Photo of family at doctor, showing importance of states maintaining compliance with Medicaid and CHIP eligibility

Medicaid and CHIP eligibility regulations: Protecting children and family healthcare coverage

On August 30, the Centers for Medicare & Medicaid Services (CMS) sent a compliance reminder letter to all 50 states, requiring states to determine if their Medicaid and CHIP eligibility systems could cause people, especially children, to be disenrolled from programs even if they are still eligible for coverage.

CMS determined that some states’ eligibility systems are incorrectly configured to automatically renew people at the family level and not the individual level. Individuals in a family could have very different eligibility requirements to qualify for Medicaid and CHIP. Renewing at the family level has caused several children, who are eligible for coverage, to become disenrolled because their parents are no longer eligible. As noted by CMS, these system issues directly violate federal renewal requirements.

If a state determines their eligibility systems are incorrectly disenrolling eligible family members, CMS advises they take the following steps immediately.

  • Pause procedural disenrollment for those individuals impacted,
  • Reinstate coverage for all affected individuals,
  • Implement one or more CMS-approved mitigation strategies to prevent continued inappropriate disenrollment, and
  • Fix state systems and processes to ensure renewals are conducted appropriately and in accordance with federal Medicaid requirements.

Here is the full CMS press release with more information.

It is important as a health plan partner that you work with your state to understand the impact this may have on their systems and identify any changes that may need to be made to the inbound/outbound processes you have in place with the state.

If you lack the resources to do so, the Garnet Care team can help you identify the impact of these state changes to your operational processes. Garnet Care also understands budget constraints and ongoing challenges, which drives our goal to help our clients do more with less.

Photo of Garnet Care practice lead Courtney Seypura

Courtney Seypura is practice lead for Garnet Care. She has more than 20 years of experience in Medicare and Medicaid operations and project management. Garnet Care helps health plans, administrators, hospitals, and providers improve patient experience and program performance through system and process optimization. Courtney can be reached by email at or by phone 518-605-0216.

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