Comments from Richard Besser, MD, on
Streamlining the Eligibility and Enrollment Processes for Medicaid,
Children’s Health Insurance Program, and the Basic Health Program
Proposed Rule

The following comments were submitted by Richard Besser, MD, Robert Wood Johnson Foundation (RWJF) President and CEO, in response to the Centers for Medicare and Medicaid Services’ (CMS) proposed rule, Streamlining the Medicaid, Children’s Health Insurance Program, and Basic Health Program Application, Eligibility Determination, Enrollment, and Renewal Processes (hereinafter ”2022 Proposed Rule”).

RWJF is committed to improving health and health equity for all in the United States. In partnership with others, we are working to develop a Culture of Health rooted in equity that provides every individual with a fair and just opportunity to thrive, no matter who they are, where they live, or how much money they have.

Health is more than an absence of disease. It is a state of physical, mental, and emotional wellbeing. It reflects what takes place in our communities, where we live and work, where our children learn and play, and where we gather to worship. That is why RWJF focuses on identifying, illuminating, and addressing the barriers to health caused by structural racism and other forms of discrimination, including sexism, ableism, and prejudice based on sexual orientation.

We lean on evidence to advance health equity. We cultivate leaders who work individually and collectively across sectors to address health equity. We promote policies, practices, and systems-change to dismantle the structural barriers to wellbeing created by racism. And we work to amplify voices to shift national conversations and attitudes about health and health equity.

RWJF is pleased to offer the following comments in response to the 2022 Proposed Rule. Our comments are grounded in the perspectives and learnings of our grantees, who include academic researchers, policy experts, advocates, and organizers with deep expertise in healthcare delivery and health financing. The comments are also based on results from RWJF-funded health services research, our investments dedicated to maximizing health coverage, and our work to ensure that everyone has a fair and just opportunity to be as healthy as possible. Promoting access to affordable, high-quality coverage has been a priority for RWJF throughout our 50-year history and continues to be an essential component to achieving our goal of equitable and accountable healthcare systems in the United States

Of note, RWJF has made significant investments in large-scale programs over the last two decades focused on maximizing enrollment of eligible children and adults in Medicaid and CHIP, including through Covering Kids: A National Health Initiative for Low-Income Uninsured Children (CKI), Covering Kids and Families (CKF), and Maximizing Enrollment: Transforming State Health Coverage. Many of the lessons learned by RWJF and our grantees and partners over the course of these programs are relevant to continued efforts to maximize enrollment and are evident in the 2022 Proposed Rule.

For example, CKI demonstrated the value of simplifying CHIP and Medicaid policies and procedures to help families enroll their children and keep them covered as well as the importance of improving coordination between CHIP and Medicaid to ensure the transfer of families’ coverage between programs if they apply for the wrong program or their eligibility changes.

Further, evaluations of the CKF and Maximizing Enrollment programs found that some of the gains in administrative simplification that states made during the RWJF grant periods eroded after the programs ended and especially during state budget crises. These findings underscore why permanent policies to streamline enrollment and promote administrative simplification as included in the 2022 Proposed Rule are critical to ensuring sustained reductions in administrative burden and consistency across states to maximize enrollment.

RWJF’s efforts to close the Medicaid coverage gap also inform our comments on the 2022 Proposed Rule. Our work includes investments to promote enrollment among individuals newly eligible for Medicaid in states that recently adopted the Affordable Care Act (ACA) Medicaid expansion. The 2022 Proposed Rule would further facilitate meaningful access to coverage for these individuals as well as shape access to coverage for individuals in states that may act to close the Medicaid coverage gap in the future. Achieving full adoption of the ACA Medicaid expansion remains a top priority for RWJF as well as a health, economic, and moral imperative for the U.S.

