DEPARTMENT OF HEALTH & HUMAN SERVICES 
Centers for Medicare & Medicaid Services 
7500 Security Boulevard, Mail Stop S2-26-12 
Baltimore, Maryland   21244-1850 
CMCS Informational Bulletin 
DATE:  December 4, 2020 
FROM:  Anne Marie Costello, Acting Deputy Administrator and Director 
Center for Medicaid and CHIP Services (CMCS) 
SUBJECT:   Medicaid and Childrens Health Insurance Program (CHIP) Renewal 
Requirements 
The purpose of this CMCS Informational Bulletin (CIB) is to remind 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 Childrens Health
Insurance Program (CHIP) beneficiaries.  The Medicaid and CHIP fiscal year (FY) 2019 and
2020 Payment Error Rate Measurement (PERM) program improper payment rates, along with
recent federal and state audits, have raised questions concerning state compliance with existing
renewal requirements, including the inappropriate continued provision of eligibility for
beneficiaries who have become ineligible due to a change in circumstances.1  The PERM
program measures improper payments in Medicaid and CHIP and produces statistically valid
improper payment estimates that represent payments that did not meet statutory, regulatory,
administrative, or other legally applicable requirements.
States must comply with renewal regulations, which set forth the responsibilities of states to 
conduct periodic renewals of eligibility for all Medicaid and CHIP beneficiaries and to 
redetermine eligibility between renewals when the state receives information about a change in a 
beneficiarys circumstances that may affect eligibility.  These regulations are designed to ensure 
that states achieve high levels of program integrity and make efficient and appropriate use of 
federal and state dollars, by ensuring that only individuals who meet the Medicaid and CHIP 
eligibility standards remain enrolled.2  The requirements also ease administrative burden on 
1 CMS Fact Sheet: 2019 Estimated Improper Payment Rates for Centers for Medicare & Medicaid Services (CMS) 
Programs. November 18, 2019. Available at https://www.cms.gov/newsroom/fact-sheets/2019-estimated-improper-
payment-rates-centers-medicare-medicaid-services-cms-programs; FY 2020 HHS Agency Financial Report.  
November 13, 2020.  Available at https://www.hhs.gov/sites/default/files/fy-2020-hhs-agency-financial-report.pdf  
Examples of recent federal and state audits are available at 
https://www.lla.la.gov/PublicReports.nsf/1CDD30D9C8286082862583400065E5F6/$FILE/0001ABC3.pdf 
https://oig.hhs.gov/oas/reports/region7/71604228.pdf; https://oig.hhs.gov/oas/reports/region5/51800026.pdf, 
https://oig.hhs.gov/oas/reports/region4/41806220.pdf, and https://oig.hhs.gov/oas/reports/region5/51700008.pdf. 
2 During the 2019 Novel Coronavirus (COVID-19) Public Health Emergency (PHE), the requirement to ensure only 
eligible individuals remain enrolled is temporarily modified under the Families First Coronavirus Act for states 
receiving a temporary 6.2 percentage point FMAP increase.  Section 6008(b)(3) of the FFCRA generally prevents 
states from terminating coverage for individuals enrolled as of or after March 18, 2020, through the end of the 
month in which the COVID-19 PHE ends as a condition of the temporary FMAP increase.  See Additional Policy 
and Regulatory Revisions in Response to the COVID-19 Public Health Emergency (CMS-9912-IFC) for additional 
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 - CMCS Informational Bulletin      
 
states by minimizing the churn of beneficiaries on and off Medicaid and CHIP coverage when 
their eligibility is terminated at renewal for procedural reasons, and they then reapply or return 
required information during the reconsideration period to establish that they continue to meet 
eligibility requirements. 
 
Accurate and timely eligibility redeterminations are critical to ensuring that states provide 
medical and child health assistance only to individuals who remain eligible and avoid making 
payments for ineligible individuals.  Since 2014, states have made significant progress on the 
development and implementation of modernized enrollment and renewal systems and processes.  
These efforts have improved states ability to leverage electronic data to verify eligibility 
information in a timely manner and make accurate Medicaid and CHIP eligibility determinations 
and redeterminations to ensure that only eligible individuals remain enrolled.  Despite these 
efforts, a contributing factor driving the FY 2019 and 2020 PERM improper payment rates in 
Medicaid and CHIP is states failure to conduct timely and accurate redeterminations.3 
  
In addition, the disruption to program operations in a number of states due to the 2019 Novel 
Coronavirus (COVID-19) Public Health Emergency (PHE) further heightens the importance of 
states accurately and efficiently processing the backlog of overdue renewals that is accumulating 
over the course of the PHE.  States and territories have faced stay-at-home orders, social-
distancing recommendations, and transitions to telework, which affected routine state operations.  
This volume of pending actions is also likely to be larger in light of the requirement that states 
continue enrollment for Medicaid beneficiaries enrolled as of or after March 18, 2020, through 
the end of the month in which the PHE ends, to qualify for a temporary 6.2 percentage point 
increase in the federal medical assistance percentage (FMAP).4  CMS released initial guidance 
on the continuous enrollment requirement for states seeking the temporary FMAP increase in the 
form of Frequently Asked Questions in the spring of 2020, and revised guidance in an interim 
final rule, the Additional Policy and Regulatory Revisions in Response to the COVID-19 Public 
Health Emergency interim final rule with request for comments, published on November 06, 
2020.5  In addition, CMCS intends to release additional guidance to assist states to restore 
eligibility and enrollment operations after the PHE when the continuous enrollment requirement 
for states seeking the temporary FMAP increase sunsets. 
  
                                                           
information. Available at https://www.federalregister.gov/public-inspection/2020-24332/additional-policy-and-
regulatory-revisions-in-response-to-the-covid-19-public-health-emergency. 
3 Fiscal Year (FY) 2019 Medicare Fee-For-Service Improper Payment Rate is Lowest Since 2010 While Data Points 
to Concerns with Medicaid Eligibility. November 18, 2019. Available at https://www.cms.gov/newsroom/press-
releases/fiscal-year-fy-2019-medicare-fee-service-improper-payment-rate-lowest-2010-while-data-points; FY 2020 
HHS Agency Financial Report.  November 13, 2020.  Available at https://www.hhs.gov/sites/default/files/fy-2020-
hhs-agency-financial-report.pdf   
4 Families First Coronavirus Response Act (FFCRA), Public Law No. 116-127, Coronavirus Aid, Relief, and 
Economic Security (CARES) Act, Public Law No. 116-136: Frequently Asked Questions (FAQs). April 12, 2020. 
Available at https://www.medicaid.gov/state-resource-center/downloads/covid-19-section-6008-CARES-faqs.pdf.  
5 Families First Coronavirus Response Act  Increased FMAP FAQs. Updated April 13, 2020. Available at 
https://www.medicaid.gov/state-resource-center/downloads/covid-19-section-6008-faqs.pdf; Additional Policy and 
Regulatory Revisions in Response to the COVID-19 Public Health Emergency (CMS-9912-IFC). Available at 
https://www.federalregister.gov/public-inspection/2020-24332/additional-policy-and-regulatory-revisions-in-
response-to-the-covid-19-public-health-emergency. 
 
