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us/guidance/cms/sho — Axiom

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elect to cover these groups under Medicaid only or under both Medicaid and CHIP. The law does not permit States to cover these new groups only in CHIP, without also extending the option to Medicaid.

While the phrase “lawfully residing in the United States” has not previously been used when describing individuals who could be eligible for Medicaid and CHIP, it has been used in various other contexts, such as by the United States Department of Agriculture (USDA) and the Social Security Administration (SSA).

For example, for purposes of determining whether certain individuals are eligible to receive food stamps (now called the Supplemental Nutrition Assistance Program (SNAP)), regulations at 7 CFR 273.4(a)(7) state that “lawfully residing in the U.S.” means that the individual is lawfully present as defined in regulations at 8 CFR 103.12(a). Likewise, for purposes of Title II benefits under SSA, “lawfully residing in the U.S.” means that an individual is “lawfully present” as defined by 8 CFR 103.12(a) and is a resident of the U.S. as defined in SSA regulations and program instructions. In both of these programs, the terms “lawfully residing” and “lawfully present” are broader than the term “qualified alien” in section 431 of PRWORA (8 U.S.C. § 1641) with respect to immigration status (the term “qualified alien” does not include residence- based criteria). We have looked to these programs to assist us in defining “lawfully residing” for purposes of implementing section 214 of CHIPRA.

In interpreting “lawfully residing,” we will rely on existing immigration regulations for the purpose of defining lawful presence and longstanding Medicaid rules to establish residency. In other words, the “residing” part of the “lawfully residing” requirement is construed as synonymous with the longstanding Medicaid residency requirement, rather than as requiring a separate and redundant residency determination for the sole purpose of determining “lawful residence.” For example, a nonimmigrant visitor for business or pleasure may be lawfully present under immigration regulations, but not meet Medicaid or CHIP residency requirements, and therefore will not be able to qualify for Medicaid or CHIP.

Lawfully Present

Children and pregnant women that fall into one of the categories below will be considered lawfully present. Therefore, these individuals are eligible for Medicaid and CHIP coverage if the State elects the new option under CHIPRA, and the child or pregnant woman meets the State residency requirements and other Medicaid or CHIP eligibility requirements.

The basis of our construction of lawful presence is the broad definition provided in DHS regulations at 8 CFR 103.12(a) for the specific purpose of Title II Social Security benefits, with some revisions necessary for updating or clarifying purposes, or as otherwise deemed appropriate for the Medicaid and CHIP programs consistent with the Act.

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A child or pregnant woman shall be considered lawfully present if he or she is:

(1) A qualified alien as defined in section 431 of PRWORA (8 U.S.C. §1641);

(2) An alien in nonimmigrant status who has not violated the terms of the status under which he or she was admitted or to which he or she has changed after admission;

(3) An alien who has been paroled into the United States pursuant to section 212(d)(5) of the Immigration and Nationality Act (INA) (8 U.S.C. §1182(d)(5)) for less than 1 year, except for an alien paroled for prosecution, for deferred inspection or pending removal proceedings;

(4) An alien who belongs to one of the following classes:

(i) Aliens currently in temporary resident status pursuant to section 210 or 245A of the INA (8 U.S.C. §§1160 or 1255a, respectively); (ii) Aliens currently under Temporary Protected Status (TPS) pursuant to section 244 of the INA (8 U.S.C. §1254a), and pending applicants for TPS who have been granted employment authorization; (iii) Aliens who have been granted employment authorization under 8 CFR 274a.12(c)(9), (10), (16), (18), (20), (22), or (24); (iv) Family Unity beneficiaries pursuant to section 301 of Pub. L. 101-649, as amended; (v) Aliens currently under Deferred Enforced Departure (DED) pursuant to a decision made by the President; (vi) Aliens currently in deferred action status; or (vii) Aliens whose visa petition has been approved and who have a pending application for adjustment of status;

