Dual Eligible Renewal Strategies

The U.S. Department of Health and Human Services (HHS) first declared a Public Health Emergency (PHE) in January 2020. Section 6008 of the Families First Coronavirus Response Act (FFCRA) as amended by the Coronavirus Aid, Relief, and Economic Security (CARES) Act provides states with a temporary 6.2 percentage point increase in their federal medical assistance percentage (FMAP) if they meet certain criteria, one of which is continuous enrollment. With very few exceptions, states are to maintain continuous enrollment of all their Medicaid beneficiaries, including those who are also receiving Medicare.


The PHE must be renewed every 90 days. When the final renewal comes to an end, every Medicaid beneficiary must have a renewal conducted. This blog posting looks at a handful of strategies states can employ, and advocates can be watchful for, to keep the neediest enrolled, those known as “dual eligibles.”


Partial Dual or Full Dual

Medicare Savings Programs (MSP) are administered by the state and help otherwise eligible Medicare beneficiaries pay for Medicare Part A and/or B premiums and/or cost sharing. These MSP programs typically have income and asset criteria, but it can vary by state. Recipients of both Medicare and MSP are known as “partially dual eligible” or “partial duals.” In contrast, “fully dual eligible” or “full duals” are recipients of both Medicare and Medicaid. Medicaid offers a package of services beyond payment for Medicare premiums and cost sharing. Some Medicare beneficiaries are eligible for and receive both Medicaid and MSP.


Ex Parte Renewal

States must attempt to conduct an ex parte renewal for all beneficiaries. This means states must attempt to redetermine eligibility using available information whenever possible and only request documentation when sufficient information is not available through electronic data sources. A strategy states can use to maximize use of the ex parte renewal process for dual eligibles is to accept as reliable, information in the case record which the state determines is highly unlikely to change. Income is a good example of this. A state can choose to do this even if they require documentation of income not verified electronically from other beneficiaries.


Renewal Form

States are prevented from denying, terminating, or reducing benefits based on information received through electronic data sources unless the state reached out to the beneficiary and provided a reasonable opportunity for them to respond. If a state is unable to renew a beneficiary, it must send them a renewal form.


A renewal form for a MAGI-based beneficiary must be prepopulated. MAGI is a term you are going to hear often and is short for Modified Adjusted Gross Income (MAGI). It is basically an income methodology that applies to the Children’s Health Insurance Program (CHIP) and numerous Medicaid programs including, but not limited to, children, pregnant women, parents and caretakers, and expansion adults. A strategy for states to consider is to also prepopulate the form for non-MAGI beneficiaries like the aged, blind, disabled and dually eligible.


Extended Timeframes

The state sends the beneficiary a renewal notice. Now what? A MAGI-based beneficiary has 30 days to return the form. If they do not, and they lose coverage, they have a 90-day reconsideration period to return the form and it will be used as an application. Retroactive coverage may be an option which would essentially leave them without a coverage gap. In contrast, a non-MAGI beneficiary must return their renewal form within “a reasonable period of time” and the reconsideration period is optional for states. Strategies include allowing non-MAGI beneficiaries like the aged, blind, disabled and dually eligible 30 days to return the form and a 90-day reconsideration period.


Eligibility Period Exceeded

Here is another scenario. A beneficiary’s “eligibility period” is the time between initial application and regularly scheduled renewal. If the beneficiary does not return their renewal form within the timeframe established by the state but does return it before the end of their eligibility period, the state must act on the information. The beneficiary must continue receiving coverage until a final determination is made, even if state processing time exceeds the end of the eligibility period. A strategy here is to make sure the state doesn’t auto-terminate the beneficiary while the state is still processing the renewal. This would most likely be a state system (technology) issue.


MSP Eligibility Criteria

Dual eligible strategies reviewed above can be implemented by states without approval from the Centers for Medicare and Medicaid Services (CMS). There are other strategies requiring CMS’ approval of a State Plan Amendment (SPA). One example applies less restrictive income and/or resource criteria. States can raise or eliminate the income and/or resources standards for the MSPs.


All Options Pursued

There are three scenarios based on the outcome of the eligibility renewal. One is that they are potentially eligible for a different Medicaid category. The beneficiary must continue receiving coverage while this evaluation occurs. A second scenario is that they are eligible for the same category of Medicaid. The beneficiary is sent an approval notice and the process ends. The third scenario is where the beneficiary is no longer eligible. For beneficiaries who are determined ineligible for Medicaid the state must do two things:

  • First, send them at least 10-days advance notice of termination and include their right to a Medicaid fair hearing.
  • Second, determine potential eligibility for other insurance affordability programs.


Managing your Dual Eligible population is a complex process, Centauri Health Solutions has the knowledge and experience to advocate for your duals. Partner with us to develop your renewal strategy for the end of PHE.


Shanna Hanson, FHFMA, ACB
Manager, Business Knowledge
Centauri Health Solutions, Inc.