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 3 - CMCS Informational Bulletin      
 
This CIB will assist states in meeting their ongoing obligations to make accurate and timely 
redeterminations of eligibility both during regular periodic renewals and when the state agency 
receives information indicating a change in a beneficiarys circumstances that may impact 
eligibility.  In addition, this CIB will serve as a resource for states that are restoring eligibility 
and enrollment operations to their routine functioning after the COVID-19 PHE.  CMCS will 
continue to work with states to ensure timely redeterminations of eligibility, especially as states 
resolve backlogs of redeterminations that may have developed during the PHE.  
 
Periodic Renewal Requirements 
 
As required at 42 C.F.R. 435.916 and 457.343, which generally requires states administering a 
separate CHIP to follow the renewal procedures described in 42. C.F.R. 435.916, states must 
renew eligibility for Medicaid and CHIP beneficiaries whose eligibility is determined using 
methodologies based on modified adjusted gross income (MAGI), whom we refer to in this CIB 
as MAGI beneficiaries, once every 12 months and no more frequently than once every 12 
months.  For beneficiaries excepted from MAGI-based financial methodologies under 42 C.F.R. 
435.603(j) (non-MAGI beneficiaries), states must renew eligibility at least once every 12 
months.6  States have flexibility to implement periodic data checks of electronic data sources 
between regular renewals in order to identify beneficiaries who may have experienced a change 
in circumstances affecting their eligibility.7  Such periodic checks, which are discussed later in 
this CIB, can further enhance states effectiveness in minimizing the provision of coverage to 
beneficiaries whose circumstances have changed such that they no longer meet all eligibility 
requirements.  
 
We refer to the time between initial application and regularly scheduled renewals as a 
beneficiarys eligibility period.  States must begin their renewal process early enough in order 
to complete a redetermination of eligibility prior to the end of the eligibility period consistent 
with 42 C.F.R. 435.916 and 457.343.  This includes the time beneficiaries have to return the 
renewal form and any required documentation as well as 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.   
 
Renewals based on reliable information available to the state (ex parte renewals) 
  
States must first attempt to conduct an ex parte renewal for all beneficiaries.8  An ex parte 
renewal is a redetermination of eligibility that states can make based on reliable information 
available to the agency without requiring information from the individual.9  Reliable information 
may include information available in the beneficiarys account and other more current 
information available to the state.  This includes, but is not limited to, information accessed 
through electronic data sources described in 42 C.F.R. 435.948, 435.949, and 457.380 as well 
as recent information available from other benefit programs or reliable sources (e.g., information 
from a recent Supplemental Nutrition Assistance Program (SNAP) recertification).  Information 
                                                           
6 42 C.F.R. 435.916(b) 
7 42 C.F.R. 435.940 and 457.380(h) 
8 42 C.F.R. 435.916(a)(2) and (b) and 457.343 
9 An ex parte renewal is sometimes referred to as auto renewal, passive renewal, or administrative renewal. 
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 4 - CMCS Informational Bulletin      
 
from the initial determination at application or the beneficiarys last renewal is not considered 
recent or reliable, unless it relates to a circumstance generally not subject to change, such as 
citizenship10 or satisfactory immigration status.11  Eligibility criteria for which a beneficiarys 
information is not generally subject to change does not need to be re-verified in conducting an 
eligibility renewal. 
 
If the agency is able to renew eligibility based on the available reliable information, the agency 
must provide notice consistent with 42 C.F.R. 435.917, 42 C.F.R. 431, subpart E, and 42 C.F.R. 
457.340(e), as applicable.  This includes notifying the individual of the eligibility 
determination, the information upon which the agency relied in making the determination and 
basis for continued eligibility, and the beneficiarys obligation to inform the agency if any of the 
information contained in the notice is inaccurate or subsequently changes. 12  The beneficiary is 
not required to sign and return such notice or otherwise notify the agency if all information in the 
notice is accurate.13  
 
Renewals when sufficient information is not available to the state  
 
If sufficient information is not available to complete a redetermination through an ex parte 
process, or if the state has information that indicates the beneficiary may be ineligible, the 
agency must provide the beneficiary with a renewal form and inform the individual of any 
additional information or documentation needed to determine eligibility.14  For CHIP and MAGI 
Medicaid beneficiaries, the renewal form must be prepopulated with the most recent and reliable 
information about the beneficiary which is known by the agency and relevant to the 
redetermination.15  The agency may, but is not required to, provide a prepopulated renewal form 
to non-MAGI beneficiaries.16  The renewal form may only require beneficiaries to provide the 
information needed to renew eligibility.17 
  
Along with the renewal form, the agency must provide the beneficiary with clear instructions on 
how to complete the form and correct any inaccurate pre-populated information; the need to sign 
the form; how the form and additional documentation needed can be returned, and the date by 
which the beneficiary must do so.18  States must provide MAGI beneficiaries with at least 30 
days from the date of the prepopulated renewal form to return the form and provide any 
additional information requested by the agency;19 non-MAGI beneficiaries must be provided 
                                                           
10 Verification of citizenship is a one-time occurrence and states should not re-verify citizenship at renewal or 
subsequent application unless the individual reports a change in citizenship or the state agency has received 
information indicating a potential change in the individuals citizenship status.  See 42 C.F.R. 435.956(a)(4)(ii). 
11 An individuals immigration status does not need to be re-verified if it is not likely to change (e.g. Lawful 
Permanent Resident status) unless the individual reports such a change has occurred.  However, while the 
immigration status of many non-citizens is not likely to change, there are some exceptions such as individuals with 
Temporary Protected Status.  The immigration status of such beneficiaries must be re-verified at renewal.  
12 42 C.F.R. 435.916(a)(2)(i) and (ii), 435.917, and 457.343 
13 42 C.F.R. 435.916(a)(2)(ii) and 457.343 
14 42 C.F.R. 435.916(a)(3) and (b) and 457.343 
15 42 C.F.R. 435.916(a)(3)(i)(A) and 457.343 
16 42 C.F.R. 435.916(b) 
17 42 C.F.R. 435.916(e) and 457.343 
18 42 C.F.R. 435.905(b) and 457.340 
19 42 C.F.R. 435.916(a)(3)(i)(B) and 457.343 
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 5 - CMCS Informational Bulletin      
 
with a reasonable period of time to return their renewal form and any required documentation.20  
As at application, states may not require MAGI beneficiaries to complete an in-person interview 
as part of the renewal process.21  States may adopt the procedures required for MAGI 
beneficiaries for non-MAGI beneficiaries whose redetermination cannot be completed on an ex 
parte basis.22 
  
