities  afforded by the unique  
circumstances of the PHE  and the end of the continuous enrollment condition to set a renewal  
schedule that spreads renewal volume over  a full  12-month period and aligns renewal dates for  
                                                           
9  While 42 C.F.R.    431.230(b) grants states the option to institute recovery  for benefits pending if the states action is sustained 
by the fair hearing decision, states cannot  do so if they claim the temporary FMAP increase authorized by section 6008 of the  
FFCRA.  An individual whose Medicaid eligibility is  maintained in order to comply  with the  continuous enrollment  condition,  
which includes individuals receiving benefits pending, may not have  their  eligibility retroactively terminated.  In order to receive 
the temporary FMAP increase authorized under section 6008 of the FFCRA, states  must maintain the eligibility, and benefits, of 
all individuals who are enrolled or determined eligible for Medicaid as of March 18,  2020, through the end of the month in which 
the public  health emergency  ends. Section 6008(b)  of the FFCRA does not authorize recoupment of funds from any individual  
whose Medicaid  eligibility was  continued in order to comply  with the terms of section 6008(b) of the FFCRA.   Page 11  State Health Official  
 
individuals within households and with recertification timing for  the Supplemental Nutrition  
Assistance Program (SNAP) and other human services programs.  Additional information on 
how to implement these strategies is available in  Appendix B  of this letter.   
  Table 1. Guidelines for  Establishing Renewal Dates during the 12-Month Unwinding  
Period  
Outcome of Last Renewal  Attempted During   Permissible Timing of Renewal During 12-
the Last 12 Months of PHE   Month Unwinding Period  
Ex parte  renewal attempted but not completed.  Any time  (states  are encouraged to  consider  
No further state action taken.   strategies to  align renewals  with  SNAP  
recertifications  or renewals for members of  a  
household)  
Ex parte renewal attempted  but  not completed.   Any time  (states  are encouraged to  consider  
State sent renewal form.  Beneficiary   strategies to align  renewals with SNAP  
determined ineligible or  did not respond.  recertifications  or renewals for members of  a 
household)  
Renewal completed based on beneficiarys   12 months after beneficiarys last renewal for  
return of renewal form and/or additional   MAGI-beneficiaries; 12 months or shorter  
information. Individual  continues to meet   eligibility period established by the state for non-
eligibility requirements.  New eligibility period   MAGI beneficiaries per  42 C.F.R.  435.916(b)  
established.  
Ex parte renewal attempted and successfully   12 months after beneficiarys last renewal  or 
completed. New  eligibility  period established.10   original renewal  month, at state option, for 
MAGI-beneficiaries; 12 months or  shorter 
eligibility period established by the state for non-
MAGI beneficiaries per  42 C.F.R.   435.916(b)   
No renewal attempted in last 12 months of   Any time  
PHE.  
 
E.  Acting on Changes in Circumstances  during  the Unwinding Period   
 
Consistent with regulations at 42 C.F.R.  435.916(d) and 457.343, states must promptly  
redetermine eligibility between regular renewals of eligibility whenever they  receive information  
about a change in a beneficiary's circumstances that may affect eligibility.   However, due to the  
continuous enrollment condition, states have been  unable to complete regular renewals during  
the PHE for many Medicaid beneficiaries.  Given how long it has been since some individuals  
have been renewed,  there is an increased risk that individuals who may be  eligible for CHIP or  
Medicaid on another basis may be terminated based on a change in circumstances related to a 
single factor of  eligibility.  Consequently, during the unwinding period, prior to taking adverse 
action based on an identified or reported beneficiary  change in  circumstances, states  must  
complete a full renewal  for any beneficiary unless a renewal was  completed in the 12 months  
prior to the identified change.  The one  exception to this general rule involves beneficiaries for  
whom (1) a renewal completed within the prior 12 months resulted in a determination that the  
beneficiary continues to  meet eligibility  requirements, and (2) the state has received information  
that the beneficiarys circumstances changed after  the last renewal was completed.   If a state 
identifies a change in circumstances during the unwinding period for an individual who has not  
received a renewal in the prior 12 months, the state may choose to complete a full renewal  at the 
                                                           
10  For  beneficiaries  whose eligibility is renewed during the  PHE based on information available to the  state without requiring  
additional information from the individual (ex parte  renewal) consistent with 42 C.F.R.   435.916(a)(2) and (b), states continue  
to have the  option described in the December 2020 SHO (1) to retain the beneficiarys initial eligibility period had the renewal  
been completed timely or (2) to start a new eligibility period based on the date the  ex parte  renewal  was completed during the  
PHE.  States electing to retain  the eligibility period associated with  the  ex parte  renewal completed during the  PHE must do so 
for all such renewals through the  end of the  PHE; states may not implement the option on a case-by-case basis.    
The contents of this document do not  have the force  and effect of law and are not meant to bind the public in any way, unless  
specifically incorporated into a contract. This document is intended only to provide clarity to the  public regarding existing  
requirements under the law.   Page 13  State Health Official  
 
time when the change in  circumstances is identified, or the state may wait to process the new  
information when it completes the beneficiarys  renewal in a subsequent  month.   
 
F.  Special  Considerations for  CHIP and BHP  
 
As states are aware, the continuous enrollment condition does not apply to separate CHIP  
programs  and BHPs.  However, states have taken  different  approaches to processing CHIP  and 
BHP  renewals during the PHE, and these approaches will impact how states must handle CHIP  
and BHP  renewals following the  eventual end of  the PHE. We have  included several scenarios  
below, highlighting  where renewal processes may  differ for CHIP and BHP from Medicaid.  
 
CHIP Beneficiaries  Who Became  Ineligible During the PHE   
As stated in the January  6, 2021, COVID-19 Frequently Asked Questions (FAQs) for State  
Medicaid and Childrens  Health Insurance Program (CHIP) Agencies (January 2021 
FAQs),11  states are not permitted under the CHIP state plan to extend eligibility periods for  
separate CHIP  enrollees  who have been determined ineligible for coverage.  If a state receives  
information from an enrollee, processes that information, and determines the individual  
ineligible for its separate  CHIP, the state must process the termination and transfer the individual  
to Medicaid or the Marketplace, in accordance with 42 C.F.R.  457.350(b) and (i).  States that 
completed CHIP  renewals during the PHE  are  expected to have terminated ineligible individuals  
and to continue to process terminations throughout the remainder of the PHE and unwinding  
period.  
 
Similarly, as stated in the January 2021 FAQs, states are not permitted under the CHIP state plan 
to extend coverage to young adults aging out of CHIP or, for pregnant individuals enrolled in 
CHIP, ending their postpartum coverage period.  Because this  guidance was not formally  
published until  January 6, 2021, we recognized that some states may have  continued to provide  
coverage to these individuals until that date.  However, we explained that states are expected to  
continue to process terminations of individuals determined ineligible  for a separate CHIP  under  
the state plan throughout  the remainder of the PHE.   
 
CMS is aware that some  states, using state-only  funds, have continued to cover CHIP  
beneficiaries found not eligible for  coverage during the PHE, including  young adults aging out of  
CHIP, and/or pregnant individuals ending their postpartum period, and/or children found 
ineligible for  coverage  after a change in circumstances.  States may submit a COVID-19 section 
1115 demonstration application for CMS consideration requesting expenditure authority to 
enable the state to claim federal financial participation (FFP)  for such CHIP beneficiaries  
through the  end of the unwinding period, or until a redetermination is conducted during the  
unwinding period.  States interested in pursuing a  section 1115 demonstration to receive  FFP for  
these individuals should contact their state lead or section 1115 demonstration project officer.  
 
In addition, we note  that states may  elect  to provide 12 months of extended postpartum coverage  
to pregnant individuals enrolled in Medicaid and CHIP beginning April 1, 2022, under  sections  
9812 and 9822 of the American Rescue Plan Act of 2021 (P.L. 117-2)  (ARP). States that elect  
this  postpartum extension option may  consider deprioritizing renewals and redeterminations of  
                                                           
11  COVID-19 Frequently Asked Questions (FAQs)  for State Medicaid and Childrens Health Insurance Program (CHIP)  
Agencies, January 6, 2021, available at:  https://wwwmedicaid.gov/state-resource-center/downloads/covid-19-faqs.pdf.    Page 14  State Health Official  
 
eligibility for CHIP beneficiaries who are pregnant or in a postpartum period during the  
unwinding period to ensure smooth implementation of the extended postpartum coverage option.  
 
CHIP Beneficiaries  Whose Renewals were Delayed  during the PHE   
We recognize that some states may not have been able to process CHIP renewals in accordance 
with the timeliness standards of 42 C.F.R.  457.340(d)(1) during the PHE.  These states  
requested and received authority through CHIP SPAs to waive the timely  processing of renewals  
during the PHE.  As states resume processing  renewals, we strongly encourage states to initiate 
CHIP renewals along the same timeline as Medicaid renewals  and follow the guidance in 
Sections D and E above.  States should incorporate CHIP  eligibility  and enrollment actions in  
their unwinding operational plans and must restore operations consistent with the timeframes and  
guidance outlined in the  August 2021 SHO and this  letter.  This includes ensuring that states  
initiate CHIP renewals no later than when the state begins its  12-month unwinding period and 
complete all work initiated during the  12-month unwinding period by the  end of the 14th month 
once the state begins its unwinding period. 
 
BHP Beneficiaries  Whose Renewals were Delayed  During the PHE   
We also recognize that states that operate a BHP  may not have been able to process  BHP  
renewals in accordance  with the timeliness standards of 42 C.F.R.  600.340 during the PHE. 
These states requested  and received authority through  BHP  Blueprint amendments to waive the  
timely processing of renewals during the PHE.  States that have been unable to process  BHP  
renewals during the PHE may follow the same processes for resuming the timely processing of  
renewals for  BHP as they are for Medicaid.   However, we note that a state may not be able to  
begin processing  BHP renewals within one month of the end of the PHE if  that month does not  
align with when the state typically conducts BHP  renewals.   
 
For example, if the PHE  ends in April 2022, but a state has elected to align  renewals with the  
Open Enrollment period in the Marketplace such that the state would not normally process any  
BHP renewals until Fall  2022 for a new coverage  year beginning January 1, 2023, the state  
would not be required to change  its typical renewal processing timelines.   However, states can  
elect to change this policy  by submitting a  BHP  Blueprint revision, and we  encourage states that  
operate  a BHP and currently only  conduct renewals to coincide with the Marketplace Annual  
Open Enrollment to consider whether to instead spread out the processing  of BHP renewals  
throughout the  year.  The 12-month unwinding period presents a unique opportunity for  BHP  
states to reestablish a renewal schedule that is sustainable in future years.   CMS  is available to  
provide technical assistance to states exploring this option.  
 
III.   Prioritization  and Distribution of Pending Eligibility and Enrollment Work  
For states to maintain coverage  for eligible individuals, complete the volume of work that will 
need to be addressed in the 12-month unwinding  period, and reestablish a renewal schedule that  
is sustainable in future  years, states will need to determine how they will prioritize and distribute  
their work across the unwinding period.  States should first assess the scope of their workload 
and consider strategies discussed in Section  V of this letter on Strategies to Promote Continuity  
of Coverage  and Mitigate Churn.  States  will then need to prioritize the order in which they  will  
initiate and  complete eligibility and  enrollment actions  to minimize the extent to which ineligible  
individuals remain enrolled, prevent inappropriate terminations of coverage for eligible   Page 15  State Health Official  
 
individuals, and achieve  a manageable distribution of renewals in future  years.  Finally, states  
will need to identify how they  will distribute prioritized work  scheduled to be initiated within the 
timelines specified in this letter.  
 
