Jan, 03, 2023

Improving Ex Parte Renewal Rates to Support Unwinding: Questions and Answers

Patricia Boozang, Kinda Serafi, Kaylee O’Connor, and Michelle Savuto, Manatt Health

Introduction

When the federal Medicaid continuous coverage requirement expires, states will be required to redetermine eligibility for over 90 million Medicaid enrollees, threatening the historic coverage gains achieved during the federal public health emergency (PHE). One of the most effective tools for states to mitigate coverage loss for eligible people during “unwinding” and beyond is ex parte redetermination whereby the Medicaid and Children’s Health Insurance Program (CHIP) agency attempts to make a redetermination of an individual’s eligibility based on available data, without requiring information from the individual. States are required to attempt ex parte redetermination for all for all Modified Adjusted Gross Income (MAGI) and non-MAGI enrollees, pursuant to federal regulation.[1] 

Eligible enrollees in state Medicaid/CHIP programs that maximize use of ex parte are more likely to retain their coverage. Conversely, in states that do not fully deploy ex parte, and instead rely on sending requests for information to enrollees, there is a higher likelihood that eligible individuals will lose coverage, either because they moved or because they cannot or do not respond to the requested information in a timely way. Ex parte redetermination is an effective strategy to help states reduce the administrative workload on an already taxed eligibility workforce. Robust ex parte processes also help address persisting disparities in access to health coverage and care that reflect the structural racism embedded within the Medicaid program and healthcare system more broadly. 

Federal regulations require states to first attempt to renew eligibility ex parte, prior to requesting any information from the enrollee and sending a renewal form.[2] CMS has also made available new section 1902(e)(14) waiver flexibilities[3] intended to improve states’ ex parte rates during the PHE unwinding period. This Q&A is intended to serve as a resource for states looking to improve their current ex parte processes to support their efforts during unwinding and well beyond. 

For more information, see the State Health and Value Strategies (SHVS) diagnostic assessment that states can use to examine current ex parte processes and identify additional strategies to increase their ex parte rates. Also see this slide deck that provides an overview of ex parte processes and includes key resources in the appendix.

Ex Parte Q&A

1. Question: What data is considered timely and reliable for use in ex parte renewals and redeterminations?

Answer: The Centers for Medicare & Medicaid Services (CMS) has given states considerable flexibility to determine what they consider timely and reliable data sources. States are required to memorialize the data that is used for verifying income at application and renewal in their verification plan. As a general rule, states should feel comfortable relying on data verified within the last six months, which includes information from a Supplemental Nutrition Assistance Program (SNAP) recertification. Notably, states may also deem data timely and reliable even if it is older than six months, so long as such information is memorialized in a state’s verification plan. (https://www.hitc.com) For example, many states use Internal Revenue Service data when verifying income, which may be older than six months. CMS has recently clarified that states can also consider information reliable if it was verified more than six months ago and is not subject to change.

(See CMS’ Ex Parte Renewal deck and CMS’ Opportunities to Support Unwinding Efforts for States with Integrated Eligibility Systems and/or Workforces deck for more information.)

 

2. Question: Should a state attempt to renew Medicaid or CHIP eligibility on an ex parte basis for an enrollee without first receiving a returned renewal form from the enrollee?

Answer: Yes, if the available information from reliable data sources is sufficient to determine continued eligibility without requiring information from the enrollee, the state Medicaid or CHIP agency must renew eligibility on an ex parte basis and should not send a renewal form. Under 42 CFR 435.916, if available information is insufficient to determine continued eligibility, the state would then need to send a renewal form (that is prepopulated for MAGI populations) and request additional information from the member.

(See CMS’ Ex Parte Renewal deck for more information.)

 

3. Question: Are states required to attempt to renew Medicaid and CHIP eligibility via ex parte for people who were formerly self-employed?

Answer: Yes, states must attempt to renew eligibility on an ex parte basis for all enrollees—including individuals with (or who at one point had) self-employment income. Eligibility for these enrollees may be verified using State Wage Information Collection Agency or other available income data sources. Individuals who at one point may have had self-employment income could have experienced a change in circumstances and now have an alternate source of earned income that can be verified using available sources. In the eligibility determination notice, states should notify individuals of the basis of their eligibility determination and remind individuals to report changes in circumstances.

(See CMS’ Ex Parte Renewal deck for more information.)

 

4. Question: Under the temporary section 1902(e)(14) Targeted SNAP Strategy, are Medicaid determinations that are based on findings from SNAP conducted at the individual or household level?

Answer: Medicaid determinations based on findings from SNAP must be conducted at the individual level; these determinations do not have any implications on other members of the individual’s household. For example, if a parent is found eligible for SNAP and has income below 138% of the federal poverty level, they may be deemed Medicaid eligible as long as they meet other programmatic requirements, such as citizenship/immigration status and residency. If the parent’s child is eligible for SNAP, the child may also be deemed Medicaid eligible if their MAGI income falls below the Medicaid eligibility levels.

(See SHVS’ Leveraging Section 1902(e)(14) Waiver Authority Amid Unwinding expert perspective, CMS’ COVID-19 PHE Unwinding Section 1902(e)(14)(A) Waiver Approvals webpage, and CMS’ Opportunities to Support Unwinding Efforts for States with Integrated Eligibility Systems and/or Workforces deck for more information.)

 

5. Question: How can a state Medicaid agency leverage the section 1902(e)(14) Targeted SNAP strategy if its enrollees have either aligned or misaligned Medicaid and SNAP renewal dates?