All beneficiaries must be able to submit their renewal form through any of the modes of 
submission available for submitting an application (i.e., online, by phone, by mail, or in person).  
The beneficiary (or as appropriate, a parent, guardian, or authorized representative) must sign the 
renewal form under penalty of perjury; telephonic and electronic signatures, as well as 
handwritten signatures submitted electronically, must be accepted.23  Renewal forms and notices 
must be accessible to persons who are limited English proficient and persons with disabilities, 
consistent with 42 C.F.R. 435.905(b).24  Once the renewal form is received, the agency must 
verify any information provided by the beneficiary in accordance with 42 C.F.R. 435.945 
through 435.956 or 42 C.F.R 457.380, as applicable, and the states verification plan.25 
  
Once a final determination is made, the agency must provide all beneficiaries with timely and 
adequate written notice of any decision affecting their eligibility consistent with 42 C.F.R. 
431.206 through 431.214, 42 C.F.R. 435.917, and 42 C.F.R. 457.340(e), as applicable.  A 
minimum of 10 days advance notice must be provided for adverse determinations under 
Medicaid.26  Separate CHIPs must provide sufficient notice to enable the child's parent or other 
caretaker to take any appropriate actions that may be required to allow coverage to continue 
without interruption.27 
 
Timeliness of renewals 
 
States must establish renewal procedures and internal milestones that allow for adequate time to 
complete the renewal process before the end of a beneficiarys eligibility period in order to meet 
the requirements at 42 C.F.R. 435.916 and 457.343.  Such processes need to account for the 
time given to beneficiaries to provide documentation as well as sufficient time for the agency to 
process and verify any information received from the beneficiary and provide proper notice of 
the agencys determination.  Exceptions may occur when (1) the agency needs additional time to 
evaluate eligibility on another basis (see discussion below); or (2) an administrative or other 
emergency beyond the agencys control justifies a longer period, consistent with 42 C.F.R. 
435.912(e) and 457.340(d), as applicable.  In such cases, the state must document the reasons 
for delay in the beneficiarys case record.28 
 
                                                           
20 42 C.F.R. 435.952 
21 42 C.F.R. 435.916(a)(3)(iv) and 457.343 
22 42 C.F.R. 435.916(b) 
23 42 C.F.R. 435.916(a)(3)(i)(B) and 457.343.  The required modes of submission are described at 42 C.F.R. 
435.907(a), which is referenced at 42 C.F.R 457.330 for CHIP. 
24 42 C.F.R. 435.916(g),  457.110(a), and 457.343 
25 42 C.F.R. 435.916(a)(3)(ii) and 457.343 
26 42 C.F.R. 431.211 
27 42 C.F.R. 457.340(e)(1)(D)(iii) 
28 42 C.F.R. 435.912(f) and 457.340(d) 
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 6 - CMCS Informational Bulletin      
 
In addition, if a beneficiary does not return requested documentation within the timeframe 
established by the state, but does return a signed renewal form and any requested documentation 
prior to the end of the eligibility period, the state must act on the information.29  If it is not 
possible for the agency to make a determination by the end of the eligibility period, the state is 
expected to redetermine eligibility as expeditiously as possible.  We believe that 30 days from 
the date all information provided by, or on behalf of, the beneficiary is received by the agency 
generally provides ample time for state agencies to determine eligibility based on the renewal 
form and information received. 30 
 
Consistent with regulations at 42 C.F.R. 435.930(b), the agency must continue to 
furnish Medicaid to beneficiaries who have returned their renewal form and all requested 
documentation unless and until they are determined to be ineligible.  If a renewal form or 
additional information is returned prior to the end of the eligibility period, the state must have a 
mechanism in place, pursuant to 42 C.F.R. 435.930(b), to ensure that eligibility and coverage 
continue until the information received is evaluated and a final redetermination is made. 
  
Consideration of other bases of eligibility 
 
If a Medicaid beneficiary is found to no longer be eligible for the eligibility group under which 
he/she is receiving coverage, the agency must consider whether the beneficiary may be eligible 
under one or more other eligibility groups covered by the state.31   Other possible eligibility 
group(s) or bases of eligibility should be identified using information provided on the initial 
application or in the current or previous renewal forms and other information known to the 
agency.  If the Medicaid agency identifies any such other group(s) but additional information is 
necessary to make a determination of eligibility, the Medicaid agency must request, and give the 
beneficiary a reasonable period of time to provide, the additional information needed.32  For 
Medicaid enrollees, eligibility cannot be terminated, and benefits must continue to be furnished, 
until a beneficiary is found ineligible for eligibility under all groups covered by the state, or until 
the beneficiary does not timely provide requested information that is needed to make a 
determination.33, 34, 35 
                                                           
29 42 C.F.R. 435.916(a) and (b),435.952(a), 457.343, and 457.380 
30 The reasonable timeframe described reflects the time for the state to process the renewal after necessary 
information is received and not an extension to a beneficiarys eligibility period.  However, given that some states 
provide coverage through the end of the month, this period may extend until the end of the month following the 
beneficiarys scheduled renewal date.  
31 42 C.F.R. 435.916(f)(1) 
32 42 C.F.R. 435.916(e), 435.916(f)(1), and 435.952 
33 42 C.F.R. 435.916(f)(1) and 435.930 
34 Section 6008(b)(3) of FFCRA generally prevents states from terminating coverage for individuals enrolled as of 
or after March 18, 2020, through the end of the month in which the COVID-19 PHE ends as a condition of the 
temporary 6.2 percentage point FMAP increase authorized under FFCRA.  See Additional Policy and Regulatory 
Revisions in Response to the COVID-19 Public Health Emergency (CMS-9912-IFC) for additional information. 
Available at https://www.federalregister.gov/public-inspection/2020-24332/additional-policy-and-regulatory-
revisions-in-response-to-the-covid-19-public-health-emergency. 
35 States are required to determine eligibility on other bases prior to terminating coverage.  In the case of 
beneficiaries enrolled in the COVID-19 testing group described under section 1902(a)(10)(A)(ii)(XXIII) of the Act, 
states may satisfy the requirement to determine eligibility on all bases by providing individuals enrolled in the 
COVID-19 testing group with notice at their initial determination of eligibility and enrollment into the group, and 
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 7 - CMCS Informational Bulletin      
 