A.   Adopting a Risk-Based Approach to Prioritize Work 
 
CMS expects states to adopt a risk-based approach to prioritize pending eligibility and 
enrollment actions related to post-enrollment verifications, changes in circumstances, and 
renewals the state will conduct during the 12-month unwinding period.  A risk-based approach  
ensures states  prioritize  their  workload in a manner that considers the need to prevent  
inappropriate terminations and enables smooth program transitions for individuals no longer  
eligible for Medicaid, CHIP, or a  BHP.  CMS  also  encourages  states to prioritize work in a way 
that  will achieve an evenly-distributed renewal workload that is sustainable  in future  years.   
 
States may select among  four risk-based approaches to address the backlog of pending cases.  
 
1.   Population-Based Approach: Prioritizes outstanding eligibility and enrollment actions  
based on characteristics  of cohorts or populations who are  likely to  have become eligible 
for more expansive  benefits  or who are likely to be  eligible for different coverage (e.g., 
QHP  through the  Marketplace).  Examples of populations states may wish  to prioritize  
include individuals who have reported a decrease  in income, individuals enrolled during  
the PHE through a temporary eligibility option, or  individuals who have aged out of a  
group or otherwise have become categorically ineligible for the  group in which they  are  
enrolled.  
 
Populations whose eligibility tends to be stable, such as children, former  foster  youth, or  
individuals dually  eligible for Medicaid and Medicare, are not among the types  of 
populations CMS would expect  states to prioritize in a population-based approach.  
However, CMS  encourages states to  consider  available options and flexibilities to  
streamline enrollment and promote continuity of  coverage  for individuals  as they  
prioritize their work.   
 
For example, states  electing the  extended  postpartum  coverage option under sections  
9812 and 9822 of the  ARP that implement the option during the states unwinding period 
may  choose to deprioritize  renewals and redeterminations of eligibility  for beneficiaries  
who are pregnant or in  a postpartum period when the continuous enrollment condition 
expires, to ensure smooth implementation of the extended postpartum coverage option.  
States may refer to the  December 2021 SHO, Improving Maternal Health and Extending  
Postpartum Coverage in Medicaid and CHIP, for more information on the state plan 
option to provide 12 months of continuous postpartum coverage.12    
 
A population-based approach  should address  both the risk that ineligible individuals  
remain enrolled and the risk that eligible individuals may be inappropriately terminated.  
                                                           
12  CMS State Health Official Letter #21-007: Improving Maternal Health and Extending  Postpartum Coverage in Medicaid and  
the Childrens Health Insurance Program (CHIP). December 7, 2021. Available at:  https://wwwmedicaid.gov/federal-policy-
guidance/downloads/sho21007.pdf.  
  Page 16  State Health Official  
 
However, unless authority  for, or expanded eligibility under, a  group expires at the end of  
the PHE (e.g., as  is the case for the optional  COVID-19 group13  or in the case of an  
income or resource disregard adopted temporarily for the duration of the PHE),  states  
may not prioritize populations based solely on the Medicaid eligibility  group  in which 
they are enrolled, de-prioritize cases  based on the  availability of  FFP at  a matching  rate 
that exceeds the states regular  FMAP (e.g., states  may not de-prioritize completion of  
outstanding eligibility actions for individuals enrolled in the adult group)  or prioritize  
populations in a manner that would constitute a violation of federal law, including, but  
not limited to, the Americans with Disabilities Act of 1990 (ADA), Title VI of the Civil 
Rights Act of 1964, Section 504 of the Rehabilitation Act of 1973 (Section 504), the Age 
Discrimination Act of 1975, and Section 1557 of the Affordable Care Act  (Section 1557). 
Further, compliance  with these laws includes providing reasonable  accommodations to 
individuals with disabilities under the ADA, Section 504, and Section 1557, with 
eligibility and documentation requirements, understanding program rules  and notices, to 
ensure they understand program rules  and notices, as well as meeting other  program  
requirements necessary to obtain and maintain benefits. 
 
2.   Time or Age-Based Approach: Prioritizes cases based on the length of  time  the action has  
been pending.  Under a time-based  approach, states can process  the oldest cases first in  
the 12-month unwinding  period, or they may  process  cases by maintaining  the original 
month of renewal.  
 
3.   Hybrid Approach: Combined population- and time-based approaches.  For example, a  
state may  adopt a time-based approach  to prioritizing outstanding post-enrollment 
verifications and  changes in circumstances  and a population-based approach to 
prioritizing pending renewals.  Alternatively, states may adopt a population-based  
approach for  processing  the first wave  of pending  actions and then switch to a time-based  
approach.  
 
4.   State-Developed  Approach: Any other  approach that  meets the  goals of keeping  eligible  
individuals enrolled, minimizes the extent ineligible individuals may remain enrolled,  
achieves  a sustainable renewal schedule, and meets the 12-month unwinding  timeline for  
addressing outstanding  eligibility actions.   
 
Regardless of how  a state chooses to categorize its  risk-based approach and prioritize  its work, 
states must ensure their risk-based approach is described in the unwinding  operational plan.  
 
B.   Distributing Pending  Actions Across the  Unwinding Period  
 
Once a state determines how it will prioritize  its  eligibility and enrollment work,  we expect states  
to  establish a distribution schedule to initiate  and process  renewals and other actions over the 12-
month unwinding period.  The redistribution plan should ensure that states  are able to maintain  
coverage for  eligible individuals and manage transitions to other coverage  for individuals  
determined potentially eligible for  enrollment in another insurance affordability program.   An  
                                                           
13  Section 6004(a)(3)  of the FFCRA added a new optional Medicaid eligibility group for uninsured individuals  during the  
COVID-19 PHE. This group, added at section 1902(a)(10)(A)(ii)(XXIII)  of the Social Security  Act, was previously referred to as  
the COVID-19 optional testing group; the ARP expanded the coverage available to such individuals.    Page 17  State Health Official  
 
evenly-distributed renewal schedule will also mitigate  future  challenges  states might experience 
if they process  a large volume of actions  at  the beginning of the unwinding period, or if they  
delay beginning to process renewals until later in the  unwinding period.  States that do not make  
plans to distribute their work during the 12-month unwinding period run the risk of errors in  
processing renewals  and inappropriately terminating coverage for  eligible individuals, not only  
during the 12-month unwinding period but also in future  years  as  distributing this work over a  
shorter period could create peaks in routine  renewal volume in particular months.   
 
In addition to the pending  renewals and redeterminations that states will need to address when  
the continuous enrollment condition expires, new  eligibility  actions  also will arise during the 12-
month unwinding period (e.g., for  eligible beneficiaries who experience a  change in 
circumstances and individuals whose enrollment  or whose eligibility was  renewed in the last 12 
months of the PHE).  States can address such new actions in accordance with the timeframes that  
ordinarily  would apply in accordance with 42 C.F.R.  435.916 (i.e., in the absence of the 
continuous enrollment condition).  Alternatively, states can integrate such new actions into the 
prioritization plan and distribution schedule developed by the state for backlogged actions  
pending  at the end of the  continuous  enrollment condition, even if doing so would result in some  
delay in addressing the newly-arising actions.  
 
C.   Preventing  Inappropriate Terminations   
 
Based on our experience  in working with states over the  years, CMS is concerned that the  
combination of  several factors creates an  acute risk that eligible beneficiaries will lose coverage 
when states begin to process renewals and other eligibility and enrollment actions, including, the 
significant increases in  Medicaid and CHIP  enrollment during the PHE, the disruption to 
eligibility and  enrollment  operations, the length of  time that has elapsed since state agencies had  
any  contact with their beneficiaries,  and significant staffing shortages.  While states will need to  
expeditiously restore routine operations, states are obligated to ensure accurate determinations of  
eligibility and are  advised to take steps during the PHE to complete as much eligibility and 
enrollment work as possible in order  to limit the volume of actions that will need to be  
completed in the 12-month unwinding period.  Once states have begun to conduct renewals and 
process other  eligibility  actions, they  will need to  balance how quickly they  work through their  
total caseload with the need to prevent  errors resulting  in  the termination of coverage  for eligible  
beneficiaries  and churn, as eligible individuals terminated from coverage subsequently  re-apply.  
 
In providing technical  assistance to states to ensure they are able make timely  and accurate 
redeterminations of eligibility, we have found that states that have a more  even distribution  of 
renewals over the course of a year are better able to maintain  a workload that is sustainable in 
future years,  thereby  enabling the state to avoid renewal backlogs  and reduce risk of  inaccurate  
redeterminations and inappropriate  terminations  in future  years.  Based on  this experience,  CMS  
recommends  that states  initiate  no more than  1/9 of their total caseload  of Medicaid and CHIP  
renewals  in a  given month during the unwinding  period.   
 
We believe this target will not only  mitigate the risk of  inappropriate terminations and churn, but  
also  establish a sustainable renewal schedule by helping  states  avoid renewal bulges in some  
months  that increase the  risk of future  renewal backlogs.  We  believe states that distribute  the 
unprecedented volume of renewals  that must be initiated  during the 12-month unwinding period  Page 18  State Health Official  
 
will  be more likely  to avoid erroneous determinations  of ineligibility and avoid coverage losses  
for procedural reasons.  In addition, CMS believes that  initiating  more  than  1/9 of renewals in a 
given month risks a  compressed renewal workload that could put states at risk of inappropriately  
shortening or extending  beneficiary eligibility periods  described at  42 C.F.R.  435.916(a) and 
(b)and 457.343 in order  to manage workload in future  years.   
 
The 1/9 threshold also recognizes that  there are natural  fluctuations in the volume of renewals  
typically processed in different months that would prevent a state from  evenly distributing  
renewals throughout the  entire unwinding period (i.e., initiating  1/12 of a states total caseload  
each  month).   For example, some states experience higher application volume during certain 
periods in a  given year (e.g., due to Open  Enrollment  or adoption of a coverage expansion).  In 
others, staffing levels  may drop in certain months  (e.g., over the winter holidays), which may  
impact a states preferred  distribution  of renewals  in future years.  For these reasons, CMS  
believes  that initiating renewals for  no more than 1/9 of a states  total caseload  in a  given month 
strikes a reasonable balance between achieving a  relatively  even  distribution of renewals  with the  
need to accommodate fluctuations in the volume of work and state staff capacity  that naturally  
occur throughout the  year.   
 
Note that in  calculating  1/9 of total caseload  as of  the end of the month prior to the month in 
which the states unwinding period begins, some states  may  measure their total caseload based  
on the total number of individuals enrolled in their programs, while others  may measure total 
caseload based on the total number of households  with one or more household members enrolled  
in the states programs.   
 
CMS will require states to  submit certain  information, including how each state plans to 
distribute renewals  as well as what strategies the state is considering or has  adopted to mitigate  
against inappropriate  coverage loss during the unwinding period.  CMS will use this information  
to identify  states at  greatest risk of inappropriate coverage losses.14   CMS will provide states  
with a form to submit summary information  about their renewal distribution plans  and will 
follow up with states  as needed  to ensure that proper mitigation  strategies are in place to reduce 
risk of inappropriate  terminations  and that states plans will establish a sustainable workload in 
future years (this form is  separate from the states  unwinding operational plan which, as  
mentioned in Section II.A., states are  not required to submit to CMS for approval).  For more  
information on the monitoring and evaluation of  a states distribution schedule  and strategies to  
prevent inappropriate terminations, please see Section VII  of  this letter on Monitoring State  
Progress and Corrective Action.  
 