(5) A pending applicant for asylum under section 208(a) of the INA (8 U.S.C. § 1158) or for withholding of removal under section 241(b)(3) of the INA (8 U.S.C. § 1231) or under the Convention Against Torture who has been granted employment authorization, and such an applicant under the age of 14 who has had an application pending for at least 180 days;

(6) An alien who has been granted withholding of removal under the Convention Against Torture;

(7) A child who has a pending application for Special Immigrant Juvenile status as described in section 101(a)(27)(J) of the INA (8 U.S.C. § 1101(a)(27)(J));

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(8) An alien who is lawfully present in the Commonwealth of the Northern Mariana Islands under 48 U.S.C. § 1806(e); or

(9) An alien who is lawfully present in American Samoa under the immigration laws of American Samoa.

Under CHIPRA, a State electing to cover children or pregnant women who are considered to be lawfully residing in the U.S. must offer coverage to all such individuals who meet this definition of lawfully residing, and may not cover a subgroup or only certain groups (e.g., only the PRWORA group of qualified aliens, or only citizens of Compact of Free Association nations, or only aliens residing for a specified period, such as 3 years).

Residency Children and pregnant women who meet the definition set forth above of “lawfully present” also must be residents of the State in which they are applying in order to qualify for Medicaid or CHIP. An individual would not be eligible for Medicaid or CHIP, even if he or she is considered to be lawfully present in the U.S., if the individual is not a resident of the State, as the individual would not be considered as either “lawfully residing” in the U.S. or as a State resident. At the same time, an individual would be eligible for Medicaid and CHIP if he or she is considered to be lawfully present in the U.S. and is a State resident, even if the individual’s current immigration status is of a temporary nature (such as TPS). Implementing regulations at 42 CFR 435.403 specify State residence in Medicaid to mean living in a State and having the intent to remain permanently for an indefinite period. Each individual should have an opportunity to establish that he or she lives in the State and intends to remain there.

Sponsor Deeming and “Public Charge” The alien sponsor deeming requirements described in section 421 of PRWORA may not be applied to individuals covered under the new CHIPRA section 214 option. A sponsor’s income and resources are not considered when determining eligibility. In addition, no debt will be created for the sponsor by any services provided to such individuals who have been found eligible for Medicaid or CHIP. The cost of Medicaid or CHIP assistance will not be considered as an unreimbursed cost associated with the “public charge” provisions.

Eligibility Determinations and Redeterminations

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States that elect the new option under CHIPRA must verify that the individual meets the definition of lawfully residing in the U.S. at the time of application, according to the rules established under section 1137(d) of the Act. Eligibility also must be verified at renewal. Consistent with other Medicaid requirements, the State should first rely on information provided at the time of initial application under the rules established at section 1137(d) to determine ongoing eligibility. States should only require the individual to provide further documentation or to re-verify satisfactory status if the State cannot verify continued eligibility based on the information already available to the State.

State Plan Amendments

A State may elect the section 214 CHIPRA option by submitting a State plan amendment (SPA) under Medicaid only or amendments under both Medicaid and CHIP. Section 214 of CHIPRA does not permit the application of this option under CHIP only. Attached are two draft State plan templates that States can use to elect the section 214 option under Medicaid and CHIP. States electing to provide CHIP coverage of children and/or pregnant women must submit concurrent CHIP and Medicaid SPAs to CMS for consideration. Also, a State must choose whether to adopt this option for children (all children up to age 19 for CHIP or up to age 21 for Medicaid), pregnant women, or both.

Federal Financial Participation

Because this is a new eligibility group, children up to age 19 covered under the section 214 option (at any income level) are considered targeted low-income children under section 2110(b) of the Act. As such, claims paid on behalf of children eligible under the new option created by section 214 may be matched at the enhanced title XXI match rate, regardless of whether the child is covered through Medicaid or a separate CHIP program. States also have the option under Section 115 of CHIPRA to claim regular Medicaid Federal Financial Participation (FFP) for the children enrolled in Medicaid or a CHIP-funded Medicaid expansion.