If a state determines that a separate CHIP enrollee is no longer eligible for CHIP, it must screen 
the individual for eligibility in other insurance affordability programs, including Medicaid on all 
bases and Exchange coverage.36  Other possible bases of eligibility should be identified using 
information provided on the initial application or in the current or previous renewal forms and 
other information known to the agency.  If the CHIP agency identifies any such other bases of 
eligibility but additional information is necessary to make a determination of eligibility, the 
agency must request, and give the beneficiary a reasonable period of time to provide, the 
additional information needed.37 
 
We recognize that states may not be able to complete a determination of eligibility on another 
basis prior to the end of a beneficiarys eligibility period.  States are expected to make 
determinations in this situation as expeditiously as possible, and terminate eligibility for 
individuals who either are determined ineligible on all bases or do not provide needed 
information or documentation in a timely manner.  
 
Termination of eligibility for ineligible beneficiaries and reconsideration period 
  
For beneficiaries who are determined ineligible for Medicaid or CHIP, the agency must (1) 
determine potential eligibility for other insurance affordability programs and transfer the 
beneficiarys electronic account to such program;38 and (2) provide advance notice of 
termination and appeals rights consistent with 42 C.F.R. 431, Subpart E and 42 C.F.R. 
457.340(e), as applicable.39 
  
For beneficiaries who fail to return the renewal form or other needed documentation requested 
by the agency in a timely manner, the agency still must provide advance notice of termination, 
but need not determine potential eligibility for other insurance affordability programs.  
Consistent with guidance provided in a July 25, 2016, CIB, states should not transfer accounts 
for individuals whose eligibility has been terminated for procedural reasons.40  
For MAGI beneficiaries whose eligibility has been terminated, if the renewal form and/or 
necessary information is returned within 90 days after the date of termination, or a longer period 
                                                           
again in the advance notice required prior to termination, on how to submit an application for comprehensive 
Medicaid coverage.  For additional detail, see the COVID-19 Frequently Asked Questions (FAQs) for State 
Medicaid and Childrens Health Insurance Program (CHIP) Agencys, available at https://www.medicaid.gov/state-
resource-center/downloads/covid-19-faqs.pdf and the Operationalizing Implementation of the Optional COVID-19 
Testing (XXIII) Group Potential State Flexibilities available at  https://www.medicaid.gov/state-resource-
center/downloads/potential-state-flexibilities-guidance.pdf.  
36 42 C.F.R. 457.350(b) 
37 42 C.F.R. 457.343, and 457.380 
38 42 C.F.R. 435.916(f)(2) and 457.350 
39 Section 6008(b)(3) of FFCRA generally prevents states from terminating Medicaid coverage for individuals 
enrolled as of or after March 18, 2020, through the end of the month in which the COVID-19 PHE ends as a 
condition of the temporary 6.2 percentage point FMAP increase authorized under FFCRA.  See Additional Policy 
and Regulatory Revisions in Response to the COVID-19 Public Health Emergency (CMS-9912-IFC) for additional 
information. Available at https://www.federalregister.gov/public-inspection/2020-24332/additional-policy-and-
regulatory-revisions-in-response-to-the-covid-19-public-health-emergency.  
40 CMCS Informational Bulletin: Coordination of Eligibility and Enrollment between Medicaid, CHIP and the 
Federally Facilitated Marketplace (FFM or Marketplace). July 25, 2016. Available at 
https://www.medicaid.gov/federal-policy-guidance/downloads/cib072516.pdf.  
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 8 - CMCS Informational Bulletin      
 
elected by the state, the agency must reconsider the individuals eligibility without requiring the 
individual to fill out a full new application to be determined eligible for benefits.41  States may, 
but are not required, to provide a similar reconsideration period for non-MAGI beneficiaries who 
return their renewal form or needed documentation after their termination date. 
  
The renewal form returned within the reconsideration period serves as an application.  This 
means that a determination or denial of eligibility must be made consistent with timeliness 
standards in 42 C.F.R. 435.912 and 457.340(d), as applicable.  For individuals who are 
determined to be eligible for Medicaid, the effective date of coverage will be the date that, or 
first day of the month in which, the renewal form was returned, in accordance with the states 
election in the state plan.  In addition, for those individuals for whom retroactive eligibility may 
apply, up to three months of retroactive coverage, (based on the date the renewal form was 
returned) is available if the individual received Medicaid services following his or her 
termination and met the Medicaid eligibility requirements at the time services within the 
retroactive period were received.42  For individuals who are determined to be eligible for CHIP, 
the effective date of coverage will be based on the date the form is returned or another 
reasonable method that is specified in the state plan, as specified in 42 C.F.R. 457.340(g).  
 
Redetermining Eligibility Based on Changes in Circumstances 
 
States must have procedures designed to ensure that beneficiaries make timely and accurate 
reports of any change in circumstances that may affect their eligibility, and beneficiaries must be 
able to report such changes online, by phone, by mail, or in-person.43  States also have the option 
to seek information about any changes in circumstances through periodic data checks or other 
information available to the agency.44  
 
Whenever the state receives information on a change in circumstances that may affect a 
beneficiarys eligibility, the agency must act promptly to determine whether the beneficiary 
continues to meet the eligibility criterion to which the change relates.45  This includes, but is not 
limited to, taking action on information reported to states or obtained electronically that indicates 
a beneficiary has an increase in income, has moved out of state, or is deceased.  Similarly, if the 
agency has information about anticipated changes in a beneficiarys circumstances that may 
affect his or her eligibility, it must redetermine eligibility at the appropriate time based on such 
changes.46  This includes, but is not limited to, anticipating action when beneficiaries reach an 
age milestone that impacts eligibility such as a child enrolled in a group for individuals under age 
19 in Medicaid or a separate CHIP who is turning 19 or an individual enrolled in the adult group 
described at 42 C.F.R. 435.119 who is turning 65.  See Appendix A for the steps states need to 
take in acting on a change in circumstances. 
                                                           