D.  Aligning Work on Pending Actions  
 
All beneficiaries, including limited benefit populations or groups, will require  a renewal during  
the 12-month unwinding  period, which means there is a unique opportunity  for states to align 
other  eligibility actions with  renewals during the  unwinding period to manage workload and 
reestablish a renewal schedule that is sustainable in future years.  The  following alignment  
strategies, which can support states in achieving an even distribution of work both during the 12-
                                                           
14  These reports will be required under the authority in sections  1902(a)(4)(A), 1902(a)(6)  and 1902(a)(75)  of the Act and at 42 
C.F.R.   431.16 to ensure  proper  and efficient administration of the Medicaid program and section 2101(a) of the Act to promote  
the administration of CHIP in an  effective and efficient manner.   Page 19  State Health Official  
 
month unwinding period and in subsequent  years, are only available during  the 12-month 
unwinding period.  However, states may not shorten an individuals  established  eligibility period  
when using these strategies for the purposes of alignment.  After the 12-month unwinding period 
ends, states must resume timely processing of periodic renewals  and redeterminations  of 
eligibility in accordance  with 42 C.F.R.  435.912, 435.916, 457.340, and 600.320 as well as  
post-enrollment verifications in accordance  with the verification plan  described at   435.945(j)  
developed by the state.  BHP states must follow the verification requirements of  600.345 and 
their  certified BHP Blueprints.  
 
Aligning Work on Verifications and Changes in Circumstances  at Renewal  
States may wait to complete pending post-enrollment verifications and act  on changes in 
circumstances  reported or identified during the  PHE  and unwinding period for beneficiaries with  
a renewal scheduled to be initiated during the 12-month unwinding period, with one exception 
related to verification of  citizenship  or  immigration status and the reasonable opportunity period 
(ROP) required under 42 C.F.R.  435.406 and 435.956, which  allows applicants and states  
additional time to complete those verification processes.  This  alignment strategy  will create 
efficiencies  for states by  allowing them to use information obtained at renewal to  simultaneously  
resolve other  pending eligibility  and enrollment actions and also limit the need to send multiple  
requests for information to individuals  to complete multiple pending actions.   
 
As required  under current regulations at 42 C.F.R.  916(a)(2), states must ensure eligibility  
notices  inform beneficiaries of the basis of the eligibility determination and remind  them  that 
they must inform the state if any of the information used to determine their  eligibility  is not  
accurate.   After the 12-month unwinding period, states must resume timely  processing of post-
enrollment verifications and promptly act on changes in circumstances that occur  between  
renewals consistent with federal  regulations.   
 
Individuals whose Medicaid benefits have been maintained during an ROP  have not had an 
eligibility determination completed pending verification  of U.S. citizenship or satisfactory  
immigration status; rather, they  are receiving benefits pending a determination of eligibility that 
rests on the verification of their status.   Therefore, states  will need to  review the verification and 
ROP process  applied during the PHE in order to determine the appropriate  action for individuals  
whose citizenship or verification status was not completed during the PHE  but whose enrollment 
has been maintained under an ROP to comply  with the continuous enrollment condition.  If  a 
state did not send an individual  notice to initiate an ROP  during the  PHE, or delayed or otherwise 
did not complete the regular verification of satisfactory immigration status  or U.S. citizenship  
process as  required under  435.406 and 435.956, the agency must send the required notice 
after the PHE  ends  and provide the 90-day ROP for the individual to provide  any needed 
documentation and the state to complete its verification process  in accordance with  435.406, 
435.407, and 435.956.  We note that the ROP begins on the date the beneficiary receives notice 
of such opportunity  from the agency, in accordance with  435.956(b)(2)(i).     
 
Even if  a state has provided  a fully compliant notice and ROP to all affected  beneficiaries but   
some beneficiaries have  not resolved their  citizenship or immigration status inconsistency during  
the PHE, we encourage  states to  attempt to reverify  eligibility   for these beneficiaries  before the 
states  unwinding period begins.  This  may be  necessary in order to provide  the due process  
protections, including  advance notice of termination and fair hearing rights,  for these individuals.   Page 20  State Health Official  
 
States  may extend the ROP period during this additional verification in certain situations.  
Specifically, for individuals who have  attested to satisfactory immigration status, states may  
attempt to re-verify immigration status again  after the continuous enrollment condition expires, 
as  435.956(b)(2)(ii)(B)  allows states to provide for a reasonable  extension of the ROP  for 
individuals attesting to satisfactory immigration status and who are making a good  faith  effort to  
obtain any necessary documentation, or if the state needs more time to verify the individuals  
status or assist the individual in obtaining documents needed to verify their status.  For  
individuals who have attested to U.S. citizenship status, states may re-verify their  US citizenship  
during the unwinding period through a COVID-19 1115 demonstration, which would provide for  
an extension of the ROP beyond the 90-day timeframe required under section 1902(ee) of the  
Social Security Act  (the Act).  CMS is available to provide technical assistance to states  
interested in  pursuing this approach.  
 
After the continuous enrollment condition expires, the state can terminate individuals  who  still 
have not provided needed documentation of citizenship or immigration status during a  fully 
compliant  ROP  and for whom  the state is not able to verify their status,  as long as  the state 
provides a minimum of 10 days  advance notice of  termination and fair hearing rights consistent  
with   435.917 and 42 C.F.R. Part 431, Subpart E.  
 
Aligning Renewals  with SNAP  Recertification  
For beneficiaries also enrolled in  SNAP, states may  schedule their Medicaid renewals  to coincide  
with the individuals SNAP recertification, provided such recertification occurs  within the 12-
month unwinding period.  This strategy not only  may achieve greater  administrative  efficiencies  
for states but  also can  minimize  the burden for individuals.   
 
Aligning Renewals for all Individuals in a Household 
States may choose to align work on renewals for  all members in a household during the 12-
month unwinding period.  This strategy  will minimize beneficiary burden  by allowing families to  
receive one request for information from the state.   It also will help to  align renewals  for all  
members  of a household in  future years.     
 
CMS reminds states that, while states  may process renewals for an  entire household at the same 
time, redeterminations of eligibility are made on an individual basis.  Thus, a state may not 
terminate coverage for one member whose eligibility is verified with information available to the  
state  because the state was not able to  verify eligibility for another member  in the household.  
For example, a family of  four (two parents and two children) is enrolled in Medicaid through 
different eligibility groups.   The parents  are enrolled in the adult group and the two children are 
enrolled in the childrens group.  The state chooses to align work on renewals for the entire  
family during the 12-month unwinding period.  The state initiates the renewal by  checking  
available data.   The state has sufficient  income  and other  information to determine eligibility  
continues for the two children, but the  income data obtained by the state indicates that the 
parents income exceeds  the standard for the adult group.  The state sends the family  a pre-
populated renewal form  and provides a minimum  of 30 days for the  family  to return the renewal  
form.  The family does not return the renewal  form.  Because the state does not have sufficient  
information to renew  eligibility for the  parents, it must send advance notice of termination 
related to  their  coverage.  However, the state may  not terminate coverage  for the children and 
must begin a new 12-month eligibility period  for them.  Page 21  State Health Official  
 
 
Aligning Renewals for Individuals  Who Missed Their Medicare  Initial Enrollment Period 
Some individuals who have retained Medicaid coverage during the PHE may  have become  
eligible for Medicare since March 2020 but have  not signed up for Medicare during their  
Medicare initial enrollment period because they continue to be covered by  Medicaid and may  
think they do not need Medicare coverage at this time.  An individuals Medicare initial 
enrollment period is the  7-month period that starts three months before an individual is first  
eligible  to enroll in Medicare.  
 
Unless the individual is eligible for  a special  enrollment period, individuals who miss their  
Medicare initial enrollment period may only sign up for Medicare during the Medicare  general  
enrollment period, which runs from January 1 to March 31 each year.  Those individuals  may 
also have to pay a monthly late  enrollment penalty.  However, certain Medicaid enrolled  
individuals may obtain Medicare coverage  at other times of the  year through their states  
Medicare buy-in process.   
 
A Medicare-eligible beneficiary who misses  their  Medicare initial enrollment period,  is not  
enrolled into Medicare through the states buy-in process, and loses  their Medicaid eligibility  
outside of the Medicare  general  enrollment period (i.e., after the state resumes regular  
terminations), may  experience a gap in coverage before their Medicare coverage begins. Such 
individuals  also  may incur  late enrollment penalties once they  do enroll  in Medicare.  
 
States may leverage available data matching  processes to help identify beneficiaries who may  
have become eligible for  Medicare during the PHE.15  To minimize disruptions in coverage and 
to avoid imposition of late enrollment penalties, CMS encourages states to  attempt to identify  
these beneficiaries  and to reach out to advise them to enroll in Medicare during their initial 
enrollment period or during  the current Medicare general  enrollment period (before March 31, 
2022), whichever applies.  States should refer these individuals to their  local State Health  
Insurance Assistance Program (SHIP) for  counseling.   Additionally, states  should consider the  
timing of the next Medicare general enrollment period in scheduling  renewals  during the  
unwinding period for individuals who may be Medicare  eligible, in order  to facilitate seamless  
coverage transitions and avoid gaps in coverage by  scheduling these individuals renewals to 
coincide with the Medicare  general enrollment period. 
 
IV.   Notices and Fair Hearings   
 
A.   Notices  
 
Whenever  a  Medicaid  or CHIP  agency makes a  decision affecting  a beneficiarys eligibility, the  
state generally must send  the beneficiary a notice  at least 10 days prior to the date of  action  
(defined at 42 C.F.R.  431.201 as the intended date on which a termination, suspension, 
reduction, transfer or discharge becomes  effective) of the agencys decision.  This advance  
                                                           
15  CMCS Informational Bulletin,  Strategies to Streamline Transitions for Medicare-eligible  Beneficiaries Who Newly Qualify  
for Medicare,  (June 2017). Available at  https://wwwmedicaid.gov/federal-policy-guidance/downloads/cib060717.pdf. The 2021 
MAPD State User Guide is available at  https://www.cms.gov/Research-Statistics-Data-and-Systems/CMS-Information-
Technology/mapdhelpdesk/MAPD-State-User-Guide.     Page 22  State Health Official  
 
notice must include certain information, including the beneficiarys right to a Medicaid fair  
hearing, as described  at  42 C.F.R.  435.917 and 42 C.F.R. Part 431, Subpart E,  or a CHIP  
review, as described at  42 C.F.R.  457.340(e) and 457.1120-1190.  
 
States must provide beneficiaries with advance notice of any action resulting from an eligibility  
determination conducted during the unwinding period.  This requirement applies even in cases  
where the unwinding period eligibility determination  yields the same action as a determination  
conducted during the PHE, and for which the state previously provided notice, as it is important  
for beneficiaries to have accurate and up-to-date information regarding the specific end date for  
their Medicaid and CHIP eligibility.  Regulations  at 42 C.F.R.  431.210(a) and 
457.340(e)(1)(ii)(A) require the notice to include the effective date of the  action. 
 
As a reminder, states  may  need to revise timeframes for individuals to request a fair hearing.   
During the PHE, CMS  approved section 1135 waiver authority to provide many  states  with  the 
flexibility to allow applicants or beneficiaries more than 90 days to request a fair hearing.  
Following the  end of the  PHE, states using this flexibility  may  either revert  back to the time  
provided for individuals to request a  fair hearing prior to the grant of section 1135 authority  or 
may modify their  policy to provide another  reasonable time period not to exceed  90 days, in 
accordance with federal regulations (42 C.F.R.  431.221(d)), which does not require a 
submission of a  SPA.  As discussed in the December 2020 SHO, the state must provide  
individuals the amount of time the individual was informed they have  to request a fair hearing  
following an adverse action after the PHE  ends,  even if the state stops providing the additional  
time allowed during  the  PHE going forward.  
 