We focus our comments on the 2022 Proposed Rule on the significance of CMS’ efforts to ensure that people who are eligible for Medicaid, the Children’s Health Insurance Program (CHIP), and the Basic Health Program (BHP) enroll in and retain coverage and offer our analysis and recommendations related to elements of the 2022 Proposed Rule as outlined below. RWJF’s recommendations for areas where CMS can strengthen the 2022 Proposed Rule are included as text that is both bolded and indented.

1. Undoing the impacts of structural racism and advancing health and racial equity;
2. Tackling uninsurance and coverage disruptions and promoting continuity of care;
3. Removing barriers to coverage and care by reducing administrative burden;
4. Promoting coverage, continuity of care, and access to care for children;
5. Promoting coverage, continuity of care, and access to care for older adults and individuals with disabilities;
6. Interplay of the 2022 Proposed Rule with the unwinding of Medicaid continuous enrollment; and
7. Looking ahead: Twelve-month (and more) continuous coverage.

I. Undoing the impacts of structural racism and advancing health and racial equity

If finalized and appropriately enforced, the 2022 Proposed Rule could significantly advance health and racial equity, in large part because people of color are more likely than White people to be enrolled in Medicaid and CHIP for health coverage. As of July 2022, Medicaid and CHIP provided health coverage to nearly 90 million people in the United States—more than 1 in 4 people. Roughly 60 percent of Medicaid and CHIP enrollees were non-White as of 2021. Among non-elderly individuals, Medicaid and CHIP covered roughly one-third of Black people, about one-third of Hispanic people, and nearly 40 percent of Indigenous people in 2021.

Historically, Medicaid eligibility practices in many states have reflected often racist concepts of “deservingness.” Though the ACA reduced many long-standing eligibility restrictions and administrative burdens in the Medicaid program and made advances toward a more coordinated system of health coverage, states have not uniformly made it easier for individuals to enroll in and retain coverage, ensuring that significant racial inequities in coverage enrollment and retention persist.   

The 2022 Proposed Rule rightly moves CMS and states away from an over-emphasis on making sure that ineligible individuals do not enroll or remain enrolled in Medicaid and CHIP and instead centers the goal that all people who are eligible for these programs are and remain covered. CMS estimates that the 2022 Proposed Rule will result in significant increases in Medicaid enrollment by individuals eligible for coverage. Further, the 2022 Proposed Rule will help to address the compounding negative impacts that racism, ableism, and ageism have on health and wellbeing by targeting for change policies and practices that disproportionately harm individuals based on race, disability status, age, language, and other characteristics.

II. Tackling uninsurance and coverage disruptions and promoting continuity of care

Enrollment churn—the temporary loss of coverage in which enrollees disenroll and then re-enroll within a short period of time—affects millions of people in the U.S., with 10 percent of Medicaid and CHIP enrollees in 2018 experiencing a gap in coverage over the course of a year. Even short coverage disruptions are associated with lapses in physician care and medication adherence; increased administrative costs for providers, Medicaid managed care organizations, and states; and, in some cases, higher healthcare costs when delayed care results in more expensive healthcare needs.

Despite important gains made under the ACA, which envisioned a coordinated system of health coverage with seamless transitions between insurance programs, uninsurance and coverage disruptions continue to affect significant cross-sections of the U.S. population. In 2020, 27.4 million people were uninsured, even though more than a quarter were eligible for Medicaid or CHIP and almost 40 percent were eligible for subsidies to purchase Marketplace plans. The uninsured population is predominantly composed of people of color—40 percent are Hispanic while about 16 percent are Black—and almost 60 percent have families with one or more full-time workers.

The 2022 Proposed Rule would directly address some of the causes of uninsurance and coverage disruptions within Medicaid and CHIP by streamlining the enrollment process for eligible individuals, including transitions between programs, and making it easier for eligible individuals to remain covered. 

III. Removing barriers to coverage and care by reducing administrative burden

Research shows that administrative burdens, such as requiring people to return forms rather than relying on electronic data and verification, reduce the number of people who enroll in and retain health coverage. The impact of administrative burden has been evident in states that implemented Medicaid work requirements, where new employment verification requirements resulted in significant Medicaid coverage losses despite the fact that the vast majority of individuals either met the work requirements or should have been exempt from them. RWJF offers the following comments on provisions of the 2022 Proposed Rule that will reduce administrative burden and promote access to health coverage.