41 42 C.F.R. 435.916(a)(3)(iii) and 457.343; 77 FR 17182 (March 23, 2012) 
42 42 C.F.R. 435.915; 77 FR 17182 (March 23, 2012) 
43 42 C.F.R. 435.916(c) and 457.343 
44 42 C.F.R. 435.940 and 457.380(h) 
45 42 C.F.R. 435.916(d).  Examples of a change in circumstances on which states need to act promptly include a 
change in income, state residency, household composition, immigration status, or the death of the beneficiary. 
46 42 C.F.R. 435.916(d)(2) and 457.343.  Anticipated changes may include, for example, a child turning 19 who 
would no longer be eligible for the eligibility group described at 42 C.F.R. 435.118, an anticipated future increase 
in earnings reported at application, or the end of a postpartum period.   
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 9 - CMCS Informational Bulletin      
 
 
For certain individuals whom the agency determines continue to be eligible following a change 
in circumstances, a new 12-month renewal period may begin if the agency has information 
available to it to verify eligibility with respect to all eligibility criteria without requiring any 
additional information from the beneficiary (other than the information related to the change in 
circumstances).47  Alternatively, the agency may retain the beneficiarys current eligibility 
period.  States may request, but not require, additional information from the beneficiary about 
other factors needed to start a new renewal period when the state is unable to verify all eligibility 
criteria based on information available to the agency. 
 
Interaction between Redeterminations Based on Change in Circumstances and Eligibility 
Periods for Pregnant Women 
 
Under Medicaid, pregnant women are entitled to continuous eligibility through the last day of the 
month in which a 60-day period, beginning on the last day of pregnancy, ends, regardless of 
changes in income that would otherwise result in a loss of eligibility.48  This protection applies 
both to women eligible based on pregnancy under 42 C.F.R. 435.116 as well as women who are 
pregnant, but eligible under an eligibility group unrelated to pregnancy status.  Hereinafter in this 
CIB, we refer to the period following the end of the womans pregnancy to the last day of the 
month in which the 60-day period falls as her postpartum period. 
 
For many pregnant women, the end of the postpartum period represents a change in 
circumstances that may impact their eligibility.49  Because the end of a given womans 
postpartum period may not coincide with the end of her eligibility period and regularly-
scheduled renewal, the steps states must take to comply with the regulations differ depending on 
whether the end of the womans postpartum period occurs before or after her renewal date. 
  
For women who apply while pregnant and are determined eligible under the group for pregnant 
women described in 42 C.F.R. 435.116, their postpartum period typically will end before the 
end of their 12-month eligibility period and first regularly scheduled renewal.  For these women, 
the end of the postpartum period represents a change in circumstances between regularly 
scheduled renewals, which is subject to the same policies and procedures as any other change in 
circumstances.  Once the birth or other end of her pregnancy is confirmed, the state will need to 
determine whether or not the woman will remain eligible following the end of the postpartum 
period under another eligibility group  most typically, as a parent or caretaker relative under 42 
C.F.R. 435.110 or under the adult group described in 42 C.F.R. 435.119.  Since the woman 
would still be within her eligibility period in this case, the state generally would not contact the 
woman to verify her income consistent with 42 C.F.R. 435.916(d)(1)(i) when determining if she 
is eligible under another group at the end of her post-partum period.  The state, however, would 
                                                           
47 42 C.F.R. 435.916(d)(1)(ii) and 457.343 
48 Section 1902(e)(5) and 1902(e)(6) of the Social Security Act; 42 C.F.R. 435.170 
49 For example, women eligible during their pregnancy under the group for pregnant women described in 42 C.F.R 
435.116 will no longer be eligible under that group following the end of the postpartum period; however, such 
women may be eligible as a parent or caretaker relative under 42 C.F.R. 435.110 or under the adult group described 
in 42 C.F.R. 435.119.  For a woman covered under the group for parents and caretaker relatives, who becomes 
pregnant while receiving coverage under that group, the end of the postpartum period does not itself represent a 
change in circumstances likely to impact her eligibility. 
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unless specifically incorporated into a contract.  This document is intended only to provide clarity to the public 
regarding existing requirements under the law.  Page 10 - CMCS Informational Bulletin      
 
need to verify income when her post-partum period ends in the middle of her eligibility period if 
it has received other information indicating her income has changed since her initial 
determination such that her income may exceed the income standard for coverage under the other 
eligibility groups under which she might be eligible.  Such verification often will require 
additional documentation or other information from the woman.  If the state is able to determine 
the woman eligible under another group (with or without requiring additional information from 
her), she would be moved to the new eligibility group, and her next regular renewal date would 
remain the same  i.e., 12 months after her initial determination. 
  
For women whose postpartum period ends after their regularly-scheduled renewal date, the 
agency must conduct the full renewal at the end of the individual womans postpartum period 
(when her continuous eligibility ends) in accordance with the regulations at 42 C.F.R. 
435.916(a) or (b), depending on whether the woman is enrolled in a MAGI or non-MAGI 
eligibility group.  This typically will be the case for women who are enrolled in Medicaid when 
they become pregnant. 
 
Medicaid Agency Oversight Responsibilities 
 
The single state Medicaid agency is responsible for administering or supervising the 
administration of the Medicaid state plan, including determinations of eligibility at initial 
application, regular renewals, and following changes in beneficiary circumstances.50  States are 
permitted to delegate all or part of this responsibility to another state or local agency, such as a 
state human services agency.  However, the single state Medicaid agency ultimately is 
responsible for exercising appropriate oversight to ensure that eligibility determinations and 
renewals are compliant with the Medicaid statute, federal regulations, and the Medicaid state 
plan.51  
 
Additional Resources 
 
CMS previously provided states a model renewal form for populations whose eligibility is based 
on MAGI and information on state practices and lessons learned through the Medicaid and CHIP 
Coverage Learning Collaborative. These resources are available on Medicaid.gov.52  
 
For additional information about this CIB, please contact Jessica Stephens, Director, Division of 
Enrollment Policy & Operations, at Jessica.Stephens@cms.hhs.gov.  
                                                           
50 Section 1902(a)(5) of the Social Security Act, 42 C.F.R. 431.10(b) 
51 42 C.F.R. 431.10(c) and (d) 
52 Expanding Coverage under Medicaid and CHIP, Medicaid & CHIP Renewals & Coverage Transitions.  Available 
at https://www.medicaid.gov/state-resource-center/mac-learning-collaboratives/coverage/index.html.  
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unless specifically incorporated into a contract.  This document is intended only to provide clarity to the public 
regarding existing requirements under the law.  Page 11 - CMCS Informational Bulletin      
 
Appendix A 
 
Acting on Changes in Circumstances 
 
Whenever a state has information indicating a change in a beneficiarys circumstances, the 
agency must act promptly to determine whether or not the beneficiarys eligibility is impacted as 
required at 42 C.F.R. 435.916(d) and 457.343.  The following steps will help states to ensure 
that they are acting appropriately on such information, and that only eligible individuals continue 
to receive coverage. 
 