For  additional  information regarding notice requirements for the end of  flexibilities and  
authorities granted to states during the PHE, see the December 2020 SHO.  
 
B.   Medicaid Fair Hearings  and CHIP Reviews   
 
Typically,  a state Medicaid  or CHIP  agency must  provide an individual the opportunity to have a 
Medicaid fair hearing  or a CHIP review  when an individual believes the state  has taken an  action  
erroneously, including suspensions, terminations, or reductions of  eligibility  or  when the state  
has denied the individuals claim for eligibility (42 C.F.R.  431.220(a) and 457.1120).   One  
exception is that states are not required to provide a Medicaid fair hearing  or a CHIP review  
when the action is due to a change in law or policy, such as  the end of eligibility that was  
authorized only during the PHE (e.g., the  extension of eligibility to non-residents temporarily  
residing in the state due to the PHE) (see 42 C.F.R.  431.220(b) and 457.1130(c)).   However, a 
beneficiary always has the right  to request a Medicaid fair hearing or a CHIP review  to contest  
that the eligibility determination  was wrong on another basis under  existing authority.  In  
Medicaid, beneficiaries  also have the right to continue to receive benefits pending the fair  
hearing  decision when the individual requests the  fair hearing prior to the date of the action in 
accordance with  42 C.F.R.  431.230. 
 
During the PHE, a number of states were granted  a regulatory concurrence that  allowed a state to  
take more than 90 days to take final administrative action on Medicaid fair hearing requests due 
to an emergency beyond the states control (42 C.F.R.  431.244(f)(4)(i)(B)).  All states,  
including those  granted this regulatory concurrence, are expected to begin processing  fair  Page 23  State Health Official  
 
hearing requests timely  when the continuous enrollment condition ends (see 42 C.F.R.  
431.244(f)(1)-(3)).  However, we understand that some states are  concerned that the volume of  
fair hearings may increase dramatically  and exceed the states capacity to adjudicate all fair  
hearing  requests within the regulatory time  limits.    
 
For states that encounter  such challenges in their  fair hearing process, CMS will consider  
providing authority under section 1902(e)(14) of  the Act  to provide the state with additional time  
to take final action provided that certain beneficiary protections are provided.  For more  
information on the section 1902(e)(14) waiver opportunity, see  section V.A. below.  The CHIP  
review regulations require states to complete the reviews of eligibility and  enrollment matters in  
a reasonable amount of  time (42 C.F.R.  457.1160(a)).  CMS interpreted that regulation to 
contain sufficient flexibility for states to  take additional time to complete CHIP reviews during  
the PHE, and thus did not find it necessary to grant states explicit authority  to do so.  Following  
the end of the PHE, states  will need to continue completing reviews within a  reasonable 
timeframe  as described  at 42 CFR   457.1160(a).  
 
As states restore  routine  eligibility and  enrollment practices, including  eligibility terminations,  
states may see a  return to a normal or higher than normal volume of fair hearing  requests.  As  
states develop their unwinding operational plans, they should consider the volume of requests  
their fair hearing programs can process in a timely  fashion  and take the anticipated volume of  
requests and the states operational capacity into account as they determine  how to distribute  
pending  actions across the unwinding period.  Just as some states may have been unable to hold 
in-person fair  hearings  and reviews during the PHE or had reduced the number of in-person 
hearings, states may modify certain fair hearing  and review  processes  without the need for  
additional state plan authority to avoid and reduce backlogs of fair hearings.  States may hold fair  
hearings and reviews by telephone or video, as long as the state is providing access to the fair  
hearing process in accordance with 42 C.F.R. Part  431 subpart E (including  providing access to 
individuals with disabilities and those who have  LEP) and 42 C.F.R.  457.1140(d).   States may  
also explore establishing  or expanding an informal resolution process to resolve fair hearing  
requests prior to holding  a fair hearing, an option which is available to states without additional  
state plan authority.   
 
CMS  plans to post on Medicaid.gov a resource document  with additional strategies that states  
may want to consider to  help manage the anticipated increase in fair hearing requests and  is 
available to provide technical assistance to states  related to fair hearing  processes  generally, and  
specifically regarding timeframes  after the PHE  eventually  ends.  
 
V.   Strategies to  Promote Continuity of Coverage and Mitigate Churn  
 
A.   Temporary 1902(e)(14)(A) Waiver  Unwinding  Strategies to Promote Continuity of  
Coverage and Mitigate Churn  in Medicaid  
 
As states prepare to restore routine operations, CMS has worked closely  with state agencies  and  
other stakeholders to identify  ways to  efficiently  enroll eligible individuals, and reduce churn.  In 
order to support states facing  significant operational issues and streamline the renewal  or fair 
hearing processes to protect  otherwise eligible  beneficiaries at risk of  inappropriately losing   Page 24  State Health Official  
 
coverage during the unwinding period, CMS will allow for the limited use of  section  
1902(e)(14)(A)  authority. 
 
Section 1902(e)(14)(A) of the Act, added by section 2002 of the Affordable  Care Act, allows for  
waivers as are necessary  to ensure that states establish income and eligibility determination  
systems that protect beneficiaries.  Since 2013, CMS has granted section 1902(e)(14)(A) waiver 
authority to protect beneficiaries access to coverage by  providing  administrative relief to many  
states facing operational  issues (e.g., backlogs  and application processing delays), navigating  
serious challenges  with eligibility systems, and facilitating the enrollment of newly eligible  
individuals.  
 
To protect beneficiaries in addressing the challenges states may face as they  transition to routine 
operations during the unwinding period, CMS has determined that states  may seek approval to 
use this  authority in a time-limited manner to implement the  five  specific targeted strategies  
outlined below.  These strategies can efficiently  facilitate  the renewal  process by limiting the  
need for  requests for additional information from  beneficiaries, thus leading  to fewer procedural  
terminations and reducing state  administrative burdens during this transition period.  The 
strategy to address states  significant operational  challenges in the fair hearing process can  
protect the due process rights and maintain coverage of individuals pending the outcome of a  fair 
hearing, reducing loss of  coverage and state administrative burden during this  transition  period.  
 
1.   Renewal for  Individuals Based on SNAP Eligibility: Consistent with guidance for  
implementing Strategy 3  in  SHO  letter #13-00316  and revised parameters in  SHO  letter  
#15-00117, states may use this authority to renew Medicaid eligibility for SNAP  
participants without conducting a separate MAGI-based income redetermination.  An  
approved section 1902(e)(14)(A)  waiver request would allow states to rely  on SNAP data  
for renewals for individuals under 65 years of  age, despite the differences in household 
composition and income-counting rules, when necessary to protect  beneficiaries in the 
face of systems limitations.  Please note that a state can permanently leverage SNAP  
information for renewal,  by pursuing the  facilitated enrollment strategies  described in  
Appendix B. 
 
2.   Ex Parte Renewal for  Individuals with No Income and No Data Returned: CMS may 
grant section 1902(e)(14)(A) authority to temporarily permit renewals, on an ex parte  
basis, for households whose attestation of zero-dollar income was verified  within the last 
twelve months, at the initial application or  the previous  renewal, when no information is  
received/returned from a financial data source at renewal.   In order to complete the  ex 
parte  renewal, the state must take appropriate steps to review the non-financial 
components of eligibility consistent with  the requirements at 42 C.F.R.  435.916 and 
435.956. CMS reminds states that the  renewal notice also must instruct beneficiaries to  
inform the agency  if any  of the information used to make the eligibility determination is 
inaccurate.   
                                                           
16  State Health Official letter #13-003,  Facilitating Medicaid and CHIP  Enrollment and Renewals in 2014,  May 17, 2013.  
Available at:  https://wwwmedicaid.gov/federal-policy-guidance/downloads/sho-13-003.pdf.   
17  State Health Official letter #15-001, Policy Options for Using SNAP to Determine Medicaid Eligibility and an Update on  
Targeted Enrollment Strategies, August 31,  2015. Available at:  https://www.medicaid.gov/federal-policy-
guidance/downloads/sho-15-001.pdf.    Page 25  State Health Official  
 
 
3.   Facilitating Renewal for  Individuals with No Asset Verification System (AVS) Data  
Returned within a Reasonable Timeframe: Under  this approach, CMS may  grant states  
authority under section 1902(e)(14)(A) of the Act  to permit renewals  of beneficiaries for  
whom no information is returned by the AVS within a reasonable timeframe.    
 
In  accordance with regulations at 42 C.F.R.  435.916, states must attempt to make an  ex 
parte  determination at renewal and  check income data sources at renewal,  consistent with  
its verification plan.  Additionally, section 1940 of the Act requires that states verify  
assets using the states AVS for individuals excepted from MAGI-based methodologies 
and subject to an asset test.  While states are required to comply  with these requirements,  
the state may establish  a reasonable  time frame  for AVS information to be  returned.   
Currently, if the  AVS does not return information  within the timeframe established by the  
state, the state must attempt to redetermine eligibility in accordance with its verification  
process, which may include requesting additional information and documentation or  
obtaining a new attestation of assets from the individual by sending  the beneficiary  a 
renewal form requesting  the additional information.  Time-limited authority  granted  
under this approach would allow a state to assume  there has been no change in resources  
that are verified through the AVS when no information is returned within a reasonable  
timeframe, and therefore complete the renewal process without any further  verification of  
the assets that are verified through the  AVS. 
 
4.   Partnering with Managed Care Plans to Update Beneficiary Contact  Information:  States  
generally  are required to contact the beneficiary to confirm the accuracy of  updated 
contact information received from a health plan and to provide a reasonable period for the  
beneficiary to dispute the information provided by the plan, prior to updating the  
beneficiary record  (see Overview of Strategic Approach to Engaging Managed Care 
Plans to Maximize Continuity of Coverage as States Resume Normal Eligibility  and  
Enrollment Operations - February 2022 Update).   However, CMS recognizes that some 
states may have system or operational limitation that prevent the state for doing so.   CMS  
may  grant section 1902(e)(14)(A) authority to temporarily permit such states to accept  
updated enrollee contact information from managed care plans without additional  
confirmation with the individual where doing so would serve to protect beneficiaries in 
the aggregate.  Under this temporary waiver authority, states may treat updated contact 
information received from the plan as reliable and update the beneficiary  record with the 
new contact information  without first sending a notice to the address on  file with the  
state.   
 
5.   Extended  Timeframe to  Take Final Administrative Action on Fair Hearing Requests: 
CMS may  grant  states authority under section  1902(e)(14)(A) to temporarily  extend the  
timeframe to take  final administrative action on fair hearing requests.  In order to use this  
option in a manner that protects beneficiaries, states would be required to provide  
benefits pending the outcome of a fair hearing decision (including reinstating  benefits  
pursuant to 42 C.F.R.  431.231), regardless of whether or not  a beneficiary has  
requested  a  fair hearing prior to the date of  the adverse action, and to forgo recoupment  
from beneficiaries if the fair hearing ultimately upheld the agencys determination. 
  Page 26  State Health Official  
 
While  we have outlined five  targeted strategies  requiring approval under section 1902(e)(14)(A)  
of the Act, CMS may consider  other 1902(e)(14)(A) waiver renewal strategy requests  that impact 
the states ability to process renewals, including  flexibilities that address streamlining application  
processing in order to maximize state resources or  enrollment strategies for  other populations to 
promote continuity of  coverage.   
 
However, CMS will not  approve 1902(e)(14)(A)  waiver requests  unrelated to  the states  
unwinding period or requests that fail to protect beneficiaries.  For  example, states may not use 
the authority to extend beneficiary  eligibility periods  beyond the unwinding period.  In addition, 
CMS will not approve requests to shorten eligibility periods or  bypass renewal  or fair hearing  
requirements that minimize beneficiary burden and ensure eligible individuals remain enrolled 
(e.g., eliminating the  requirement to complete  ex parte  renewals), as such requests would not  
serve to protect beneficiaries, as required by section 1902(e)(14)(A) of the  Act. 
 