Medicaid eligible individuals for whom the State receives FFP at the CHIP enhanced rate and who would be subject to the 5-year waiting period under section 403 of PRWORA, must be claimed at the Medicaid FFP rate once these children have met the 5-year waiting period. For example, a child who entered the country on November 1, 2008 as a “qualified alien” (under section 431 of PRWORA) may be claimed at the enhanced rate until October 31, 2013, the end of the 5-year waiting period for that child. Subsequently, a State must cover this child using title XIX funds. Therefore, States that choose to claim the title XXI enhanced match must have a process for tracking these children in order to determine when the regular matching rate would come into effect. States may continue to claim enhanced title XXI enhanced matching for children under age 19 who are lawfully residing in the U.S. and who are not considered qualified aliens under PRWORA as described above.

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Enclosure

Section 4. Eligibility Standards and Methodology – Expanding Coverage to Individuals Lawfully Residing in the US

Section 4. Eligibility Standards and Methodology

4.1.10 _____ Check if the State is electing the option under section 214 of the Children’s Health Insurance Program Reauthorization Act of 2009 (CHIPRA) to provide coverage to the following otherwise eligible pregnant women and children as specified below who are lawfully residing in the United States including the following:

A child or pregnant woman shall be considered lawfully present if he or she is:

(1) A qualified alien as defined in section 431 of PRWORA (8 U.S.C. §1641);

(2) An alien in nonimmigrant status who has not violated the terms of the status under which he or she was admitted or to which he or she has changed after admission;

(4) An alien who belongs to one of the following classes:

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(1) A qualified alien as defined in section 431 of PRWORA (8 U.S.C. §1641);

(2) An alien in nonimmigrant status who has not violated the terms of the status under which he or she was admitted or to which he or she has changed after admission;

(4) An alien who belongs to one of the following classes:

(6) An alien who has been granted withholding of removal under the Convention Against Torture;

(7) A child who has a pending application for Special Immigrant Juvenile status as described in section 101(a)(27)(J) of the INA (8 U.S.C. § 1101(a)(27)(J));

(8) An alien who is lawfully present in the Commonwealth of the Northern Mariana Islands under 48 U.S.C. § 1806(e); or

(12-002)SHO #12-002 (State Health Official letter, August 28, 2012)#

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DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop S2-26-12 Baltimore, Maryland 21244-1850

Center for Medicaid and CHIP Services

SHO# 12-002

August 28, 2012

Re: Individuals with Deferred Action for Childhood Arrivals

Dear State Health Official: Dear Medicaid Director:

This guidance is intended to inform you about the implications for Medicaid and the Children’s Health Insurance Program (CHIP) of the U.S. Department of Homeland Security’s (DHS) announcement on June 15, 2012, that it will consider providing temporary relief from removal by exercising deferred action on a case-by-case basis with respect to certain individuals under age 31 as of June 15, 2012 who meet certain guidelines, including that they came to the United States as children and do not present a risk to national security or public safety.1 This process is referred to by DHS as Deferred Action for Childhood Arrivals (DACA).2 DHS has explained that the DACA process is designed to ensure that governmental resources for the removal of individuals are focused on high priority cases, including those involving a danger to national security or a risk to public safety, and not on low priority cases.3 DHS began accepting requests for consideration of deferred action on August 15, 2012.

Section 214 of the Children’s Health Insurance Program Reauthorization Act of 2009 (CHIPRA) gave states the option to provide Medicaid and CHIP eligibility to children and/or pregnant women who are “lawfully residing” in the United States and otherwise eligible for Medicaid or CHIP. CMS provided guidance on the definition of “lawfully residing” in a July 1, 2010 State Health Official Letter (http://downloads.cms.gov/cmsgov/archived-downloads/SMDL/downloads/SHO10006.pdf). Because the reasons that DHS offered for adopting the DACA process do not pertain to eligibility for Medicaid or CHIP, HHS has determined that these benefits should not be extended as a result of DHS deferring action under DACA. For this reason, individuals with deferred action under the DACA process shall not be eligible for Medicaid and CHIP under the CHIPRA state option with respect to any of the categories (1)-(9) set forth in the July 1, 2010 letter.

