§ 435.912 Timely determination and redetermination of eligibility. ( a ) *Definitions.* For purposes of this section— *Performance standards* are overall standards for determining, renewing and redetermining eligibility in an efficient and timely manner across a pool of applicants or beneficiaries, and include standards for accuracy and consumer satisfaction, but do not include standards for an individual applicant's determination, renewal, or redetermination of eligibility.
*Timeliness standards* refer to the maximum periods of time, subject to the exceptions in paragraph (e) of this section and in accordance with § 435.911(c), in which every applicant is entitled to a determination of eligibility, a redetermination of eligibility at renewal, and a redetermination of eligibility based on a change in circumstances.
( b ) *State plan requirements.* Consistent with guidance issued by the Secretary, the agency must establish in its State plan timeliness and performance standards, promptly and without undue delay, for: ( 1 ) Determining eligibility for Medicaid for individuals who submit applications to the single State agency or its designee in accordance with § 435.907, including determining eligibility or potential eligibility for, and transferring individuals' electronic accounts to, other insurance affordability programs pursuant to § 435.1200(e);
( 2 ) Determining eligibility for Medicaid for individuals whose accounts are transferred from other insurance affordability programs, including at initial application, as well as at a regularly scheduled renewal or due to a change in circumstances;
( 3 ) Redetermining eligibility for current beneficiaries at regularly scheduled renewals in accordance with § 435.916, including determining eligibility or potential eligibility for, and transferring individuals' electronic accounts to, other insurance affordability programs pursuant to § 435.1200(e);
( 4 ) Redetermining eligibility for current beneficiaries based on a change in circumstances in accordance with § 435.919(b)(1) through (5), including determining eligibility or potential eligibility for, and transferring individuals' electronic accounts to, other insurance affordability programs pursuant to § 435.1200(e); and
( 5 ) Redetermining eligibility for current beneficiaries based on anticipated changes in circumstances in accordance with § 435.919(b)(6), including determining eligibility or potential eligibility for, and transferring individuals' electronic accounts to, other insurance affordability programs pursuant to § 435.1200(e).
( c ) *Timeliness and performance standard requirements* — ( 1 ) *Period covered.* The timeliness and performance standards adopted by the agency under paragraph (b) of this section must— ( i ) For determinations of eligibility at initial application or upon receipt of an account transfer from another insurance affordability program, as described in paragraphs (b)(1) and (2) of this section, cover the period from the date of application or transfer from another insurance affordability program to the date the agency notifies the applicant of its decision or the date the agency transfers the individual's electronic account to another insurance affordability program in accordance with § 435.1200(e);
( ii ) For regularly-scheduled renewals of eligibility under § 435.916, cover the period from the date that the agency initiates the steps required to renew eligibility on the basis of information available to the agency, as required under § 435.916(b)(1), to the date the agency sends the individual notice required under § 435.916(b)(1)(i) or (b)(2)(i)(C) of its decision to approve their renewal of eligibility or, as applicable, to the date the agency terminates eligibility and transfers the individual's electronic account to another insurance affordability program in accordance with § 435.1200(e);
( iii ) For redeterminations of eligibility due to changes in circumstances under § 435.919(b)(1) through (5), cover the period from the date the agency receives information about the reported change, to the date the agency notifies the individual of its decision or, as applicable, to the date the agency terminates eligibility and transfers the individual's electronic account to another insurance affordability program in accordance with § 435.1200(e); and
( iv ) For redeterminations of eligibility based on anticipated changes in circumstances under § 435.919(b)(6), cover the period from the date the agency begins the redetermination of eligibility, to the date the agency notifies the individual of its decision or, as applicable, to the date the agency terminates eligibility and transfers the individual's electronic account to another insurance affordability program in accordance with § 435.1200(e).
( 2 ) *Criteria for establishing standards.* To promote accountability and a consistent, high quality consumer experience among States and between insurance affordability programs, the timeliness and performance standards included in the State plan must address— ( i ) The capabilities and cost of generally available systems and technologies;
( ii ) The general availability of electronic data matching, ease of connections to electronic sources of authoritative information to determine and verify eligibility, and the time needed by the agency to evaluate information obtained from electronic data sources;
( iii ) The demonstrated performance and timeliness experience of State Medicaid, CHIP, and other insurance affordability programs, as reflected in data reported to the Secretary or otherwise available;
( iv ) The needs of applicants and beneficiaries, including preferences for mode of application and submission of information at renewal or redetermination (such as through an internet website, telephone, mail, in-person, or other commonly available electronic means), the time needed to return a renewal form or any additional information needed to complete a determination of eligibility at application or renewal, as well as the relative complexity of adjudicating the eligibility determination based on household, income or other relevant information; and
( v ) The advance notice that must be provided to beneficiaries in accordance with §§ 431.211, 431.213, and 431.214 of this chapter when the agency makes a determination resulting in termination or other action as defined in § 431.201 of this chapter.