Response times and timely determination and redetermination of eligibility

RWJF supports CMS’ proposals that would ensure applicants have enough time to gather and provide additional information and documentation requested by a state as well as requirements that states complete initial determinations and redeterminations of eligibility within a reasonable timeframe at application, at regular renewals, and following changes in circumstances.

Many individuals who are denied Medicaid at application or lose coverage during a renewal are in fact eligible but unable to successfully gather and submit the correct documents within the agency’s timeframes. The 2022 Proposed Rule would provide a minimum of 15 days for an applicant (whose eligibility is not based on disability) to fulfill an agency’s request for information (RFI). This would increase the likelihood that an applicant can meet the agency’s timeframes and receive an accurate eligibility determination. Allowing at least 15 days strikes a balance between the need to give applicants time to gather and submit documents and the need for timely determinations of eligibility.

Changes in circumstances

RWJF supports the addition of procedures and standards for processing changes in circumstances if such changes result in ineligibility for Medicaid and CHIP. In particular, we support the requirement that agencies allow 30 days from the date the agency sends the notice for an enrollee to respond to an RFI. This will give enrollees more time to gather the necessary information and increase response rates to RFIs.

RWJF recommends that the final rule require that if a state has reliable information that an enrollee is eligible for additional benefits or lower cost sharing, that the state act on that information in the same manner as is required for ex parte renewals.

Returned mail

RWJF supports the 2022 Proposed Rule’s requirements for how states must follow up on returned mail, depending on whether there is no forwarding address, an in-state forwarding address, or an out-of-state forwarding address. We support the proposal to require states to check available data sources and conduct outreach using at least two different modalities in each situation. This will create a standardized process for states to address returned mail and ensure that states have the most current and reliable enrollee mailing information. We believe these processes will promote retention of eligible individuals, reduce procedural disenrollments, avoid churn, and accelerate the pace at which states are adopting efficient, cost-effective, and timely enrollee communications using non-mail modes.

Returned mail has consistently been a challenge for state Medicaid agencies. Some states currently terminate enrollees’ coverage when their mail comes back as returned without first attempting additional contact. The unwinding of Medicaid continuous coverage at the conclusion of the Public Health Emergency (PHE) will present new challenges given that many people have been enrolled for long periods without needing to reply to notices they receive in the mail. In addition, the disruptions caused by the pandemic have forced many people to relocate. Because of these circumstances, Medicaid agencies lack a current address for many enrollees, may find it difficult to reach them by mail, and would benefit from utilizing multiple communications channels.

RWJF supports the proposed requirements for states to follow up on returned mail. We recommend that follow-up requirements be added when information is needed to determine eligibility at application, renewal, or when there is a change in circumstances.

Combined eligibility notice

RWJF supports the 2022 Proposed Rule’s requirement that states provide a combined Medicaid/CHIP eligibility notice when either the Medicaid agency determines an individual ineligible for Medicaid and eligible for CHIP, or the separate CHIP agency determines an individual ineligible for CHIP and eligible for Medicaid. This requirement will alleviate confusion for enrollees and promote continuity of coverage.

The preamble notes that a combined notice will help families transitioning from Medicaid to CHIP learn about premium requirements or any plan selection process they need to complete. However, it is not clear the regulation requires combined eligibility notices to include this information.  

RWJF recommends that CMS conform the definition of combined notices at §§ 435.4 and 457.340(f) to clarify that the notices must include information about premium requirements and any plan selection processes that need to be completed by beneficiaries.