1 June 15, 2012 Memorandum of Secretary of Homeland Security Janet Napolitano, available at http://www.dhs.gov/xlibrary/assets/s1-exercising-prosecutorial-discretion-individuals-who-came-to-us-as-children.pdf. 2 Consideration of Deferred Action for Childhood Arrivals, available at http://www.uscis.gov/childhoodarrivals. 3 See supra nn. 1-2.

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State Medicaid Director

We hope this information will be helpful. Thank you for your commitment to the Medicaid and CHIP programs.

Sincerely,

/s/

Cindy Mann

Director

cc:

CMS Regional Administrators

CMS Associate Regional Administrators Division of Medicaid and Children’s Health Operations

Matt Salo Executive Director National Association of Medicaid Directors

Alan R. Weil, J.D., M.P.P. Executive Director National Academy for State Health Policy

Ronald Smith Director of Legislative Affairs American Public Human Services Association

Joy Wilson Director, Health Committee National Conference of State Legislatures

Heather Hogsett Director of Health Legislation National Governors Association

Debra Miller Director for Health Policy Council of State Governments

Christopher Gould Director, Government Relations Association of State and Territorial Health Officials

(21-007)SHO #21-007, Improving Maternal Health and Extending Postpartum Coverage (December 7, 2021)#

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DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop S2-26-12 Baltimore, Maryland 21244-1850

SHO# 21-007 RE: Improving Maternal Health and Extending Postpartum Coverage in Medicaid and the Children’s Health Insurance Program (CHIP)

December 7, 2021

Dear State Health Official:

Medicaid is the largest single payer of pregnancy-related services and covers over 42 percent of births nationally.1 The Children’s Health Insurance Program (CHIP) also covers pregnant adolescents and, in some states, low-income pregnant individuals with income over the Medicaid income limit. Together, Medicaid and CHIP play a critical role in ensuring access to care for pregnant and postpartum individuals, improving the quality of maternal health care, and addressing disparities in health outcomes and pregnant and postpartum care. Sections 9812 and 9822 of the American Rescue Plan Act of 2021 (ARP) (Pub. L. 117-2) give states a new option to provide 12 months of extended postpartum coverage to pregnant individuals enrolled in Medicaid and CHIP beginning April 1, 2022. The purpose of this State Health Official (SHO) letter is to provide guidance to states on implementation of this new state option.

The newly extended postpartum coverage option offers states an opportunity to provide care that can reduce pregnancy-related deaths and severe maternal morbidity and improve continuity of care for chronic conditions such as diabetes, hypertension, cardiac conditions, substance use disorder, and depression. More than half of pregnancy-related deaths occur in the 12-month postpartum period, and 12 percent occur after six weeks postpartum. Significant and persistent disparities exist in pregnancy-related morbidity and mortality. Black and American Indian/Alaska Native individuals are up to five times more likely than White individuals to die from pregnancy-related complications and more likely to have a preventable death.2 There are also disparities in rates of postpartum follow-up care for conditions associated with morbidity and mortality. Black individuals who had gestational diabetes were found to have among the lowest postpartum diabetes screening rates despite having the highest risk for progression to chronic diabetes.3 More generally, individuals who have a lower level of education, individuals who are Black or Hispanic, and individuals with co-existing morbidities, such as mental health

1 Medicaid covers 42.1 percent of births nationally; National Center for Health Statistics, Birth Data (updated June 14, 2021). Available at https://www.cdc.gov/nchs/nvss/births htm. 2 Petersen, E. E., N.L. Davis, D. Goodman, et al. “Vital Signs: Pregnancy-Related Deaths, United States, 2011–2015, and Strategies for Prevention, 13 States, 2013–2017.” Morbidity and Mortality Weekly Report, vol. 68, no. 18, 2019, pp. 423–429. Exact rates differ by demographic data. 3 Herrick, C. J., Puri, R., Rahaman, R., Hardi, A., Stewart, K., & Colditz, G. A. (2020). Maternal Race/Ethnicity and Postpartum Diabetes Screening: A Systematic Review and Meta-Analysis. Journal of women's health (2002), 29(5), 609–621. Available at https://doi.org/10.1089/jwh.2019.8081.