To  request authority to implement one or more of these strategies, states  can request such waiver  
authority under section 1902(e)(14)(A) of the Act on a time-limited basis during  the unwinding  
period.  CMS  is available to provide technical  assistance and  can provide sample language the  
state can use to  craft a letter requesting the waiver  authority.   States interested in  one or more of  
the temporary waiver  authorities described above  should contact their  CMS State Lead.  
 
B.   State  Plan and Operational Strategies to Promote Continuity of Coverage and Mitigate  
Churn  
 
As states develop their plans to complete pending  eligibility  and enrollment actions, they should 
also consider strategies that will help eligible individuals maintain coverage, prevent  churning on 
and off of  coverage, and mitigate procedural denials based on the absence of a returned renewal  
form or other information needed by the state to complete a redetermination of eligibility.  These 
strategies may include:   
 
   State plan options, such as:  
   continuous eligibility  for children  
   12 months continuous postpartum coverage (beginning April 2022)  
   express lane eligibility  for children  
   Options to streamline renewals, such as:   
   expanding the number  and type of  data sources used to attempt an ex parte  
renewal   
   aligning MAGI  and non-MAGI renewal policies   
   Improving  communications and outreach to beneficiaries, such as  by:   
   updating contact information 
   partnering with health plans  
   establishing processes to  address returned beneficiary mail  
   using multiple modalities to reach individuals  (e.g., mail, email, text)18  
o
 
                                                           
18  CMS is working with other federal partners to examine potential statutory constraints around the use of text  messaging.  We  
will pass along additional information as it becomes available.   Page 27  State Health Official  
 
As part of their unwinding operational planning, states should assess their readiness to complete  
eligibility and enrollment actions and adopt policy options and operational  strategies that will 
address  situations in which  eligible beneficiaries  may be at risk of losing coverage and create 
efficiencies for states  to address the volume of work during the unwinding period.  States should 
ensure that their  eligibility  and  enrollment workforce is aware of any new strategies that are  
adopted through memorandums, updated internal  procedures and policy manuals, formal  
trainings, or other methods of communication.  States may refer to Appendix  B and the  
November 2021 tool, Strategies States and U.S. Territories Can Adopt to Maintain Coverage of  
Eligible  Individuals as they Return to Normal Operations," for examples of  strategies that 
promote continuity of  coverage  and mitigate churn and additional guidance on how states may  
implement them.19  
 
VI.   Facilitating Transitions  between Medicaid, CHIP,  BHP,  and the  Marketplace  
 
In completing renewals  once the continuous enrollment condition expires, states are likely to  
identify many beneficiaries who are no longer  eligible for Medicaid, CHIP, or coverage through 
a BHP.  Many of these individuals will likely be  eligible for  enrollment in a  QHP  through the  
Marketplace with  significant financial assistance.   Facilitating smooth transitions to the  
Marketplace for these beneficiaries  will be critical to ensuring that such eligible individuals do 
not  become uninsured.  
 
Regardless of whether  a state has  an SBM  that operates its own eligibility  and enrollment 
platform or a Marketplace that relies on the  federal eligibility and enrollment platform to 
complete eligibility determinations for  coverage in a QHP, state Medicaid, CHIP, and BHP  
agencies  are required to have  an  agreement with the relevant  Marketplace  and, consistent with 
the requirements at 42 C.F.R.  435.1200, 457.350, and 600.330, have  a coordinated process to 
send electronic accounts  and other  information  to  the Marketplace, to receive electronic accounts  
and other information from the Marketplace, and to ensure prompt determinations of eligibility  
and enrollment in the appropriate program.  As noted above, for individuals determined by the  
agency  as not eligible  for Medicaid, CHIP, or  BHP following a renewal or  redetermination of  
eligibility, the agency must promptly  assess the individuals potential eligibility for  Marketplace 
coverage and timely transfer the individuals electronic account to the Marketplace.   The account  
must include all of the information collected and generated by the state regarding the individuals  
Medicaid, CHIP, and/or  BHP  eligibility.  
 
Medicaid and CHIP agencies may have insufficient information to assess an individual as  
potentially eligible for  Advanced Premium Tax Credits or Cost-Sharing Reductions through the  
Marketplace, as such  assessment requires  application of different financial  methodologies, 
evaluation of access to or enrollment in employer-sponsored or other  forms of coverage, and, in 
some cases, non-citizen eligibility criteria.   States  are not required to conduct individual  
assessments but instead may implement a streamlined approach that will reduce  the 
administrative burden for states and ensure timely  transfer of individuals potentially eligible for  
QHP enrollment.   States can treat anyone who is determined ineligible for  Medicaid or CHIP as  
potentially eligible for QHP enrollment, other than individuals  whose coverage was  denied or  
                                                           
19  Strategies States and the U.S. Territories  Can Adopt to Maintain Coverage of Eligible Individuals  as They Return to Normal  
Operations,  (November 2021).  Available at:  https://wwwmedicaid.gov/state-resource-center/downloads/strategies-for-covrg-of-
indiv.pdf.    Page 28  State Health Official  
 
terminated for  a procedural reason (e.g., failing to  complete the renewal process) and individuals  
who do not attest to U.S. citizenship or  a lawfully  present non-citizen status.  BHP agencies  
should continue to follow the requirements related to coordination with other insurance  
affordability programs under  600.330.  
 
States are also encouraged to implement additional approaches that may help with  transitions to 
and enrollment in a  QHP.  While most appropriate for states served by a Marketplace that relies  
on the federal eligibility  and enrollment platform or those in which the state  
Medicaid/CHIP/BHP  and Marketplace systems are not integrated,  the following  strategies may  
be helpful  for all states  to consider.  States can:  
 
   Improve eligibility determination notice language for individuals found ineligible for  
Medicaid/CHIP/BHP  so that they  are aware that the Medicaid/CHIP/BHP  agency will be  
transferring their application to the  Marketplace  and that the Marketplace will be sending  
them a notice with information on applying for  coverage  and financial assistance through 
the Marketplace;   
   Transmit all available contact information  provided on the application or contained in the  
beneficiary record  for individuals on the application, including email addresses, phone  
numbers, and beneficiary communication preferences, to the Marketplace. The  Medicaid  
Enterprise State Systems Officer assigned to each  state will follow up with  states  
technical teams to discuss any missing contact information from accounts that are  
transferred to the Marketplace and  will offer technical assistance as necessary to ensure 
that accounts are transferred with  complete contact information as quickly  as feasible;   
   Transmit all eligibility  information the state has on an individual in the account transfer  
to the  Marketplace.  Consider including notice language to beneficiaries that includes  
contact information for  Navigator and assister programs which can help them with the  
transition to the Marketplace; and  
   Work with community-based organizations that comprise the Administration for  
Community  Living (ACL)s aging and disability  networks, including  Area Agencies on 
Aging (AAAs), Centers for  Independent  Living  (CILs), and Protection and Advocacy  
organizations (P&As), as well as beneficiary  advocates to ensure consumers get  
information and assistance they need to navigate this transition.  
 
For more information, states may refer to the July 2016 CIB, Coordination of Eligibility and 
Enrollment Between Medicaid, CHIP  and the Federally Facilitated Marketplace (FFM or  
Marketplace),  which is available to assist states in meeting their obligations to  coordinate 
eligibility and enrollment among insurance  affordability programs and the  account transfer  
process.20    
 
VII.   Monitoring State  Progress and Corrective Action  
 
CMS will monitor states progress in meeting the timelines and completing  required  eligibility  
and  enrollment actions described in this letter.  Under the authority in sections 1902(a)(6) and 
1902(a)(75) of  the Act  and 42 C.F.R.  431.16, all states will be expected  to submit data  
                                                           
20  CMCS Informational Bulletin,  Coordination  of Eligibility and Enrollment Between Medicaid,  CHIP and the Federally  
Facilitated  Marketplace (FFM or Marketplace),  (July 2016). Available at: https://wwwmedicaid.gov/federal-policy-
guidance/downloads/cib072516.pdf.      Page 29  State Health Official  
 
demonstrating progress in completing  pending  applications and initiating the states total 
caseload of renewals, along with the disposition of renewals.  States will be required to submit 
baseline data to CMS  and  report  additional data on a monthly basis, for  a  minimum of 14 
months.  Where reported  data indicate that states  are not meeting timelines described in this  
letter, or in circumstances where data demonstrate other  potential compliance issues, including  
potential erroneous disenrollments of eligible beneficiaries, states may be expected to report  
additional data and/or report information more frequently.  CMS will identify the data elements  
to be reported and provide a reporting template for states to use.  
 
In addition, states that do not resolve their pending eligibility and enrollment  actions within the  
timelines specified may  be required to separately  submit a corrective action plan to CMS  
outlining strategies and  a timeline to come into compliance with federal requirements.   
 
VIII.   PERM or MEQC  Programs    
 
CMS will not consider eligibility  and enrollment actions  that are  delayed due to the PHE as  
untimely for purposes of  the PERM or MEQC programs if such actions are  initiated within the  
timelines detailed in this  letter and completed before the end of the 14th month once the state 
begins its unwinding period.  States with an approved section 1902(e)(14)(A) waiver, that are 
compliant with the parameters outlined in Section  V.A. of this SHO  letter, shall be not be  
considered in violation of Medicaid statute and regulations for purposes of  PERM and MEQC  
reviews.     
  
IX.   Closing   
 
CMS  shares states  goal of ensuring that eligible individuals remain enrolled in Medicaid, CHIP, 
and/or  BHP  coverage  and that  individuals who are no longer eligible are able to transition 
seamlessly to other coverage options for which they  are eligible, including  Marketplace  
coverage.  CMS also  remains interested in hearing state and stakeholder feedback and concerns  
as states plan for the  eventual end of the PHE and the continuous enrollment condition, and the 
return to routine operations.  We are committed to providing states with  updated guidance and 
resources, as appropriate,  as well as ongoing technical assistance necessary  for states  to complete  
eligibility and  enrollment work as described in this letter.  Please submit any  additional requests  
for technical assistance to  your CMS State Lead.  
 
Sincerely,   
 
Daniel Tsai  
Deputy  Administrator and Director  
 
Cc:   
 
National Association of  Medicaid Directors   
National Academy for State Health Policy    Page 30  State Health Official  
 
National Governors Association  
American Public Human  Services Association   
Association of State and  Territorial Health Officials   
Council of State Governments   
National Conference of State Legislatures   
Academy Health   
National Association of  State Alcohol and Drug  Abuse Directors  Appendix A: 12-Month Unwinding Timeline  
 
Note: The options in this  graphic are illustrative  of when a state may begin  its 12-month unwinding period when the PHE  eventually ends and 
are based on a state with a 75-day renewal processing timeline for  a cohort  of individuals.  There will be variation depending  on individual  
state renewal processing  timelines.  
The contents of this document do not  have the force  and effect of law and are not meant to bind the public in any way, unless specifically incorporated into a contract. This document is  
intended only to provide clarity to the public regarding existing requirements under the law.   Page 32  State Health Official  
  Page 33  State Health Official  
 
 
Appendix  B: Strategies to Promote Continuity of Coverage and Mitigate Churn  
 
States will need to consider strategies that ensure  eligible individuals remain enrolled and allow  
states to efficiently complete outstanding work.   As states develop their unwinding operational  
plans, they should identify  where there is a  risk that eligible individuals may  lose coverage in 
their  current  and planned  processes  and adopt strategies that mitigate particular risks in the state.   
The following  are  examples of strategies states may  adopt to promote  continuous coverage and 
reestablish communications with beneficiaries.  
 