Improving transitions between insurance affordability programs

RWJF supports the provisions in the 2022 Proposed Rule aimed at improving coordination between insurance affordability programs. Currently, Medicaid agencies are not required to transfer accounts of individuals who fail to respond to RFIs at renewal or when the agency becomes aware of information that may indicate ineligibility for Medicaid. In these situations, Medicaid agencies can terminate coverage without determining eligibility or potential eligibility for other coverage. The 2022 Proposed Rule would change this by requiring account transfers whenever the agency determines ineligibility and shows potential eligibility for another insurance affordability program.

Further, RWJF supports the 2022 Proposed Rule’s requirement that Medicaid agencies must, in addition to determining eligibility for other programs when an individual is ineligible for Medicaid, also determine eligibility when the individual is only eligible for a Medicaid benefit that does not meet minimum essential coverage requirements.

RWJF recommends that CMS provide guidance to states on how they should determine whether an individual is potentially eligible for another insurance affordability program.

IV. Promoting coverage, continuity of care, and access to care for children

 Following passage of the ACA, CMS made notable gains in establishing a streamlined and coordinated eligibility and enrollment system across all health coverage programs. However, some CHIP administrative barriers remain in place that are not allowed in Medicaid and other insurance affordability programs. RWJF supports efforts to align CHIP to Medicaid and end outdated practices as described in the proposed rule and as outlined in the below recommendations.

Eliminating Waiting Periods

RWJF supports eliminating waiting periods in CHIP as proposed in the 2022 Proposed Rule. The waiting period policy is unique to CHIP and does not effectively serve the program’s interests.

States are currently permitted to establish waiting periods of up to 90 days before children can enroll or reenroll in CHIP to prevent the substitution of private coverage with public coverage. However, there is negligible evidence that waiting periods have been effective in preventing this substitution while there is substantial research highlighting the harms of waiting periods to child health and development. Substitution of private coverage can be monitored by data matching, and states can consider policy changes, such as premium assistance, to make private coverage more affordable if substitution is occurring.

States must comply with a list of exemptions in order to implement a waiting period, but 11 states still have them. In these states, a waiting period may only apply to a child following the loss of group health coverage and only in limited circumstances. If a waiting period does apply, states must transfer the child to the Marketplace temporarily and then enroll the child in CHIP once the waiting period ends. This creates not only the potential for harmful gaps in health coverage but also significant administrative burdens for families and state programs alike in churning among different types of coverage as well as maintaining continuity of care and consistent access to a trusted healthcare provider.  

In response to CMS’ request for comment on whether the final rule should permit 30-day waiting periods rather than eliminating waiting periods in CHIP, RWJF opposes this option. In the final rule, CMS should eliminate waiting periods in CHIP as proposed in the 2022 Proposed Rule and not simply reduce the allowable length of waiting periods to 30 days or some other length of time. The reasons that waiting periods are problematic at 90 days persist at 30 days or any other length of time.

Eliminating Premium Lockout Periods

RWJF supports eliminating premium lockouts in CHIP as proposed in the 2022 Proposed Rule. Premium lockout periods create a forced period of uninsurance for children during which they may miss needed care or incur higher healthcare costs. Research has shown that children—for whom access to regular care to monitor development is crucial—who experience gaps in coverage are less likely to have a usual source of care and more likely to have trouble affording healthcare compared to children who are insured year-round. Low and moderate-income children and children of color are especially likely to experience gaps in coverage. As of January 2020, 14 states imposed a lockout period of up to 90 days for nonpayment of premiums, and some states require repayment of past due premiums as a condition of eligibility.  

In response to CMS’ request for comment on whether the final rule should permit 30-day premium lockout periods rather than eliminating premium lockout periods in CHIP, RWJF opposes this option. In the final rule, CMS should eliminate premium lockout periods in CHIP as proposed in the 2022 Proposed Rule and not simply reduce the allowable length of premium lockouts to 30 days or some other length of time. The reasons that premium lockout periods are problematic at 90 days persist at 30 days or any other length of time.

Eliminating Annual and Lifetime Dollar Limits on Benefits

RWJF supports eliminating annual and lifetime dollar limits in CHIP as proposed in the 2022 Proposed Rule. Such limits are not allowable in Medicaid or other insurance affordability programs and continuing to allow them in CHIP is unjustified and harmful to children’s health.