1.  For a change in circumstances that is reported by the beneficiary, promptly evaluate 
whether the information received, if correct, would result in a loss of eligibility or change 
in the amount of medical assistance to which the beneficiary is entitled (e.g., a change in 
premiums, cost sharing, or covered benefits).  If the agency determines eligibility would 
not be impacted, no further action is required.  However, CMS encourages states to 
acknowledge the reported change by providing the beneficiary with notice 
acknowledging receipt of information and explaining that there is no impact on eligibility 
or coverage. 
 
2.  For information received from an electronic data source or other third-party source, if the 
agency determines that the information received, if correct, would impact a beneficiarys 
eligibility, the agency must contact the beneficiary.  The beneficiary must be given an 
opportunity to provide information or other documentation to establish that the 
information received by the agency is not correct and the individual continues to meet the 
eligibility criterion at issue.53, 54  The agency must provide the beneficiary with a 
reasonable period of time to provide such information or documentation and must enable 
the beneficiary to respond to the agencys request online, by phone, by mail, or in 
person.55 
 
a.  If the beneficiary does not respond to the request in a timely manner, the agency 
must provide advance notice of termination and appeal rights in accordance with 
42 C.F.R. 435.917, 42 C.F.R. 431, subpart E, and 42 C.F.R 457.340(e), as 
applicable.  
 
b.  If the beneficiary does timely respond to the agencys request, the agency must 
promptly evaluate all information and documentation before it redetermines the 
beneficiarys eligibility.  If the beneficiary remains eligible, a notice indicating 
that the eligibility is not affected should be provided; we recommend that the 
                                                           
53 42 C.F.R. 435.952(d) and 457.380 
54 Per 42 C.F.R. 435.916(d)(1)(i) and 42 C.F.R 457.343, for renewals of Medicaid and CHIP beneficiaries whose 
financial eligibility is determined using modified adjusted gross income (MAGI)-based financial methodologies, the 
agency must limit any requests for additional information from the individual to information relating to the 
eligibility criterion impacted by the change in circumstances.   
55 42 C.F.R. 435.952(c) and 457.380.  The required modes of submission are described at 42 C.F.R. 435.907(a), 
which is referenced at 42 C.F.R 457.330 for CHIP. 
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agency inform beneficiaries who continue to be eligible when their next regular 
periodic renewal will occur.  
 
3.  Similar to the requirements at a periodic renewal, if while processing a change in 
circumstances the agency determines that the beneficiary no longer meets the eligibility 
requirements for the eligibility group under which he or she is receiving coverage, it must 
consider whether the beneficiary may be eligible under one or more other eligibility 
groups covered by the state.56  The agency must follow up with the beneficiary to make 
an appropriate determination, prior to sending advance notice of termination; in this case, 
the agency must follow the same process described for periodic renewals (see discussion 
in the CIB on Consideration of other bases of eligibility). 
  
a.  If the agency determines the beneficiary is eligible on another basis, the agency 
must provide notice of such determination.57  
 
b.  If the agency determines that the beneficiary is not eligible on another basis, the 
agency must provide advance notice of termination in accordance with 42 C.F.R. 
435.917, 42 C.F.R. 431, subpart E, and 42 C.F.R. 457.340(e), as applicable. 
The state must also assess eligibility for other insurance affordability programs, as 
applicable.58  
 
c.  If the beneficiary does not provide the information or documentation requested by 
the agency in a timely manner, the agency must also provide advance notice of 
termination in accordance with 42 C.F.R. 435.917, 42 C.F.R. 431, subpart E, and 
42 C.F.R. 457.340(e), as applicable. 
 
4.  Current regulation indicates that states must promptly act on changes in circumstances 
that may affect eligibility.  While promptly is not currently defined in regulations, CMS 
believes the following parameters for processing changes generally would be reasonable. 
 
a.  When the state receives information about a change in circumstances and has 
sufficient information to evaluate any potential impact on eligibility, we believe 
that thirty days from the date the state received the information generally would 
be a reasonable timeframe to complete the processing of the change in 
circumstances. 
 
b.  If additional information is needed, it may be reasonable for states to allow 
beneficiaries 30 days to respond and provide any necessary information.  This is 
consistent with the minimum timeframe allowed to beneficiaries whose financial 
eligibility is determined using MAGI-based financial methodologies, during their 
annual renewal, to return a pre-populated renewal form and provide needed 
documentation.59  In these instances, we believe that it generally would be reasonable 
                                                           
56 42 C.F.R. 435.916(f)(1) and 457.350  
57 42 C.F.R. 435.917 and 457.340(e) 
58 42 C.F.R. 435.916(f)(2) and  457.343 
59 42 C.F.R. 435.916(a)(3)(i)(B) and 457.343 
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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 - CMCS Informational Bulletin      
 
for the state to complete the processing of changes in circumstances within 60 days 
from the date the state received the information.  
 
   
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 14 - CMCS Informational Bulletin      
 
Appendix B 
 
Frequently Asked Questions (FAQs) 
Medicaid and Childrens Health Insurance Program Renewals 
December 2020 
 
Q1.  When does a new eligibility period begin and end for an individual whose eligibility is 
being redetermined at renewal? How is a beneficiarys renewal date determined? 
 
A1.  Individuals enrolled in CHIP or in a Medicaid eligibility group for which the determination 
of financial eligibility is based on modified adjusted gross income (MAGI), have a 12-month 
eligibility period.  The 12-month period extends from the effective date of the last determination 
of eligibility, or to the end of the twelfth month following the effective date of the last eligibility 
determination, if the state has elected to provide full-month coverage.  In the case of individuals 
enrolled in a non-MAGI-based eligibility group, the eligibility period extends for the length 
specified by the state, up to 12 months or until the end of the last month of the beneficiarys 
eligibility period of up to 12 months.  
 
For example, John submitted an application on January 10, 2020, in a state that has elected to 
provide full month coverage.  John was determined eligible for a MAGI-based Medicaid 
eligibility group.  His effective date of coverage is January 1, 2020, and his eligibility period 
would extend to the end of the twelfth month after his effective date of coverage, to December 
31, 2020, which would be his next renewal date.  The state would be required to complete Johns 
renewal by December 31, 2020.  If his eligibility is renewed at that time, a new eligibility period 
would begin on January 1, 2021, and extend 12 months through December 31, 2021.  If John had 
medical expenses in the three months prior to his effective date and had been provided 
retroactive coverage, any months of eligibility provided prior to application under the retroactive 
coverage period, consistent with 42 C.F.R 435.915, would not be included as part of his 
eligibility period for purposes of determining his renewal date. 
  