A. Promote Continuous  Coverage for Eligible Individuals  
 
Provide Continuous Eligibility to  Maintain Coverage for  Eligible  Individuals  
Under continuous eligibility, beneficiaries  retain eligibility for  a period, up to 12 months, elected 
by the state.  A beneficiary  for whom continuous  eligibility applies  generally  retains eligibility,  
regardless of changes in circumstances, for the duration of the continuous eligibility period 
elected by the state.  Adopting continuous eligibility for some or all populations can ease the  
burden on states during the unwinding period by relieving the state of any  need to conduct  a  
redetermination based on changes in circumstances after a  beneficiary has  been renewed  for  
coverage during the unwinding period, until the next regularly-scheduled renewal.  This would 
ensure that the state  would only need to take action on the beneficiarys  case once during the  
unwinding period. 
 
Under 42 C.F.R.  435.926 and 457.342, a state  may provide up to 12 months of continuous  
eligibility in Medicaid and CHIP for  children who are under age 19 or under a  younger  age  
specified by the state.  This option provides the state with the authority  generally  to not act on 
changes in circumstances for children during the continuous eligibility period.21   States  
implementing continuous eligibility in Medicaid must apply the policy to all  children under the  
age specified by the state who are eligible under all mandatory  and optional categorically needy  
groups under Section 1902(a)(10)(A) of the Act.  
 
Action: To elect this option, states must submit a  SPA.   
 
States can adopt income  and resource disregards under the authority of section 1902(r)(2)  of the 
Act to provide continuous eligibility for most adult beneficiaries enrolled on the basis of being  
age 65 or older, living with a disability or blindness, or need for long-term care services  and  
supports.  States that would like to provide continuous eligibility for MAGI-based  adult  
beneficiaries may consider submitting a section 1115 demonstration waiver application.   
 
Action: States interested in pursuing a  section  1902(r)(2) disregard for individuals eligible on a  
non-MAGI basis must submit a SPA.   States interested in pursuing  a  section  1115 demonstration 
to provide continuous eligibility should contact their state lead or section 1115 demonstration 
project officer.    
 
                                                           
21  There are several exceptions specified in the regulations to this general rule, in which states are expected to act on changes in a  
childs circumstances, including children turning age 19, changes in state residency, death, or voluntary termination, and,  for  
children enrolled in CHIP, becoming eligible  for Medicaid.   Page 34  State Health Official  
 
Extend  Postpartum Coverage in Medicaid and CHIP   
Sections 9812 and 9822 of the ARP give states  a  new option to provide 12-months of extended 
postpartum coverage to individuals who were  enrolled in Medicaid or CHIP while pregnant.  
Individuals eligible for extended postpartum coverage are  entitled to continuous eligibility  
despite  changes in  circumstances that would otherwise affect eligibility during the  extended  
postpartum period.  States may adopt this option beginning April 1, 2022, and, as  noted earlier in 
this letter, states may  wish to deprioritize  work on actions for pregnant and postpartum  
individuals during the 12-month unwinding period  until the  extended postpartum coverage  
option becomes effective and the state has taken steps to adopt  it.  States may  refer to SHO #21-
007 Improving Maternal Health and Extending Postpartum Coverage in Medicaid and CHIP,  
for more information on implementing this option.22    
 
Action: To elect this option, states must submit a  Medicaid and CHIP SPA.  
 
Maximize Success  of Ex  Parte Renewals Through Use of Expanded Data Sources  
States must attempt to  renew eligibility based on available information (ex parte  renewal)  for all  
beneficiaries as required at 42 C.F.R.  435.916(a)(2) and (b).  States may expand the number  
and type of data sources  used during the  ex parte  process as well as create a data source 
hierarchy to prioritize sources that provide the most recent and  reliable data.  States can  also  
adopt policies during the  unwinding period (or longer) to  maximize  the use of the  ex parte  
renewal processes and increase the rate at which beneficiaries  eligibility may be renewed using  
information available to the state and without requiring a  renewal form or other documentation 
from beneficiaries.   For  example, states may rely on  information in the case  record which the  
state determines is highly unlikely to change, especially for particular populations (such as  
income for  children eligible  for coverage under section 1902(e)(3) of the Act (Katie  Beckett 
group) without regard to their parents income, beneficiaries dually eligible  for Medicare and  
Medicaid,  or beneficiaries over a specified age), as reliable information even if the state requires  
documentation of income not verified electronically  from other beneficiaries.  States pursuing  
this option may need to update their verification plan.   
 
Action: No SPA is needed, but updated verification plans for MAGI-based determinations must  
be submitted to CMS.     
 
Adopt MAGI Renewal  Policies for  Non-MAGI Renewals to  Minimize  Beneficiary Burden  
States that currently  renew eligibility more frequently than once every 12 months for some or all  
of their non-MAGI beneficiaries may elect to renew eligibility  for some or  all of their non-
MAGI populations only  once every 12 months.  Extending the renewal timeframe may also  
support  other state priorities, such as increasing access to home and community-based services, 
by reducing the frequency  in which beneficiaries  must respond to state requests.   
 
Action: To elect this option, states must submit a  SPA.   
 
Under 42 C.F.R.  435.916(b), states may also adopt renewal procedures required for MAGI  
beneficiaries under  435.916(a)(3) for non-MAGI beneficiaries.   Such procedures include using  
                                                           
22  CMS State Health Official Letter #21-007,  Improving Maternal Health and Extending  Postpartum Coverage in Medicaid and  
the Childrens Health Insurance  Program (CHIP),  December 7, 2021. Available at:  https://wwwmedicaid.gov/federal-policy-
guidance/downloads/sho21007.pdf.    Page 35  State Health Official  
 
a pre-populated renewal  form for beneficiaries whose renewal cannot be completed using only  
information available to the state; providing  a minimum of 30 days  for beneficiaries  to respond; 
and providing  a reconsideration period for beneficiaries whose eligibility  is  terminated at 
renewal for failure to return their renewal form or other required  information, but who 
subsequently do so  after their eligibility is terminated, without requiring the  submission of a new  
full application.   
 
Action: States may need to submit a SPA for CMS approval to implement these options  or 
update internal procedures. 
 
Use Information from Other  Programs like SNAP  and Temporary Assistance for Needy Families  
(TANF) to  Renew  Eligibility  
States have several options to leverage information from programs like SNAP or TANF to verify  
eligibility and  facilitate renewals in a manner that  minimizes beneficiary burden.  Some of these 
options will require states to submit a SPA.   As noted in Section V.A. of this SHO  letter, states  
may  also use a temporary 1902(e)(14)(A)  waiver.  Under the Express Lane Eligibility authority  
at  sections 1902(e)(13) and 2107(e)(1) of the Act, states are permitted to rely on findings from an 
entity designated by the state to determine whether a child satisfies one or more factors of  
eligibility for Medicaid or CHIP, including income.  States may  also adopt the facilitated  
enrollment SPA option for adults and children.  This option allows states  to  rely on income 
determinations made by  another program if the state is certain the individual would be income-
eligible using MAGI-based methods.  Both the  Express  Lane Eligibility and facilitated  
enrollment SPA options  may be used at application, renewal, or both.  States interested in these  
options may refer to the  SHO #10-003, Express Lane Eligibility23 and the  SHO #15-001 
Policy Options for  Using SNAP to Determine Medicaid Eligibility  and an Update on Targeted  
Enrollment Strategies for additional guidance.24  
 
States may also use verified information from other state and federal programs to verify the  
financial eligibility of an individual.  For example, SNAP  wage or other income data captured in 
an integrated  eligibility  and enrollment system may  be used to verify  continued eligibility  at 
renewal or a redetermination based on a change in circumstances.   
 
Action: States electing to use other program information as a reliable data source should update 
their verification plans.  Changes made to MAGI  verifications plans must be submitted to CMS.  
 
Modify or Suspend Periodic Data Matching  
States can improve coverage retention  and reduce  churn between  regular  renewals  by suspending  
periodic data matching or  modifying the  approach by reducing  the frequency  with which 
periodic data matches are conducted.  This strategy  will avoid or reduce  the administrative  
burden associated with redeterminations between regular  renewals  during the 12-month 
unwinding period, including the need to process new applications submitted by beneficiaries  
terminated because they  did not respond to a mid-year request for  additional information.   
                                                           
23  CMS State Health Official Letter # 10-003,  Express Lane Eligibility Option,  February 4, 2020.  Available at  
https://www.medicaid.gov/sites/default/files/Federal-Policy-Guidance/downloads/SHO10003.PDF.   
24  CMS State Health Official Letter # 15-001,  Policy Options for Using SNAP to Determine Medicaid Eligibility and an Update  
on Targeted Enrollment Strategies, August 31,  2015. Available at  https://wwwmedicaid.gov/federal-policy-
guidance/downloads/sho-15-001.pdf.    Page 36  State Health Official  
 
 
Action: States need to update their verification plans in order to suspend or  reduce the frequency  
of periodic data matches.  Changes made to MAGI verifications plans must be submitted to 
CMS.  
 
Extend  Beneficiary Response Times  
States are strongly encouraged to review their policies regarding the amount of time  beneficiaries  
are  given to provide requested information and to provide additional time as appropriate.  
Extending the timeframe  for beneficiaries to respond to requests for information will minimize  
the risk that beneficiaries lose coverage for procedural reasons.  As discussed in the Medicaid  
and CHIP  Renewal Requirements CIB, we believe it would be reasonable for states to allow  
beneficiaries 30 days to respond and provide  any  necessary information needed to verify  
eligibility.25    
 
Action: Update internal  state procedures; states do not need to submit a SPA for CMS approval  
to implement this option.  
 
Offer a  Reconsideration Period for Coverage Losses following Changes in Circumstances   
States may offer  a minimum 90-day reconsideration period, similar to  the reconsideration period 
provided for MAGI beneficiaries at  renewal under 42 C.F.R.  435.916(a)(3)(iii) and 457.343, 
for beneficiaries whose eligibility has been terminated for failure to respond to a request for  
information needed to redetermine eligibility following  a change in circumstances, if the 
individual subsequently returns the  needed  information.  Offering  a reconsideration period 
allows states to  reconsider  an individuals eligibility  without requiring the individual to fill out a  
new application.  The  required information returned within the reconsideration period serves as  
an application.  If adopted, a determination or denial of eligibility  based on the returned 
information must be made consistent with timeliness standards  specified  in  435.912 or  
457.340(d), as applicable.  In Medicaid, retroactive eligibility  would be available, consistent with 
 435.915(a), to provide  coverage for up to three  months prior to the date the information was  
returned.  States would also need to ensure they collect any additional information from the  
individual that is not available to the state but required at application, such as a signature.  
 
Action: Update internal state procedures; states do not need to submit a SPA for CMS approval  
to implement this option.  
 
B. Reestablish Communication and Conducting  Outreach with Beneficiaries   
 
CMS recognizes that  states may have had minimal or no contact with  many beneficiaries  for an  
extended period, as many  have not experienced a periodic renewal of  eligibility in several  years  
due to the continuous enrollment condition. There is an inherent risk that eligible individuals will 
lose coverage after the continuous enrollment condition expires  because they  have a new address  
or other contact information, which has not been updated with the state.  Further, beneficiaries  
may not understand that renewals of  eligibility  are  resuming, or know when their renewal may  
occur during the 12-month unwinding  period.  States will need to employ  a  variety of strategies  
                                                           
25  CMCS Informational Bulletin,  Medicaid and Childrens Health Insurance Program (CHIP) Renewal Requirements,  
(December 2020). Available at:  https://wwwmedicaid.gov/federal-policy-guidance/downloads/cib120420.pdf.     Page 37  State Health Official  
 
to reestablish communication with beneficiaries  and engage in outreach efforts to ensure eligible  
individuals maintain coverage.  
 