Answer: For enrollees with a SNAP recertification date that is aligned with the Medicaid renewal date, the state Medicaid agency could first recertify SNAP and, based on the recertification findings, extend Medicaid coverage for 12 months without having to conduct a separate ex parte renewal or send a prepopulated renewal form. The state Medicaid agency could also leverage the section 1902(e)(14) Targeted SNAP Strategy for enrollees with misaligned SNAP recertification and Medicaid renewal dates. For example, the state Medicaid agency could first recertify SNAP and, at a later date (that of the Medicaid renewal), extend Medicaid coverage for 12 months based on the recertification findings without having to conduct a separate ex parte renewal or send a prepopulated renewal form. The SNAP recertification and Medicaid renewal periods would remain separate.

(See SHVS’ Improving Ex Parte Rates to Support Unwinding deck and CMS’ Opportunities to Support Unwinding Efforts for States with Integrated Eligibility Systems and/or Workforces deck for more information, including illustrative scenarios.)

 

6. Question: Recognizing that the section 1902(e)(14) Targeted SNAP Strategy is only temporary, what are other long-term strategies that states could consider implementing to leverage SNAP and other program eligibility determinations in Medicaid?

Answer: For longer-term solutions, states could implement Express Lane Eligibility for children, which states can use to rely on findings from a state-designated entity (such as SNAP, Temporary Assistance for Needy Families, or the Special Supplemental Nutrition Program for Women, Infants, and Children) to facilitate enrollment into coverage. States can also implement the Facilitated Enrollment state plan amendment option for adults. (www.creativesystems.com) This option allows states to determine financial eligibility for a MAGI-based eligibility group using gross household income from SNAP or other means-tested benefit programs. Under this state plan option, states are required to collect discrete pieces of information to ensure the individual is certainly eligible under a MAGI-based income determination.
(See CMS’ Ex Parte Renewal deck and SHVS’ Using SNAP Information to Facilitate Medicaid Enrollment and Renewal deck for more information.)

 

7. Question: Do any 1902(e)(14) waiver flexibilities apply to CHIP enrollees?

Answer: Yes, there are two section 1902(e)(14) strategies that apply to CHIP: (1) permitting the state to accept updated in-state enrollee contact information from managed care plans without additional confirmation from the individual, and (2) permitting automatic re-enrollment into managed care plans for individuals who lost Medicaid coverage for up to 120 days and are later reenrolled. The section 1902(e)(14) Targeted SNAP Strategy is not applicable to CHIP enrollees. This is because SNAP’s gross income test is below the minimum income standard permitted for separate CHIP programs. Similarly, other section 1902(e)(14) flexibilities may not apply to CHIP because the eligibility requirements related to the strategy do not apply to CHIP. For example, the section 1902(e)(14) Streamlined Asset Verification flexibility and the Fair Hearing Timeframe Extension Strategy flexibility are unique to Medicaid eligibility. Additionally, the section 1902(e)(14) flexibility allowing states to renew eligibility for individuals who have zero income and for whom no data sources are returned does not apply to CHIP enrollees because CHIP enrollees live in low-to-moderate income families and do not have zero income.

(See SHVS’ Leveraging Section 1902(e)(14) Waiver Authority Amid Unwinding expert perspective, CMS’ COVID-19 PHE Unwinding Section 1902(e)(14)(A) Waiver Approvals webpage, and CMS COVID-19 PHE Unwinding FAQs for more information.)

 

8. Question: Is temporary section 1902(e)(14) authority necessary for states to complete ex parte renewals of individuals with no income (“zero-dollar income”) and no financial data?

Answer: Yes, CMS requires states to obtain the section 1902(e)(14) Beneficiaries with No Income Renewal flexibility to complete ex parte renewals of individuals with zero-dollar income and no financial data. Under this flexibility, the individual’s attestation of such income needs to have been verified (either at initial application or prior renewal) within the last 12 months prior to the start of the PHE or no earlier than March 2019, and states must adhere to their verification plans and applicable federal requirements. In other words, if the state Medicaid agency has previously determined an enrollee to have no income and no data sources are returned as part of the ex parte renewal process, the enrollee can be found eligible for Medicaid and no further action or documentation verification is required by the enrollee.

(See SHVS’ Leveraging Section 1902(e)(14) Waiver Authority Amid Unwinding expert perspective and CMS’ COVID-19 PHE Unwinding Section 1902(e)(14)(A) Waiver Approvals webpage for more information.)

 

9. Question: If a state has limited time and resources to improve its ex parte renewal processes, are there priority areas where it can focus its efforts?

Answer: We recommend states with resource constraints: (1) evaluate the earned and unearned income data sources that the state is using, and expand that dataset; (2) add SNAP data for ex parte verification if the state is not already doing so (and consider leveraging the section 1902(e)(14) Targeted SNAP authority if the state is already doing so); and (3) examine business rules and remove any requirements impeding ex parte processes (e.g., consent requirements). States should also focus on complementary unwinding strategies, including, but not limited to, leveraging managed care plans and other partners to update contact information and assist with renewals, conducting integrated outreach/education campaigns, and promoting seamless coverage transitions across Medicaid, CHIP and Marketplace coverage.

(See SHVS’ Improving Ex Parte Renewal Rates: State Diagnostic Assessment Tool and SHVS’ Unwinding of the Public Health Emergency: What’s Next for States webinar for more information.)

 

[1] 42 CFR § 435.911; 42 CFR § 435.916; and 42 CFR § 457.343.

[2] 42 CFR § 435.911; 42 CFR § 435.916; and 42 CFR § 457.343.

[3] For more information, see this expert perspective: Leveraging Section 1902(e)(14) Waiver Authority Amid Unwinding.