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conditions, have lower rates of postpartum care.4 Extended postpartum coverage presents an opportunity for states to improve postpartum care and address these disparities. States that have expanded Medicaid eligibility to provide coverage beyond 60 days postpartum report an increase in postpartum care visits, continuity in coverage, and enhanced engagement of individuals in health care.5 Background

Many pregnant individuals qualify for Medicaid on the basis of their pregnancy through the eligibility group for pregnant individuals described at 42 C.F.R. § 435.116. Pregnant individuals may also be eligible on another basis, for example, as a parent or caretaker relative or on the basis of disability status. States also have the option to extend coverage to lawfully residing pregnant individuals and children, if they otherwise meet eligibility requirements under the state’s program (commonly referred to as “the CHIPRA 214 option”). Under current law, pregnant Medicaid beneficiaries are eligible under the state plan for at least pregnancy-related services through the end of the month in which the 60-day period, beginning on the last day of pregnancy, ends (referred to as the “60-day postpartum period”).6 This continuous eligibility applies through the end of the 60-day postpartum period regardless of the eligibility group in which the beneficiary is enrolled, and is not affected by changes in income that would otherwise result in a loss of eligibility.7

Pregnant individuals also may be eligible for coverage in CHIP. Pregnant adolescents eligible as a “targeted low-income child” in CHIP can receive prenatal and postpartum care along with other child health assistance. States also have the option to extend CHIP eligibility to “targeted low-income pregnant women” through the end of the 60-day postpartum period, similar to Medicaid8, and to elect the CHIPRA 214 option for this population under section 2107(e)(1)(O) of the Act. In addition, states have the option to extend child health assistance to “unborn children” who meet other applicable eligibility criteria for coverage under the CHIP state plan, thereby providing coverage to pregnant individuals who themselves are not eligible for Medicaid or CHIP. Unlike postpartum coverage for targeted low-income pregnant individuals, postpartum coverage for pregnant individuals who received services during pregnancy on behalf of their unborn child is limited. State Plan Option to Provide 12 Months Postpartum Coverage

The ARP provides Medicaid and CHIP agencies a new state plan option to provide 12 months of continuous postpartum coverage, regardless of any changes in circumstances, in Medicaid and CHIP (hereafter referred to as the “extended postpartum coverage option” or “extended postpartum coverage”). Section 9812 of the ARP adds a new section 1902(e)(16) of the Social

4 Jones, E.J., T.L. Hernandez, J.K. Edmonds, and E.P. Ferranti. “Continued Disparities in Postpartum Follow-Up and Screening Among Women with Gestational Diabetes and Hypertensive Disorders of Pregnancy: A Systematic Review.” Journal of Perinatal Neonatal Nursing, vol. 33, no. 2, 2019, pp.136–148. 5 Gordon, S.H., B.D. Sommers, I. Wilson, O. Galarraga, and A.N. Trivedi. “The Impact of Medicaid Expansion on Continuous Enrollment: A Two-State Analysis.” Journal of General Internal Medicine, vol. 34, no. 9, 2019, pp. 1919–1924. 6 Section 1902(e)(5) of the Social Security Act; 42 C.F.R. § 435.170 7 Section 1902(e)(6) of the Social Security Act; 42 C.F.R. § 435.170; CMCS Informational Bulletin, “Medicaid and Children’s Health Insurance Program (CHIP) Renewal Requirements,” (December 2020). Available at https://www medicaid.gov/federal- policy-guidance/downloads/cib120420.pdf 8 Section 2112(d)(2)(A) of the Social Security Act The contents of this document do not have the force and effect of law and are not meant to bind the public in any way, unless specifically incorporated into a contract. This document is intended only to provide clarity to the public regarding existing requirements under the law.

