Medicaid Rules Are Changing for 2023: What It Means for You

Medicaid redetermination is the process that states use to ensure that people who are enrolled in Medicaid are still eligible for Medicaid coverage. People also call this process Medicaid renewal, case review, or recertification.

You’ll need to report your household income to the local county Department of Job and Family Services every 12 months so they can determine whether you’re still eligible.

Sometimes the state can verify a household’s continued eligibility electronically, called ex parte renewal. In this case, the enrollee does not have to provide additional information.

If the information is not available using electronic resources, the state will send the enrollee a request for it. It’s important to respond to these notices — your coverage will be ended if you do not provide the requested documentation by the given deadline.

Rules and minimum standards for Medicaid redetermination

• Adults who are ages 19 to 64, children, parents and caretakers of minor children, and people who are pregnant have their eligibility determined solely by modified adjusted gross income (MAGI) and must be redetermined every 12 months.
• Enrollees who are ages 65 and older, blind, disabled, or receiving home- and community-based services or long-term care services have their eligibility redetermined at least once every 12 months.
• Enrollees need to respond promptly to any requests for information.

If your income has increased past an income limit set by your state, there’s a chance you may no longer qualify for Medicaid.

If you do not reapply, you will be disenrolled and your coverage will stop. But disenrollment will not happen immediately because measures were implemented to protect enrollees when redetermination resumed.

This means the state has to make a good-faith effort to find you using the U.S. Post Office change of address database or the state Department of Health and Human Services data to ensure that your current contact information is on file with the state Medicaid office. They also can’t disenroll you simply because their mail was returned as undeliverable.

You can check your current enrollment status by logging into your HealthCare.gov account. Click on your name in the top right and select “My applications & coverage” from the dropdown menu. Select your completed application under “Your existing applications.” Here you’ll see a summary of your coverage.

If you want healthcare coverage provided by the Medicaid program, you will have to reapply. Current Medicaid enrollees need to reapply every year so that their eligibility can be re-evaluated. Eligibility requirements for Medicaid differ by state, but income and household size are the major factors.

How your application is processed depends on whether you fit into the MAGI or non-MAGI group. The Affordable Care Act (ACA) streamlined the redetermination process for the MAGI group throughout the states.

The MAGI group consists of:

• adults without children between the ages of 19 and 64
• children younger than age 19
• pregnant women
• parents and caregiver relatives

Here are the actual steps you’ll need to take:

1. Make sure your state has your current mailing address, phone number, email, or other contact information on file. This way, they’ll be able to contact you about your Medicaid or Children’s Health Insurance Program (CHIP) coverage.
2. Check your mail to make sure you don’t miss a renewal letter or other important information from your state. This mail may be time sensitive.
3. If you receive a renewal form in the mail, fill it out, provide any relevant documentation required, and return it to the given address right away. This will help get Medicaid renewed as soon as possible to avoid a gap in coverage. After you complete this step, your application should be assessed and your coverage will either be renewed or you will be disenrolled.
4. You can check the current status of your coverage by contacting your local state health office — you can get this by calling 1-800-MEDICARE (1-800-633-4227) and requesting the phone number for your state’s Medicaid office. Or check your profile online through your state’s portal.

You can find out specific information about Medicaid enrollment in your state here.

To be eligible for Medicaid, you must meet certain criteria. Financial eligibility means having an annual household income below a certain number, and nonfinancial eligibility includes other criteria, such as age and having certain health conditions.

Financial eligibility

Your MAGI is used to determine financial eligibility for CHIP and premium tax credits and cost-sharing reductions available through the health insurance marketplace.

Your financial eligibility is determined as a percentage of your income and household status, which takes into account the number of people and children in your household.

The limit in most cases is 138% of the federal poverty level (FPL). This percentage varies by state, ranging from 0% for adults who aren’t parents, to as high as 221% for parents with a family of three (in the District of Columbia).

Nonfinancial eligibility

You may also qualify for Medicaid under other criteria, including:

• being a U.S. citizen or a qualified non-citizen, such as a lawful permanent resident
• residing in your state to qualify for coverage there
• being between 19 and 64 years old
• being pregnant
• having children

Medical need is another factor that may make you eligible. Some states have a “medically needy program” for individuals with significant health needs whose income is too high to otherwise qualify for Medicaid under other eligibility groups.

For most Medicaid enrollees, reapplying for Medicaid is automatic.

When your state needs additional information to determine whether you’re eligible, the process can still be fairly simple — fill out your reapplication form and provide the necessary documentation to demonstrate your eligibility.

You can also contact your local state health office for more information.