Update Beneficiary Contact Information 
All states should take steps during the PHE to update beneficiary  contact information to prevent  
coverage losses for  eligible individuals and remind beneficiaries that they may  report updated 
information online, by phone, by mail, or in person.  Maintaining complete and accurate contact  
information is critical to ensuring beneficiaries  get renewal forms and program information  
timely in order to promote retention of coverage or facilitate seamless coverage transitions to 
BHP or  the Marketplace, as appropriate.  States can begin sending  reminders to beneficiaries to 
update their contact information and identify individuals for whom the state may have outdated 
information.     
 
States are also encouraged to work with MCOs to establish a process to engage in outreach to 
beneficiaries to update their contact information and use information made  available to the  
Medicaid agency by MCOs and/or establish processes to receive updated information on an 
ongoing basis from MCOs.  When updated address information is received by the state  from  
managed care plans, states may update the beneficiary record with the new address, provided that  
it is an in-state address and provided that the state  sends a notice to the address on file with the  
state and provides the individual with a reasonable period of time to verify the accuracy of the  
new contact information.   States are also encouraged to contact the beneficiary through other  
modalities, such as via telephone, electronic notice, email, or text message, and to send  
information to the new address, where feasible.   If the beneficiary does not respond to the  
mailing to verify the  accuracy of the contact information provided by the  managed care plan or if 
the beneficiary responds to the outreach through the other modalities and confirms the new  
address on file with the  MCO, the state may update the beneficiary  record with the new contact  
information from the managed care plan.  Critically, states should ensure that managed  care 
plans only provide updated contact information received directly  from or verified by the  
beneficiary, and not from a third party or other source.  Information provided from such sources  
is not considered reliable.  For strategies centered on working  with MCOs, states may  refer to the 
Overview of Strategic  approach to Engaging Managed Care Plans to Maximize Continuity of  
Coverage as States Resume Normal Eligibility  and Enrollment Operations resource available on  
Medicaid.gov.26  As noted in Section V.A. of this SHO  letter, states may  also request  temporary  
authority under section 1902(e)(14)(A) of the Act if systems or operational limitations prevent 
them from  sending  the beneficiary  a notice to the address on file prior to updating the  
beneficiarys record  with new contact information provided by an MCO.  
 
States are strongly encouraged to establish linkages with the U.S. Postal Service (USPS)  
National Change of Address (NCOA) database  as  they prepare to return to normal operations.  
The NCOA is a set of data that includes the permanent change-of-address  records maintained by  
the USPS.  Every time an individual or family moves and submits a change-of-address form to  
their local post office, their new address is recorded in the NCOA database.   States can establish  
agreements with USPS to gain  access to the NCOA database in order to utilize these address  
                                                           
26  Overview of Strategic approach to Engaging Managed Care Plans to Maximize Continuity of Coverage as States Resume 
Normal Eligibility and Enrollment Operations,  (December 2021).  Available at  
https://www.medicaid.gov/sites/default/files/2021-12/health-plan-strategy-12062021.pdf.  
  Page 38  State Health Official  
 
changes.  States are also encouraged to leverage  address information received from USPS when 
mail is returned to the state with an in-state forwarding address.27  Under USPS forwarding mail, 
an individual can elect to have their mail forwarded to their new address.  To mitigate against 
errors, USPS implements controls, which include  charging a  fee by  credit card to validate online  
change of  address (COA) requests, requiring individuals submitting a hardcopy COA request to 
verify that they understand an unauthorized COA order is a federal offense, and sending two 
confirmation letters (to the new and old address) to authenticate the order.  
 
Given the increased likelihood of individuals moving during the PHE, leveraging the NCOA and 
USPS in-state forwarding address information provides states with a streamlined tool to improve  
address accuracy  and locate beneficiaries  who would otherwise be at risk for a procedural  
termination during the unwinding period.  State agencies may treat information obtained from 
the NCOA and USPS returned mail with an in-state forwarding  address  as  reliable and update 
the beneficiary record with the new contact information, provided that the state conducts the  
following outreach.  
 
When updated address information is received by  the state from  NCOA  or from USPS returned  
mail with an in-state forwarding address, states  must send a notice to the  address on file with the  
state and provide the individual with a reasonable  period of time to verify the accuracy of the  
new contact information.   States are also encouraged to contact the beneficiary through other  
modalities, such as via telephone, electronic notice, email, or text message, and to send 
information to the new address, where feasible.  If the beneficiary does not respond to verify the  
accuracy of the contact information provided by  NCOA  or from USPS returned  mail  or if the  
beneficiary responds to the outreach through the other modalities and confirms the new address, 
the state may update the  beneficiary record with the new contact information.  States pursuing  
this option need to update their verification plan and may use the Other  electronic data section 
to indicate how the state  will use NCOA.   Please refer to Appendix C  of this section for a  
detailed discussion on processing  returned mail, including mail returned with an out-of-state or  
with no forwarding  address.  
 
Use Multiple  Modalities to  Reach  Beneficiaries  
While beneficiaries must be able to communicate  with the state agency  and return eligibility and  
enrollment information online, by phone, by mail, or in person, often states  rely  entirely on mail  
to facilitate communication with beneficiaries.  States are  required to communicate with 
beneficiaries through electronic notices pursuant to an individuals election under 42 C.F.R.       
 435.918 and are encouraged to explore and adopt consumer communication and outreach 
strategies through a variety of modalities, including phone  and text messaging.  States are also 
encouraged to pursue using additional methods of  outreach beyond mail to follow up in specific  
situations such as when there are outstanding requests for information, incomplete renewal  
forms, or returned mail.   
 
Update Notices and Other Consumer Facing Messages  
States are encouraged  to  review existing applicant and beneficiary  notices  and communications  
and make modifications  needed to effectively  convey key messages in plain language, consistent  
with 42 C.F.R.  435.905 and 435.917(a).  Notices must provide clear instructions on how to 
                                                           
27  Please refer to Appendix C  of this section for additional information on processing returned beneficiary  mail.   Page 39  State Health Official  
 
complete renewal forms or respond to requests for information as well as explain what  
information is needed for the state to determine eligibility.  Notices should advise beneficiaries  
to keep their contact information up-to-date.    
 
Review Communication Strategies for Individuals who have LEP  and People with Disabilities. 
States are reminded that  program information on Medicaid and CHIP must be provided in plain 
language and in  a manner that is accessible to individuals who have  LEP  and  for people  with  
disabilities, as required at 42 C.F.R.  435.905(b) and 457.110(a).  Applicants and beneficiaries  
with LEP must be able to access information about Medicaid and CHIP, including through use of  
oral interpretation and written translation.  States should ensure that written notices, applications, 
and renewal forms  are translated into multiple languages and that such information is otherwise  
available to individuals through oral interpretation (see  435.206(e), 435.907(g), 435.916(g), 
435.917(a), 435.956(b), and 457.340(e)).  States may  consider providing qualified oral  
interpretation by hiring qualified bilingual staff who speak frequently spoken non-English  
languages within the states population (e.g., Spanish), partnering with community-based  
organizations with qualified interpretation services, and providing qualified interpreters by  
telephone, consistent with 42 C.F.R.  435.901 and 45 C.F.R. Part 92.  Language services needed  
by individuals who have  LEP must be provided free of charge  in accordance with  42 C.F.R.  
435.905(b)(3)  and 457.110(a).  States must inform individuals who have LEP how to access the  
language services that are available, including through use of taglines (i.e.,  a short statement 
written in non-English languages that indicate the  availability of language  assistance services  
free of charge).28    
 
To provide  people with disabilities  accessible information, states must take appropriate steps to  
ensure that communications with applicants, beneficiaries  and members of  the public  are as  
effective as communications with others.  This includes providing  appropriate auxiliary aids  and  
services  at no cost to qualified individuals with disabilities  where necessary  to afford an equal  
opportunity to participate in, and enjoy the benefits of, a service, program, or activity, in 
accordance with  42 C.F.R.  435.905(b), federal law and  implementing regulations.29  
 
For additional detail on providing accessible information to individuals with LEP and people 
with disabilities,  see 45 C.F.R. Part 92. 
 
Utilize  MCOs and Stakeholders to Conduct Outreach  
Close collaboration between states and  contracted  managed care entities, social service 
organizations, and other  stakeholders can help ensure eligible individuals retain coverage in 
Medicaid and CHIP and ease transitions for individuals eligible for coverage through the  
Marketplace.   States  are  strongly encouraged to engage  with their contracted managed  care 
entities as they develop their  unwinding operational plans and identify clear roles and ways in 
which health plans can assist with outreach and enrollment efforts.  States are encouraged to 
                                                           
28  See also  Title VI  of the Civil Rights Act of 1964 and its implementing regulations at  45 C.F.R.  Part  80, and Section 1557 of the  
Affordable Care Act and its implementing regulations at 45 C.F.R.  Part  92.  
29  See  Section 504  of the Rehabilitation Act of  1973  and HHSs  implementing regulations at 45 C.F.R.  Part  84, Title II  of the  
Americans  with Disabilities Act and  DOJs implementing  regulations  at  28 C.F.R.  Part 35, specifically 28 C.F.R.   35.160, and 
Section 1557 of the Affordable Care Act and its implementing regulations at  45 C.F.R.  Part  92.   
  Page 40  State Health Official  
 
provide contracted managed  care entities with a  monthly list of individuals who are due for  
renewal to allow health plans to provide secondary  outreach to ensure individuals complete the  
renewal process.  This will be especially useful during the 12-month unwinding  period  as states  
are redistributing renewals and beneficiaries and health plans may not otherwise know which 
cohort of individuals is due for renewal  in each month.  
 
Engage Other  Stakeholders  
States are also strongly encouraged to engage  with other key stakeholders  (e.g., providers, 
beneficiary advocacy  groups) and with the  Indian Health Service, Tribes and Tribal  
organizations, and urban Indian organizations (ITUs) located in your state  on an ongoing basis.  
Communicating with stakeholders  and ITUs  regularly  will help identify opportunities to leverage  
their support with assisting  beneficiaries in  updating eligibility information and ensure that  they 
understand the need to respond to states notices and complete the renewal  process.   
 
C.   Consider  Additional Strategies  
 
CMS has identified several  additional policies and operational strategies  to streamline workflow, 
strengthen renewal processes to ensure eligible beneficiaries remain enrolled in coverage and  
facilitate coverage transitions between programs, and enhance oversight of  eligibility and 
enrollment operations.  These strategies  are listed in  the November 2021 tool, Strategies States  
and the U.S. Territories Can Adopt to Maintain Coverage  for Eligible  Individuals as They Return 
to Normal Operations.30   States are strongly encouraged to  review available strategies  described 
in this letter as well as  the November 2021 tool  and take any steps  needed to ensure that those  
strategies the state wants to implement are in place  before the state begins its unwinding period.  
                                                           
30  Strategies States and the U.S. Territories Can Adopt to Maintain  Coverage of Eligible Individuals  as They Return to Normal 
Operations,  November 2021. Available at:  https://wwwmedicaid.gov/state-resource-center/downloads/strategies-for-covrg-of-
indiv.pdf.    
Appendix  C: Processing Returned Mail  
 
States should take steps during the PHE to establish procedures and update  policy manuals to 
ensure that staff know the specific  actions they should take in response to returned beneficiary  
mail, as depicted in Graphic 1, below.  States are encouraged to  create a specialized and 
dedicated unit (either centralized or within each region/county) for processing returned mail from  
the USPS.   
  