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Security Act (the Act) to provide this authority in Medicaid, which is extended to CHIP through a new subparagraph (J) at section 2107(e)(1) of the Act, added by section 9822 of the ARP. When the state elects this option in Medicaid, it must also make the same election in a separate CHIP, as established under subparagraph (C) of section 1902(e)(16), as referenced in section 2107(e)(1)(J) of the Act. The option is currently limited to a 5-year period beginning on April 1, 2022.

The 12-month postpartum period begins on the last day of a beneficiary’s pregnancy and extends through the end of the month in which the 12-month period ends. Similar to the current 60-day postpartum period, under the extended postpartum coverage option, individuals are entitled to the extended postpartum coverage regardless of the reason the pregnancy ends. States that do not elect the extended postpartum coverage option must continue to provide coverage for pregnant individuals in Medicaid through the 60-day postpartum period as currently required.

States that elect to provide the extended postpartum coverage option are encouraged to educate beneficiaries about the availability of continuous extended postpartum coverage, including posting information on the state agency website and collaborating with providers and stakeholders in their state to provide outreach and education about the new option. States may use Medicaid and CHIP administrative matching funds for beneficiary and provider education and outreach. In addition, states are encouraged to update their notices to ensure pregnant individuals and beneficiaries are aware they are eligible for continuous extended postpartum coverage. States are reminded that program information on Medicaid and CHIP must be provided in plain language and in a manner that is accessible to individuals who have limited English proficiency or are living with disabilities, as required at 42 C.F.R. §§ 435.905(b) and 457.110(a).

Eligibility for Extended Postpartum Coverage

In states that elect the 12-month extended postpartum coverage option, beneficiaries who are eligible for and enrolled in Medicaid or CHIP while pregnant, including lawfully residing children and pregnant individuals covered under the state option provided for at sections 1903(v)(4)(A)(i) and 2107(e)(1)(O) of the Act (commonly known as the “CHIPRA 214” option), are eligible for continuous coverage for the duration of the extended postpartum period. Sections 1902(e)(16) and 2107(e)(1)(J) of the Act authorize 12 months of continuous extended postpartum coverage to individuals who “while pregnant” are eligible for and have received coverage under the Medicaid or CHIP state plan or a demonstration project. As a result, states cannot cover under the extended postpartum coverage option individuals who were not enrolled in Medicaid or CHIP in the state at some point during pregnancy. Note that, for Medicaid, the 12 months of extended postpartum coverage under this option applies to individuals who were pregnant and received Medicaid-covered services while pregnant during a period of retroactive eligibility granted under section 1902(a)(34) of the Act and 42 C.F.R. § 435.915(a).

The extended postpartum coverage option under the state plan is available to Medicaid beneficiaries enrolled in the group for pregnant individuals at 42 C.F.R. § 435.116 as well as pregnant individuals enrolled in any other categorically or medically needy eligibility group. States must ensure they are able to provide continuous extended postpartum coverage for The contents of this document do not have the force and effect of law and are not meant to bind the public in any way, unless specifically incorporated into a contract. This document is intended only to provide clarity to the public regarding existing requirements under the law.

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individuals enrolled in Medicaid on a basis that is not related to pregnancy status but who report a pregnancy or whom the state identifies as pregnant (e.g., based on claims data).

In states that cover children and/or pregnant individuals in a separate CHIP, if the state elects the extended postpartum coverage option in Medicaid, pregnant adolescents eligible as “targeted low-income children” and individuals eligible as “targeted low-income pregnant women” who are enrolled in the separate CHIP must also receive the extended postpartum coverage.

