§ 435.919 Changes in circumstances. ( a ) *Procedures for reporting changes.* The agency must: ( 1 ) Have procedures designed to ensure that beneficiaries understand the importance of making timely and accurate reports of changes in circumstances that may affect their eligibility; and
( 2 ) Accept reports made under paragraph (a)(1) of this section and any other beneficiary reported information through any of the modes permitted for submission of applications under § 435.907(a).
( b ) *Agency action on information about changes.* Consistent with the requirements of § 435.952, the agency must promptly redetermine eligibility between regularly scheduled renewals of eligibility required under § 435.916(a) whenever it has reliable information about a change in a beneficiary's circumstances that may impact the beneficiary's eligibility for Medicaid, the amount of medical assistance for which the beneficiary is eligible, or the beneficiary's premiums or cost sharing charges. Such redetermination must be completed in accordance with this paragraph (b) and paragraph (e) of this section. ( 1 ) The agency must redetermine eligibility based on available information, if possible. When needed information is not available, the agency must request such information from the beneficiary in accordance with § 435.952(b) and (c).
( 2 ) Prior to furnishing additional medical assistance or lowering applicable premiums or cost sharing charges based on a reported change: ( i ) If the change was reported by the beneficiary, the agency must verify the information in accordance with §§ 435.940 through 435.960 and the agency's verification plan developed under § 435.945(j).
( ii ) If the change was provided by a third-party data source, the agency may verify the information with the beneficiary.
( 3 ) If the agency is unable to verify a reported change that would result in additional medical assistance or lower premiums or cost sharing, the agency may not terminate the beneficiary's coverage for failure to respond to the request to verify such change.
( 4 ) Prior to taking an adverse action, as defined in § 431.201 of this chapter, based on information received from a third-party, the agency must request information from the beneficiary to verify or dispute the information received, consistent with § 435.952(d).
( 5 ) If the agency determines that a reported change results in an adverse action, the agency must— ( i ) Comply with the requirements at § 435.916(d)(1) (relating to consideration of eligibility on other bases) and (2) (relating to determining potential eligibility for other insurance affordability programs) prior to terminating a beneficiary's eligibility in accordance with this section.
( ii ) Provide advance notice of adverse action and fair hearing rights, in accordance with the requirements of part 431, subpart E, of this chapter, prior to taking any adverse action resulting from a change in a beneficiary's circumstances.
( 6 ) If the agency has information about anticipated changes in a beneficiary's circumstances that may affect his or her eligibility, the redetermination of eligibility must be initiated at an appropriate time based on such changes consistent with paragraphs (b)(1) through (5) of this section and the timeliness standards at § 435.912(c)(6).
( c ) *Beneficiary response times* — ( 1 ) *In general.* The agency must— ( i ) Provide beneficiaries with at least 30 calendar days from the date the agency sends the notice requesting the beneficiary to provide the agency with any additional information needed for the agency to redetermine eligibility.
( ii ) Allow beneficiaries to provide any requested information through any of the modes of submission specified in § 435.907(a).
( 2 ) *Time standards for redetermining eligibility.* The agency must redetermine eligibility within the time standards described in § 435.912(c)(5) and (6), except in unusual circumstances, such as those described in § 435.912(e); States must document the reason for delay in the individual's case record.
( d ) *90-day reconsideration period.* If an individual terminated for not returning requested information in accordance with this section subsequently submits the information within 90 calendar days after the date of termination, or a longer period elected by the State, the agency must— ( 1 ) Reconsider the individual's eligibility without requiring a new application in accordance with the application timeliness standards established under § 435.912(c)(3).
( 2 ) Request additional information needed to determine eligibility consistent with § 435.907(e) and obtain a signature under penalty of perjury consistent with § 435.907(f) if such information or signature is not available to the agency or included in the information described in this paragraph (d).
( e ) *Scope of redeterminations following a change in circumstance.* For redeterminations of eligibility for Medicaid beneficiaries completed in accordance with this section— ( 1 ) The agency must limit any requests for additional information under this section to information relating to a change in circumstance that may impact the beneficiary's eligibility.
( 2 ) If the agency has enough information available to it to renew eligibility with respect to all eligibility criteria, the agency may begin a new eligibility period, as defined in § 435.916(a).
( f ) *Agency action on updated address information* — ( 1 ) *Updated address information received from a third party.* ( i ) The agency must have a process in place to regularly obtain updated address information from reliable data sources and to act on such updated address information in accordance with paragraphs (f)(2) and (3) of this section.
( ii ) The agency may establish a process to obtain updated address information from other third-party data sources and to act on such updated address information in accordance with paragraphs (f)(2) and (3) of this section.