Receipt of returned mail indicates a potential change in  circumstances that may impact eligibility  
(i.e., state residency).  However, returned mail does not necessarily mean a move out of state or  
that a beneficiary is ineligible.  At the same time, if a state does not obtain  updated contact 
information when mail is returned, beneficiaries are at high risk for procedural termination.  For  
all  returned beneficiary  mail, states are strongly encouraged to  attempt to contact the beneficiary  
by mail and send notices  to both the current address on file and the forwarding address, if one is  
provided, requesting that  the beneficiary confirm the new address provided by USPS.  States also 
are strongly encouraged to attempt to contact the beneficiary using one or more other modalities, 
such as by phone, electronic notice, email, or text messaging  as permissible.   If a state is unable 
to locate the beneficiary  by mail or by using another modality, states should check data sources  
for updated address information (e.g., MCOs, the  state agency that administers SNAP or TANF,  
the Department of Motor Vehicles records, or the USPS NCOA database).  More information on 
state flexibilities to update addresses based on MCO and NCOA data is included in Appendix B  
of this SHO  letter  (See Appendix B, Section B. Reestablish Communication and Conducting  
Outreach  with Beneficiaries).  
 
If the states  attempts to locate the  beneficiary to confirm the contact information are 
unsuccessful, the  action states need to take upon receipt of returned mail will depend on whether  
the USPS has provided a new in-state address, a new out-of-state address, or no new address on 
the returned mail.  States must take steps to locate beneficiaries who may have moved prior to 
taking any  adverse action.  Mail returned with an in-state forwarding address is not an indication 
of a change affecting  eligibility.  Nonetheless, it is important for the state to confirm the accuracy  
of the information to ensure future  ability to contact the beneficiary.  Because this is a change 
that does not affect eligibility, states  are strongly  encouraged to verify the information by  
sending notice by mail to the current address  and also to the forwarding address and attempt to 
contact the beneficiary using one or more other modalities.  States may accept the USPS in-state 
forwarding address  and  update the beneficiarys  record  provided that the state first sends a notice  
to the current  address on file confirming the accuracy of the information.   A state may not 
terminate coverage if the  state does not receive a  response to the request for confirmation of an 
in-state address  change, even if the state does not  update the beneficiarys record with the new  
in-state address.   
 
When a beneficiarys mail is returned to the state  agency with an out-of-state address, the state 
must send notice and attempt to contact the beneficiary to confirm the accuracy of the 
information and verify  continued state residency.  Because the out-of-state address  may be an  
indication of a change in residency, the state must send notice consistent with the beneficiarys  
elected format, either  electronically or by mail, to the current address the state has on file,  
requesting that the beneficiary confirm the address  and state residency.   States are strongly  
encouraged also to send notice to the out-of-state forwarding address and/or  other  address  
provided by a third party, attempt to locate the beneficiary using other electronic or telephonic  
The contents of this document do not  have the force  and effect of law and are not meant to bind the public in any way, unless  
specifically incorporated into a contract. This document is intended only to provide clarity to the  public regarding existing  
requirements under the law.   Page 42  State Health Official  
 
modalities, and by checking third-party data sources for more  recent address information.  If the  
beneficiary does not respond with the requested information, or the information provided does  
not establish the beneficiarys continued state residency, the state must provide advance notice of  
termination or other adverse action and fair hearing rights consistent with 42 C.F.R.  431.206-
214. 
 
We encourage states attempt to locate beneficiaries whose mail is returned  to the state agency  
without a forwarding  address consistent with the steps described above prior to discontinuing  
coverage based on a determination that a beneficiarys whereabouts are unknown.  If a  
beneficiary cannot be located, and there is no forwarding  address, the state  may  terminate  
eligibility in accordance  with regulations at 42 C.F.R. part 431, subpart E.  If a beneficiarys  
whereabouts become known prior to the beneficiarys originally-scheduled  renewal date, the 
state must reinstate coverage  in accordance with regulations at  431.231(d).  
   
Graphic 1.  Agency Action Required by Three Types of Returned Mail    
The contents of this document do not  have the force  and effect of law and are not meant to bind the public in any way, unless specifically incorporated into a contract. This document is  
intended only to provide clarity to the public regarding existing requirements under the law.    
Appendix  D: Related CMS Guidance  
 
Guidance Related to Returning to Routine Operations  after the PHE  Ends  
   State Health Official  Letter (SHO) #20-004, Planning for the Resumption of  
Normal State Medicaid, Childrens Health Insurance Program (CHIP), and Basic 
Health Program (BHP)  Operations Upon Conclusion of the COVID-19 Public  
Health Emergency (December 2020 SHO):  Provides  guidance to states  on planning  
for the eventual return to regular operations, including ending temporary authorities when 
the PHE concludes, making temporary changes permanent in certain circumstances,  
procedures for  ending coverage  and policies authorized under expiring FFCRA  
provisions, and addressing pending  eligibility and enrollment actions that developed 
during the PHE.   
 
States may access the December 2020 SHO  at  https://www.medicaid.gov/federal-policy-
guidance/downloads/sho20004.pdf.   
 
   State Health Official Letter  (SHO) #21-002, Updated Guidance Related to 
Planning for the Resumption of Normal State Medicaid, Childrens Health  
Insurance Program (CHIP), and Basic Health Program Operations Upon  
Conclusion of the  COVID-19  Public Health Emergency  (August 2021 SHO):  
Updates  guidance in the  December 2020 SHO to provide states 12-months after the PHE  
ends to complete pending eligibility and enrollment work and ensures states renew  
eligibility for all beneficiaries prior to taking any  adverse  action.   
 
States may access the August 2021 SHO at  https://www.medicaid.gov/federal-policy-
guidance/downloads/sho-21-002.pdf.    
 
Medicaid and CHIP Renewal and Account Transfer Requirements  
   CMCS Informational Bulletin (CIB), Medicaid and CHIP Renewal Requirements  
(Renewal CIB):  Reminds  states about current federal requirements and  expectations  
codified in existing regulations at 42 C.F.R.  435.916 and 457.343 for completing  
redeterminations of eligibility for Medicaid and CHIP beneficiaries.   These requirements  
are intended to  ease the  administrative burden on states and beneficiaries by limiting  
requests for information to information needed to determine eligibility, ensuring  
beneficiary eligibility is assessed on all bases before determining an individual is  
ineligible and promoting  seamless transitions of coverage, and minimizing the churn of  
beneficiaries on and off  Medicaid and CHIP coverage for procedural  reasons.  
 
States may access the Renewal CIB at  https://www.medicaid.gov/federal-policy-
guidance/downloads/cib120420.pdf.  
 
   CMCS Informational Bulletin Coordination of  Eligibility and  Enrollment Between  
Medicaid, CHIP, and the Federally  Facilitated Marketplace (FFM or 
Marketplace)  (Account Transfer CIB):  Reminds  states about federal requirements  
related to coordination of eligibility and  enrollment among insurance  affordability  
programs and the  account transfer  process.  These requirements are intended to ensure 
determinations of eligibility and enrollment in the appropriate program are  made  
promptly and without delay.  
The contents of this document do not  have the force  and effect of law and are not meant to bind the public in any way, unless  
specifically incorporated into a contract. This document is intended only to provide clarity to the  public regarding existing  
requirements under the law.   Page 45  State Health Official  
 
 
States may access the Account Transfer CIB at https://www.medicaid.gov/federal-policy-
guidance/downloads/cib072516.pdf.     
 
Strategies to  Promote Continuity of Coverage and Prevent  Inappropriate Terminations  
   Overview of Strategic Approach to Engaging Managed  Care Plans to Maximize 
Continuity of Coverage as States Resume  Normal Eligibility and  Enrollment  
Operations: Provides states strategies to work with health plans to update  beneficiary 
contact information, conduct outreach, support individuals enrolled in Medicaid during  
renewal and assist individuals  transitioning  to the Marketplace.  
 
States may access the Overview of Strategic approach to Engaging Managed  Care Plans  
to Maximize Continuity  of Coverage  as States Resume Normal Eligibility  and  
Enrollment Operations  resource at  https://www.medicaid.gov/sites/default/files/2021-
12/health-plan-strategy-12062021.pdf.   
 
   Strategies States and the U.S. Territories Can  Adopt to Maintain Coverage of  
Eligible  Individuals as  They Return to Normal  Operations: Provides  states a list of  
policy and operational strategies that states can implement to support unwinding  
activities at the end of the COVID-19 PHE in order to ensure  continuous coverage  for  
eligible beneficiaries and facilitate coverage transitions for individuals eligible for other  
forms of coverage.   
 
States may access the Strategies States and the  U.S. Territories Can Adopt to Maintain  
Coverage of  Eligible  Individuals as They Return to Normal Operations tool  at  
https://www.medicaid.gov/state-resource-center/downloads/strategies-for-covrg-of-
indiv.pdf.    
 
   Medicaid and CHIP Coverage Learning Collaborative: Ensuring Continuity of  
Coverage and  Preventing Inappropriate Terminations  for Eligible Medicaid and  
CHIP Beneficiaries  Part  1 (Preventing  Inappropriate Terminations of Coverage Part 1 
deck): Provides  guidance and strategies for states to address workflow processes, 
leverage other program data and strengthen consumer outreach and communication to 
promote continuity of  coverage.  
 
States may access the Preventing  Inappropriate Terminations of Coverage  Part 1 deck  at   
https://www.medicaid.gov/state-resource-center/downloads/mac-learning-
collaboratives/ensrng-contnty-cvrg-prvntng-inprprte-trmntns-part-1.pdf.   
 
   Medicaid and CHIP Coverage Learning Collaborative: Ensuring Continuity of  
Coverage and  Preventing Inappropriate Terminations  for Eligible Medicaid and  
CHIP Beneficiaries  Part 2 (Preventing  Inappropriate Terminations of Coverage Part 2 
deck): Provides  guidance and strategies for states to maintain communication with  
beneficiaries and  address returned mail.  
  Page 46  State Health Official  
 
States may access the Preventing  Inappropriate Terminations of Coverage  Part 2 deck  at  
https://www.medicaid.gov/state-resource-center/downloads/mac-learning-
collaboratives/ensrng-contnty-cvrg-prvntng-inprprte-trmntns-part-2.pdf.   
 
   Medicaid and CHIP Coverage Learning Collaborative: Connecting Kids to 
Coverage: State Outreach, Enrollment  and Retention Strategies.   Highlights effective 
and practical strategies to improve state outreach,  enrollment, and renewal activities.  
 
States may access Connecting  Kids to Coverage:  State Outreach, Enrollment, and 
Retention Strategies at  https://www.medicaid.gov/state-resource-center/downloads/kids-
coverg-outreach-enrolmnt-retention-strategies.pdf.  
 
Tools for Effective Communication of Eligibility Determinations  
   Medicaid and CHIP continuous Coverage Unwinding Phase 1: Plan & Educate  
(Unwinding Communications Toolkit):   Provides  important information to help inform  
people with Medicaid and CHIP about steps they  need to take to renew  coverage.   
 
States may access the Unwinding Communications Toolkit at 
https://www.medicaid.gov/resources-for-states/downloads/unwinding-comms-toolkit.pdf.  
 
   Effective Communication of Eligibility Determinations:  Provides states a set of tools  
to assist in the development of key messages, including model notices.  
 
States may access the Effective Communication of Eligibility Determinations tools at 
https://www.medicaid.gov/resources-for-states/mac-learning-collaboratives/expanding-
coverage-under-medicaid-and-chip/index.html.