Section 9822 of the ARP did not change postpartum care for all pregnant individuals enrolled in CHIP, maintaining existing limitations.9 The 12-month extended postpartum coverage under section 2107(e)(1)(J) of the Act is only available to “targeted low-income children” who are pregnant or “targeted low-income pregnant women.” Pregnant individuals receiving CHIP services who do not meet the definition of either targeted population may not receive extended postpartum coverage under the ARP option. States should reach out to their CHIP Project Officer with any questions or technical assistance needs regarding coverage for such individuals.

States must submit a Medicaid and CHIP state plan amendment (SPA) to adopt the extended postpartum coverage option. In states that do so, the following populations must be provided continuous enrollment through the end of the 12-month postpartum period:

• Current beneficiaries who are pregnant as of the effective date of the SPA or who enroll based on pregnancy or become pregnant after the SPA is effective; • Current beneficiaries who were enrolled in Medicaid or CHIP while pregnant and who are no longer pregnant when the SPA becomes effective, but who are still within a 12- month postpartum period; and • Individuals who apply for Medicaid after their pregnancy ends, but who received Medicaid-covered services in the state while pregnant on or after the effective date of the SPA, if such services were received during a period of retroactive eligibility granted under section 1902(a)(34) of the Act and 42 C.F.R. § 435.915(a), provided that they would have been eligible when they received such services if they had applied.

When a state first implements the extended postpartum coverage option, there may be some individuals who were enrolled in Medicaid or CHIP while pregnant and are still less than 12 months postpartum, but whose coverage was terminated prior to the effective date of the extended postpartum coverage option in the state. While not required, states may choose to:

1) Identify these individuals and reinstate their coverage, provided they continue to be state residents. These individuals would be eligible for coverage with continuous eligibility in the group from which they were disenrolled for the remainder of their 12-month postpartum period; or

9 For individuals receiving pregnancy-related care who may not otherwise be eligible for Medicaid or CHIP, states may only provide postpartum care if (1) the post-birthing individual would otherwise satisfy all eligibility requirements for CHIP except age, as described at section 2112(f)(2) of the Act; (2) the postpartum coverage is included as part of a bundled payment for prenatal care and labor and delivery benefits (CMS SHO #02-004; available at https://healthlaw.org/wp- content/uploads/2018/09/cms release on prenatal care for fetuses.pdf); or (3) the state has implemented a health services initiative (HSI) to provide postpartum coverage. The contents of this document do not have the force and effect of law and are not meant to bind the public in any way, unless specifically incorporated into a contract. This document is intended only to provide clarity to the public regarding existing requirements under the law.

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2) Approve coverage for any such individuals who submit a new application within their 12- month postpartum period and provide them with continuous eligibility for the remainder of their 12-month postpartum period.

In Medicaid, under both options, retroactive eligibility would be available, consistent with 42 C.F.R. § 435.915(a), to provide coverage for the three months prior to the date of reinstatement or reapplication if the beneficiary had received Medicaid services, at any time during that three- month period, and would have been eligible for Medicaid at the time they received the services if they had applied. In CHIP, states may develop a reasonable methodology in their state plan to determine the effective date of eligibility and avoid gaps in coverage for this population, consistent with 42 C.F.R. § 457.340(g), including providing retroactive eligibility.

Continuous Eligibility During Pregnancy and the Extended Postpartum Period

Pregnant individuals who are eligible for extended postpartum coverage in Medicaid and CHIP are entitled to continuous eligibility through the last day of the month in which the 12-month postpartum period ends.10 Unlike the continuous eligibility provided under section 1902(e)(6) of the Act, which ensures pregnant Medicaid beneficiaries continue to be eligible through the end of the 60-day postpartum period despite changes in income, the continuous coverage afforded under section 1902(e)(16) of the Act ensures such coverage despite any changes in circumstances, similar to the continuous coverage provided to children, at state option, under section 1902(e)(12) of the Act. Individuals receiving extended postpartum coverage remain eligible regardless of changes in circumstances that may affect eligibility such as a change in income, household composition, or categorical eligibility (e.g., reaching an age milestone or loss of Supplemental Security Income (SSI) for individuals eligible for Medicaid based on receipt of SSI). For example, eligibility continues through the duration of the extended postpartum coverage period for pregnant adolescents in CHIP turning 19 and pregnant individuals enrolled in the Medicaid mandatory group for children under age 19 described at 42 C.F.R. § 435.118 at the time that they would ordinarily age out of eligibility under that group.