Q2.  If an individual whose coverage was terminated at renewal for non-response to 
requested information returns the renewal form during the reconsideration period and is 
determined to be eligible, what is the effective date of coverage for the new eligibility 
period?  
 
A2.  As described at 42 C.F.R. 435.916(a)(3)(i)(C)(iii) and 457.343, the state must 
redetermine eligibility in a timely manner for an individual whose coverage is terminated at 
renewal for failure to complete the renewal process if the individual returns their renewal form or 
requested information during the 90-day reconsideration period (or longer period elected by the 
state).  The state must accept the renewal form or information and determine the individuals 
eligibility without requiring the person to submit a full application.  The returned renewal form 
in this case is treated as an application.  The state must follow its practice for determining the 
effective date of eligibility at application consistent with 42 C.F.R. 435.915 for Medicaid 
(either the first of the month of application or the date of application at state option) or 
457.340(g) for CHIP (either the date of application or another reasonable method that is 
specified in the state plan). 
 
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unless specifically incorporated into a contract.  This document is intended only to provide clarity to the public 
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Additionally, consistent with rules related to the provision of retroactive coverage at 42 C.F.R. 
435.915(a), the state must provide coverage for unpaid medical bills incurred in any of the three 
months prior to returning the renewal form if the individual would have been found eligible for 
Medicaid had the renewal form been returned in (or before) that month.  In most cases, 
retroactive coverage will close the gap in coverage for an eligible individual between the date of 
termination and the date of reinstatement. 
  
Q3.  Which data sources are states required to access in conducting ex parte reviews?  
 
A3.  Each states verification plan identifies the electronic data sources which the state has 
determined useful in verifying different eligibility criteria.  States must access the data sources, 
identified in their verification plan, which return data on beneficiary circumstances subject to 
change (such as wages). 
  
Q4. Must states use the Asset Verification System (AVS) to verify assets at renewal for 
beneficiaries subject to a resource test?  
 
A4.  Yes, for beneficiaries subject to a resource test and for whom verification of resources using 
the AVS described in Section 1940(b) of the Social Security Act is required, states must seek 
information from the AVS to verify financial resources at renewal.  Because states are required 
to attempt an ex parte renewal for all beneficiaries using all reliable information contained in the 
individual's account or other more current information available to the agency, including those 
subject to an asset test, use of the AVS is a required part of the ex parte renewal process.  States 
must begin their renewal process early enough to complete a redetermination of eligibility prior 
to the end of the renewal period.  Because not all asset information available from financial 
institutions participating in the AVS is returned in real time, states must allow for a reasonable 
timeframe for electronic information from the AVS to be returned to complete an ex-parte 
renewal when possible.  This reasonable timeframe must also leave sufficient time for 
beneficiaries to receive and return a renewal form and any other needed documentation to 
complete a timely renewal when renewal through an ex parte process is not possible.  
 
Q5.  When must a state request additional information from a beneficiary at renewal?  
 
A5.  If, during an ex parte review, available information suggests that a beneficiary is no longer 
eligible, if the state does not have access to reliable information regarding beneficiary 
circumstances subject to change, or if the state has information that suggests that available 
information is inaccurate, the state may not complete an ex parte renewal.  In this situation, the 
state must send the beneficiary a renewal form and request any other information needed before 
either renewing or terminating eligibility. 
  
Q6. What information may the state require beneficiaries to provide at renewal? 
 
A6.  When a state is unable to renew eligibility through an ex parte process, the state may only 
require information from beneficiaries at renewal about circumstances that (1) are subject to 
change, (2) are necessary to determine eligibility, and (3) cannot be verified based on available 
data sources.  This will generally include income information for individuals eligible in an 
income-based eligibility category and assets for non-MAGI based eligibility groups with a 
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unless specifically incorporated into a contract.  This document is intended only to provide clarity to the public 
regarding existing requirements under the law.  Page 16 - CMCS Informational Bulletin      
 
resource test.  It may also include information related to residency, household composition, or 
other eligibility factors. States may not request information to re-verify citizenship or other 
circumstances not subject to change.  As at application, consistent with 42 C.F.R 435.907(e) 
and 457.340(b), Social Security Numbers (SSNs) may be requested of non-applicants or other 
unenrolled household members of beneficiaries.  However, SSNs may only be requested if 
provision of the SSN is voluntary, the SSN will be used only to redetermine a beneficiarys 
eligibility, and clear notice is provided to the individual whose SSN is requested about how the 
SSN will be used.  
 
Q7.  When must states complete renewals for beneficiaries who return required 
documentation needed to complete a renewal too late in the renewal month for a state to 
complete renewal processing? 
  
A7.  As explained in the Information Bulletin, consistent with regulations at 42 C.F.R. 
435.930(b), states must continue to furnish Medicaid to beneficiaries who have returned their 
renewal form prior to the end of their eligibility period unless and until they are determined to be 
ineligible or fail to return requested documentation.  When it is not possible for the state to make 
a determination before the renewal date because the beneficiary returned the renewal form or 
additional information too close to the end of the eligibility period, the state is expected to act as 
expeditiously as possible to redetermine eligibility and provide appropriate notice.  CMS 
believes this generally should take at most 30 days from the date the renewal form and all 
requested documentation is received. 
 
Q8.   Are states required to conduct periodic renewals for children receiving federal foster 
care maintenance payments or subject to a federal adoption assistance agreement under 
title IV-E of the Social Security Act (the Act)?  What about children in state-funded foster 
care or subject to a state adoption assistance agreement? 
  
