​Since March 2020, states have been prohibited from disenrolling any Medicaid beneficiaries from the Medicaid program. The freeze on redeterminations and prohibition on disenrollment were based on federal statutory requirements states had to meet to receive the increased federal Medicaid funding of 6.2 percent over the course of the pandemic. Now, with the public health emergency ended, states are returning to “regular” Medicaid redetermination schedules.

State Medicaid agencies have over 87 million redeterminations to conduct before May 2024. Most states have not conducted redeterminations in over three years. During that time, beneficiary information (contact information, financial information, etc.) might have become out of date  and state agencies have had significant staff turnover and shortages. In many states, state and/or county eligibility units may have few or no staff members with redetermination expertise. Despite Centers for Medicare & Medicaid Services’ guidance and support, this could result in notable breaks in Medicaid coverage.

If a beneficiary loses Medicaid eligibility, Medicaid payments stop, and beneficiaries have very clear federal protections for when these breaks occur despite the loss of Medicaid payments. For example, beneficiaries must be given 30 days’ notice before discharge steps are taken, families and beneficiaries may not be billed for care, and a clear discharge plan must be explained and shared in writing. Failure to follow these steps can result in survey deficiencies and may make providers vulnerable to legal action.

At first glance, waves of nursing facility (NF) and assisted living (AL) Medicaid redeterminations may seem of little concern. However, they are cause for concern if staff turnover in NF and AL business offices has resulted in workplaces staffed with personnel who have little to no Medicaid redetermination experience. While older adults’ and persons with disabilities’ functional criteria to meet Medicaid levels of care are unlikely to change, the people involved with managing residents’ finances likely have changed.

AHCA/NCAL Resources

The American Health Care Association/National Center for Assisted Living (AHCA/NCAL) has prepared an array of resources aimed at supporting NFs and AL facilities to manage significant numbers of Medicaid redeterminations. Working with partner organizations, AHCA/NCAL has developed three modules and related tools. Many members have used these resources to educate admissions and business office staff on unwinding and to provide refreshers on financial care planning, as well as the basics of Medicaid eligibility determination. These AHCA/NCAL members-only resources are available at https://educate.ahcancal.org/. Search for Medicaid unwinding or visit https://educate.ahcancal.org/products/medicaid-unwinding-return-to-regular-medicaid-redetermination-ensuring-resident-medicaid-coverage.

For state-specific Medicaid eligibility requirements and processes, members should work with their state affiliates, since those policies and features are state specific.