The 2022 Proposed Rule states that 12 states have an annual dollar limit on at least one CHIP benefit and six states have a lifetime dollar limit on at least one benefit, most commonly on dental or orthodontia coverage. RWJF agrees with CMS’ conclusion that dollar limits can impede access to services that children need, particularly access to dental care for low-income children. As drafted, states would still retain the authority to limit the number of services (e.g., physical therapy visits) consistent with other federal requirements. This strikes the appropriate balance between permitting states to apply utilization management controls and assuring access to critical services.

Medicaid Determinations of CHIP Eligibility

RWJF supports the 2022 Proposed Rule’s requirement that Medicaid agencies in states with separate CHIP programs make CHIP eligibility determinations and transfer files to CHIP. We agree with the preamble that Medicaid agencies have or can obtain the necessary information for CHIP determinations.

RWJF also supports the 2022 Proposed Rule’s requirement that states move forward with CHIP determinations and transfers regardless of whether individuals have confirmed reliable data. This policy is critical because under current regulations, even though a Medicaid agency may find that an individual is likely eligible for CHIP, the state can terminate the enrollee (without transferring their file to CHIP) if the individual fails to respond to an RFI.

Taken together, these changes would greatly improve coordination between Medicaid and CHIP programs and reduce disruptions in coverage and care for children as their family income and other circumstances change.

V. Promoting coverage, continuity of care, and access to care for older adults and individuals with disabilities

Improving Medicaid application and renewal processes for older adults and individuals with disabilities

The ACA and implementing regulations streamlined eligibility determinations and renewals for people whose Medicaid eligibility is determined using Modified Adjusted Gross Income (MAGI) rules. By comparison, Medicaid eligibility determinations and renewals for people who are over age 65 or who are blind or have a disability (MAGI-exempt populations) in many states continue to be done in a manner that is unnecessarily burdensome for applicants and enrollees as well as for state eligibility workers. The failure to streamline eligibility rules for non-MAGI groups has resulted in higher rates of procedural denials, even though older adults and people with disabilities are more likely to have stable incomes. Denials are more likely because these groups are more likely to lack transportation to attend an in-person interview and have health-related barriers to responding to requests for documents.

The 2022 Proposed Rule would align non-MAGI processes with many of the streamlining and simplification requirements adopted for MAGI groups under the ACA, including: disallowing a requirement for an in-person interview; conducting renewals only once a year; sending pre-populated forms; providing 30 days to return renewal information; accepting renewals through any of four modalities (online, by telephone, by mail, or in person); and providing a 90-day reconsideration period if information is returned after a procedural disenrollment.

RWJF supports the alignment of non-MAGI processes with the streamlining and simplification requirements adopted for MAGI groups under the ACA as outlined in the 2022 Proposed Rule. We believe that these changes will promote retention in non-MAGI Medicaid as well as make it easier for eligibility and call center workers, enrollees, assisters, and other stakeholders to understand the rules given the increased consistency of processes between MAGI and non-MAGI groups.

Response times and timely determination and redetermination of eligibility

For applicants who apply for Medicaid on the basis of disability, RWJF supports the 2022 Proposed Rule’s requirement that states provide 30 days for an applicant to submit additional information requested by the state. Additional time is appropriate considering the complexity of gathering necessary medical information and the longer processing timeframe for those cases.

VI. Interplay of the 2022 Proposed Rule with the unwinding of Medicaid continuous enrollment

The Medicaid continuous enrollment requirement enacted as part of the Families First Coronavirus Response Act at the start of the pandemic has contributed to significant growth in Medicaid enrollment and a decline in the uninsured rate as well as enabled people to affordably access needed care. When continuous enrollment is discontinued after the formal end of the PHE, states will restart eligibility redeterminations for Medicaid enrollees. Millions of people could lose coverage if they are no longer eligible or face administrative barriers during the process despite remaining eligible, especially among individuals with limited English proficiency, who are more likely to experience administrative barriers to completing Medicaid renewal processes.