A8.  Yes, periodic renewals for all beneficiaries are required.  However, states generally will be 
able to renew eligibility for beneficiaries, such as children receiving federal foster care 
maintenance payments, through an ex parte process as long as the individual continues to be a 
resident of the state.  This will be the case for:  
  Beneficiaries whose eligibility is based on receipt of another income-tested benefit  such 
as Supplemental Security Income (SSI) recipients eligible under section 
1902(a)(10)(A)(i)(II)(aa) of the Act or 42 C.F.R. 435.120 or children for whom foster 
care or kinship guardianship assistance maintenance payments are being made under title 
IV-E of the Act, who are eligible under 1902(a)(10)(A)(i)(I) and 42 C.F.R. 435.145  
until the beneficiary no longer receives such benefit; and  
  Beneficiaries eligible based on a particular status for which there is no income test. This 
includes, but is not limited to, children for whom an adoption assistance agreement under 
title IV-E of the Act is in effect, or for whom a state adoption assistance agreement is in 
effect, if the state covers such children with no effective income test under section 
1902(a)(10)(A)(ii)(VIII) of the Act and 42 C.F.R. 435.145; former foster youth under 
age 26 eligible under 1902(a)(10)(A)(i)(IX) and 42 C.F.R. 435.150; or individuals with 
breast or cervical cancer eligible under 1902(a)(10((A)(ii)(XVIII) of the Act and 42 
C.F.R. 435.213).  For these individuals, the agency will likely need to request additional 
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unless specifically incorporated into a contract.  This document is intended only to provide clarity to the public 
regarding existing requirements under the law.  Page 17 - CMCS Informational Bulletin      
 
information to redetermine eligibility when the beneficiary ages out of, or otherwise no 
longer qualifies for the status. 
 
Q9.  When must states conduct renewals for women who apply and are determined eligible 
for Medicaid under the pregnant women group described at 42 C.F.R. 435.116? 
 
A9.  Women determined eligible at application for the pregnant women group described at 42 
C.F.R. 435.116 must be provided a 12 month eligibility period in accordance with requirements 
for renewals for MAGI-based individuals at 42 C.F.R. 435.916(a)(1).  The state must anticipate 
the end of her postpartum period (i.e., the last day of the month in which a 60-day period, 
beginning on the last day of her pregnancy, ends) and determine whether she remains eligible at 
that point on another basis.  Many women losing coverage under the eligibility group for 
pregnant women, for example, will be eligible under the adult group described in 42 C.F.R. 
435.119 if covered by the state and if her income is at or below 133 percent FPL.  If the woman 
remains Medicaid eligible under another MAGI-based group, the date of her next regularly-
scheduled renewal would not change, unless the state is able and elects to begin a new eligibility 
period in accordance with 42 C.F.R. 435.916(d)(1)(ii). 
 
For example, Jane submitted an application on January 10, 2020, and was determined eligible for 
and enrolled in the pregnant women group with verified income equal to 50 percent FPL.  Her 
effective date of coverage is January1, 2020, and her eligibility period extends to the end of the 
twelfth month after her effective date of coverage, or December 31, 2020.  Janes baby is born on 
August 16, 2020, and her postpartum period ends October 31, 2020.  The states income standard 
for parents and caretaker relatives is 65 percent FPL.  The state does not have any information 
indicating Janes income has changed.  Therefore, at the end of her postpartum period, the state 
will shift Janes coverage to the eligibility group for parents and caretaker relatives effective 
November 1, 2020.  The state will need to complete Janes next regular renewal by December 
31, 2020.  Alternatively, if the state is able to verify Janes income and state residency at the end 
of her postpartum period without contacting Jane in accordance with the states verification plan, 
it may elect to begin a new 12-month eligibility period on November 1, 2020, which would mean 
her next regularly scheduled renewal would be due October 31, 2021. 
 
Q10.  When must states conduct renewals for women enrolled in Medicaid who become 
pregnant during their eligibility period? 
 
A10.  When a woman enrolled in Medicaid subsequently becomes pregnant, she is entitled to 
continued coverage through the end of her postpartum period regardless of any changes in 
income.  If her next regularly scheduled renewal falls after the end of her postpartum period, the 
date of her next regularly scheduled renewal will not change.  If the end of her postpartum period 
is after the date her regularly scheduled renewal had been scheduled, the state will need to 
complete a full regular renewal, consistent with 42 C.F.R. 435.916, by the end of her 
postpartum period. 
 
For example, Jane is enrolled as a parent under 42 C.F.R. 435.110.  Her eligibility period 
extends from January 1, 2020, to December 31, 2020.  Jane becomes pregnant in August 2020, 
and is eligible for continuous eligibility under 42 C.F.R. 435.170(c).  Because Jane is pregnant 
and in a period of continuous eligibility, the state does not need to conduct a full regular renewal 
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by the end of December 2020.  Janes baby is born in May 2021, and her postpartum period ends 
July 31, 2021.  The state must conduct a full renewal, consistent with 42 C.F.R. 435.916, by 
July 31, 2021. 
 
Q11.  Are there any exceptions to the timeliness requirements for completing renewals or 
acting on changes in circumstances? 
 
A11.  Yes.  Generally, states must establish renewal procedures and internal milestones that 
allow adequate time to complete the renewal process before the end of a beneficiarys eligibility 
period.  However, when there is an administrative or other emergency beyond the agencys 
control, the state may be excused from meeting expected timeliness standards under 42 C.F.R. 
435.912(e) and 457.340(d).  This may include a natural disaster or public health emergency 
during which damage to infrastructure or impact on a states workforce may affect the agencys 
ability to complete timely renewals and/or impacted individuals may be unable to receive or 
respond to notices or provide information needed to complete the redetermination process.  In 
such cases, the state must continue to furnish Medicaid to enrolled beneficiaries until the state 
determines they are ineligible for Medicaid in accordance with 42 C.F.R. 435.930(b).  The state 
must document the reason for delay in the Medicaid and CHIP beneficiarys case record per 42 
C.F.R. 435.912(f) and 457.340(d). 
  
Medicaid agencies seeking to use the exception are advised, though not required, to seek CMS 
concurrence that the use of the exception is warranted under the circumstances.  States do not 
need to make a formal request for CMS concurrence, but may send a request via email to the 
CMS state lead. 
 
CHIP agencies seeking to rely on the exception for a broader cohort of cases should submit a 
disaster relief state plan amendment (SPA) to reflect the delay in processing renewals and 
changes in circumstances due to the disaster or emergency.  States that already have a disaster 
relief SPA related to processing renewals and changes in circumstances need only notify CMS 
that they are activating this exception. 
 
We remind states that use of the exception is limited to unusual circumstances beyond the 
agencys control, and any concurrence received from CMS that the circumstances justify a delay 
does not authorize an extension beyond that required due to the circumstances.  States are 
obligated to process the redetermination as soon as possible.  
 
Q12. Can Medicaid managed care entities assist with consumer outreach during renewal? 
 
A12.  Yes, nothing in federal regulations prohibits managed care entities from conducting 
outreach to their Medicaid and CHIP managed care plan enrollees about upcoming renewal 
periods and assisting their enrolled beneficiaries in the renewal process.  Many states partner 
with managed care entities as a best practice at renewal.  However, managed care entities may 
not conduct outreach to individuals who are not enrolled with the managed care entity.  
 
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.