( 3 ) *Standard for new applications and transferred accounts.* Except as provided in paragraph (e) of this section, the determination of eligibility for any applicant or individual whose account was transferred from another insurance affordability program may not exceed— ( i ) 90 calendar days for applicants who apply for Medicaid on the basis of disability; and
( ii ) 45 calendar days for all other applicants.
( 4 ) *Standard for renewals.* The redetermination of eligibility at a beneficiary's regularly scheduled renewal may not exceed the end of the beneficiary's eligibility period, except as provided in paragraphs (e) and (c)(4)(i) and (ii) of this section. ( i ) In the case of a beneficiary who returns a renewal form less than 30 calendar days prior to the end of the beneficiary's eligibility period, the redetermination of eligibility may not exceed the end of the month following the end of the beneficiary's eligibility period.
( ii ) In the case of a beneficiary who is determined ineligible on the basis for which they are currently receiving Medicaid (the applicable modified adjusted gross income standard described in § 435.911(b)(1) and (2) or another basis) and for whom the agency is considering eligibility on another basis, the eligibility determination on the new basis may not exceed— ( A ) 90 calendar days for beneficiaries whose eligibility is being determined on the basis of disability; and
( B ) 45 calendar days for all other beneficiaries.
( 5 ) *Standard for redeterminations based on changes in circumstances.* Except as provided in paragraph (e) of this section, the redetermination of eligibility for a beneficiary based on a change in circumstances reported by the beneficiary or received from a third party may not exceed the end of the month that occurs— ( i ) 30 calendar days following the agency's receipt of information related to the change in circumstances, unless the agency needs to request additional information from the beneficiary;
( ii ) 60 calendar days following the agency's receipt of information related to the change in circumstances if the agency must request additional information from the beneficiary; or
( iii ) In the case of a beneficiary who is determined ineligible on the basis for which they are currently receiving Medicaid (the applicable modified adjusted gross income standard described in § 435.911(b)(1) and (2) or another basis) and for whom the agency is considering eligibility on another basis— ( A ) 90 calendar days following the determination of ineligibility on the current basis, for beneficiaries whose eligibility is being determined on the basis of disability; and
( B ) 45 calendar days following the determination of ineligibility on the current basis for all other beneficiaries.
( 6 ) *Standard for redeterminations based on anticipated changes.* The redetermination of eligibility for a beneficiary based on an anticipated change in circumstances may not exceed the end of the month in which the anticipated change occurs, except as provided in paragraphs (e) and (c)(6)(i) and (ii) of this section. ( i ) In the case of a beneficiary who returns information or documentation requested pursuant to § 435.919(b)(6) less than 30 calendar days prior to the end of the month in which the anticipated change occurs, the redetermination of eligibility may not exceed the end of the month following the month in which the anticipated change occurs.
( ii ) In the case of a beneficiary who is determined ineligible on the basis for which they are currently receiving Medicaid (the applicable modified adjusted gross income standard described in § 435.911(b)(1) and (2) or another basis) and for whom the agency is considering eligibility on another basis, the eligibility determination on the new basis may not exceed— ( A ) 90 calendar days for beneficiaries whose eligibility is being determined on the basis of disability; and
( B ) 45 calendar days for all other beneficiaries.
( d ) *Availability of information.* The agency must inform individuals of the timeliness standards adopted in accordance with this section.
( e ) *Exceptions.* The agency must determine or redetermine eligibility within the standards except in unusual circumstances, for example— ( 1 ) When the agency cannot reach a decision because the applicant or beneficiary, or an examining physician, delays or fails to take a required action; or
( 2 ) When there is an administrative or other emergency beyond the agency's control.
( f ) *Case documentation.* The agency must document the reason(s) for delay in the applicant's or beneficiary's case record.
( g ) *Prohibitions.* The agency must not use the timeliness standards— ( 1 ) As a waiting period before determining eligibility;
( 2 ) As a reason for denying or terminating eligibility or benefits as required under § 435.930(b) (because it has not determined or redetermined eligibility within the timeliness standards); or
( 3 ) As a reason for delaying termination of a beneficiary's coverage or taking other adverse action.
[89 FR 22867, Apr. 2, 2024]