( iii ) For purposes of paragraph (f)(1)(i) of this section, reliable data sources include: ( A ) Mail returned to the agency by the United States Postal Service (USPS) with a forwarding address;
( B ) The USPS National Change of Address (NCOA) database;
( C ) The agency's contracted managed care organizations (MCOs), prepaid inpatient health plans (PIHPs), prepaid ambulatory health plans (PAHPs), primary care case managers (PCCMs), and PCCM entities as defined in § 438.2 of this chapter, provided the MCO, PIHP, PAHP, PCCM, or PCCM entity received the information directly from or verified it with the beneficiary; and
( D ) Other data sources identified by the agency and approved by the Secretary.
( 2 ) *In-State address changes.* The following actions are required when the agency receives updated in-State address information for a beneficiary. ( i ) If the information is provided by a reliable data source described in paragraph (f)(1)(iii) of this section, the agency must— ( A ) Accept the information as reliable;
( B ) Update the beneficiary's case record; and
( C ) Notify the beneficiary of the update.
( ii ) If the information is provided by a data source not described in paragraph (f)(1)(iii) of this section, the agency must check the agency's Medicaid Enterprise System (MES) and the most recent address information received from reliable data sources described in paragraph (f)(1)(iii) of this section to confirm the accuracy of the information. ( A ) If the updated address information is confirmed, the agency must accept the information as reliable in accordance with paragraph (f)(2)(i) of this section.
( B ) If the updated address information is not confirmed by the MES or a reliable data source, the agency must make a good-faith effort, as described in paragraph (f)(5) of this section, to contact the beneficiary to confirm the information.
( C ) If the agency is unable to confirm the updated address information, the agency may not update the beneficiary's address in the case record or terminate the beneficiary's coverage for failure to respond to a request to confirm their address or State residency.
( 3 ) *Out-of-State address changes.* The following actions are required when the agency receives updated out-of-State address information for a beneficiary through the processes described in paragraph (f)(1) of this section. ( i ) The agency must make a good-faith effort, as described in paragraph (f)(5) of this section, to contact the beneficiary to confirm the information or obtain information on whether the beneficiary continues to meet the agency's State residency requirement.
( ii ) If the agency is unable to confirm that the beneficiary continues to meet State residency requirements, the agency must provide advance notice of termination and fair hearing rights consistent with part 431, subpart E, of this chapter.
( 4 ) *Whereabouts unknown.* The following actions are required when beneficiary mail is returned to the agency with no forwarding address. ( i ) The agency must check the agency's MES and the most recently available information from reliable data sources described in paragraph (f)(1)(iii) of this section for additional contact information. If updated in-State address information is available from such a reliable data source, then accept the information as reliable in accordance with paragraph (f)(2)(i) of this section.
( ii ) If updated address information cannot be obtained and confirmed as reliable in accordance with paragraph (f)(4)(i) of this section, the agency must make a good-faith effort, as described in paragraph (f)(5) of this section, to contact the beneficiary to obtain updated address information.
( iii ) If the agency is unable to identify and confirm the beneficiary's address pursuant to paragraph (f)(4)(i) or (ii) of this section and the beneficiary's whereabouts remain unknown, the agency must take appropriate steps to move the beneficiary to a fee-for-service delivery system, or to terminate or suspend the beneficiary's coverage. ( A ) If the agency elects to terminate or suspend coverage in accordance with this paragraph (f)(4)(iii), the agency must send notice to the beneficiary's last known address or via electronic notification, in accordance with the beneficiary's election under § 435.918, no later than the date of termination or suspension and provide notice of fair hearing rights in accordance with part 431, subpart E, of this chapter.
( B ) If whereabouts of a beneficiary whose coverage was terminated or suspended in accordance with this paragraph (f)(4)(iii) become known within the beneficiary's eligibility period, as defined in § 435.916(b), the agency— ( 1 ) Must reinstate coverage back to the date of termination without requiring the individual to provide additional information to verify their eligibility, unless the agency has other information available to it that indicates the beneficiary may not meet all eligibility requirements.
( 2 ) May begin a new eligibility period consistent paragraph (e)(2) of this section, if the agency has sufficient information available to it to renew eligibility with respect to all eligibility criteria without requiring additional information from the beneficiary.
( 5 ) *A good-faith effort to contact a beneficiary.* ( i ) For purposes of this paragraph (f), a good-faith effort includes: ( A ) At least two attempts to contact the beneficiary;
( B ) Use of two or more modalities (such as, mail, phone, email);
( C ) A reasonable period of time between contact attempts; and
( D ) At least 30 calendar days for the beneficiary to respond to confirm updated address information, consistent with paragraph (c)(1) of this section.
( ii ) If the agency does not have the information necessary to make at least two attempts to contact a beneficiary through two or more modalities in accordance with paragraph (f)(5)(i) of this section, the agency must make a note of that fact in the beneficiary's case record.
[89 FR 22869, Apr. 2, 2024]