While we recognize the administrative demands states will face as the PHE ends and the unwinding of the Medicaid continuous enrollment requirement begins, we believe this underscores the need for prompt implementation of the 2022 Proposed Rule, particularly for the elements of the rule that have the greatest potential to help reduce the erroneous disenrollment of individuals eligible for Medicaid. For example, the provisions related to returned mail, streamlining processes for people over age 65 and people with disabilities, and facilitating transitions between Medicaid and CHIP should be prioritized for a 90-day compliance timeline.

People who are eligible for Medicaid, CHIP, and the BHP should not have to surmount unnecessary obstacles to access needed healthcare benefits. Improved technological capabilities and a record of successful administrative simplifications for some but not all enrollees demonstrate that further streamlining is possible without sacrificing program integrity.

RWJF recommends that in the final rule CMS should emphasize that every state should be in full compliance with existing eligibility and enrollment regulatory requirements, including ex parte renewals.

The ex parte renewal procedure is an important tool states can use to quickly process eligible beneficiaries. In this process, states use existing data sources to determine a person’s eligibility rather than relying on a multi-step process of mailing out notices and requiring an individual to respond with proof of their eligibility. Maximizing the use of ex parte renewals is a state obligation under federal law. However, before Medicaid redeterminations were suspended with the PHE, states used ex parte renewals in varying degrees.

Especially as states prepare for the unwinding of the PHE, an effective ex parte process will positively impact access to coverage and is a prerequisite to operationalizing the new proposed regulatory requirements in the 2022 Proposed Rule.

VII. Looking ahead: Twelve-month (and more) continuous coverage

While the new requirements in the 2022 Proposed Rule are critically important and should be finalized to prevent coverage disruptions, they are not equivalent to or a substitute for 12-month continuous eligibility that states may adopt now for children under the state plan and for children and adults via Section 1115 demonstrations. Twelve-month continuous eligibility is a proven strategy to prevent churn and promote access to needed care.

RWJF also wants to acknowledge the tremendous opportunities presented by the Section 1115 waiver that CMS recently approved in Oregon to provide continuous Medicaid coverage to children from birth through age five and for two years for all Oregonians enrolled in Medicaid age six and older. Especially as millions of children are at risk of losing Medicaid coverage when the continuous coverage protections of the PHE lift, the Oregon Section 1115 waiver presents a model for how states can transform their approach to maximize coverage for children.

RWJF encourages CMS to continue its work to promote continuous coverage through Section 1115 waivers as a complement to the goals and mechanisms of the 2022 Proposed Rule. Like the provisions of the 2022 Proposed Rule, multiple years of continuous coverage would lessen the administrative burden on states, healthcare providers, and health plans in addition to families as well as promote continuity of care, family economic security, and health and racial equity.

We thank you for the opportunity to comment on the 2022 Proposed Rule. We have included numerous citations to supporting research, including direct links to the research. We direct HHS and CMS to each of the materials we have cited and made available through active links, and we request that the full text of each of the studies and articles cited, along with the full text of our comment, be considered part of the formal administrative record for purposes of the Administrative Procedure Act. If HHS and CMS are not planning to consider these materials part of the record as we have requested here, we ask that you notify and provide us an opportunity to submit copies of the studies and articles into the record.

We look forward to continuing to work with the HHS, CMS, and other partners to ensure that everyone has the opportunity to achieve optimal health and wellbeing.

About the Robert Wood Johnson Foundation

For more than 45 years the Robert Wood Johnson Foundation has worked to improve health and health care. We are working alongside others to build a national Culture of Health that provides everyone in America a fair and just opportunity for health and wellbeing. For more information, visit www.rwjf.org. Follow the Foundation on Twitter at www.rwjf.org/twitter or on Facebook at www.rwjf.org/facebook.

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