We have determined that, despite the broad coverage protection afforded under the statutory language, states are expected to apply the same narrow exceptions applied to continuous eligibility for children under 42 C.F.R. § 435.926(d)(2) through (d)(5) to the continuous 12- month postpartum coverage provided under section 1902(e)(16) of the Act. Thus, states providing extended postpartum coverage must ensure that pregnant and postpartum individuals eligible under the extended postpartum coverage option, who would otherwise lose eligibility due to a change in circumstances, remain enrolled in Medicaid or CHIP until the end of the 12- month postpartum period, unless:

• the individual requests voluntary termination; • the individual ceases to be a state resident; • the agency determines that eligibility was determined incorrectly at the most recent determination or redetermination of eligibility because of agency error or fraud, abuse, or perjury attributed to the individual; or • the individual dies.

10 American Rescue Plan Act of 2021, Pub. L. 117-2, §§ 9812 and 9822 The contents of this document do not have the force and effect of law and are not meant to bind the public in any way, unless specifically incorporated into a contract. This document is intended only to provide clarity to the public regarding existing requirements under the law.

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CHIP regulations at 42 C.F.R § 457.342 allow for two exceptions to continuous eligibility in addition to those in 42 C.F.R. § 435.926(d): (1) non-payment of premiums, and (2) becoming eligible for Medicaid. However, section 2107(e)(1)(J) of the Act, which applies 1902(e)(5) and (16) of the Act to CHIP, explicitly requires that individuals who were eligible while pregnant remain eligible under the state plan through the end of the 12th month after the end of the pregnancy regardless of any changes. Therefore, the additional exceptions to continuous eligibility at 42 C.F.R § 457.342 do not apply during the pregnancy and extended postpartum period under the option provided under section 2107(e)(1)(J) of the Act.11

Renewals for Individuals Eligible for Extended Postpartum Coverage

For individuals first enrolled at the end of their pregnancy, the regular renewal required under 42 C.F.R. § 435.916 may coincide with the end of the extended 12-month postpartum period. For most, however, the 12-month postpartum period will end after their regularly-scheduled renewal date. The availability of continuous coverage for 12 months post-pregnancy under the extended postpartum coverage option renders any regular renewal scheduled before the end of the 12- month postpartum period unnecessary. Rather, the Medicaid and CHIP agency must conduct the renewal at the end of the individual’s extended 12-month postpartum period in accordance with renewal regulations at 42 C.F.R. §§ 435.916 and 457.343.12 Because agencies do not need to complete renewals or redeterminations based on changes in circumstances until the end of the extended postpartum period, beneficiaries remain enrolled in the eligibility group in which the beneficiary was enrolled during pregnancy through the end of the 12-month postpartum period.

We recognize that, absent a state’s election to provide 12 months of continuous postpartum coverage, some individuals enrolled in the group for pregnant individuals would be redetermined as eligible for the adult group at the end of the 60-day postpartum period and meet the definition of “newly eligible” in 42 C.F.R. § 433.204(a)(1) for purposes of claiming the increased federal medical assistance percentage (FMAP) described in section 1905(y) of the Act. The availability of increased FMAP for such individuals is discussed below.

Benefits

States electing the extended postpartum coverage option must provide full benefits to all pregnant and postpartum individuals, as described at sections 1902(e)(16)(B) and 2107(e)(1)(J) of the Act. There may be some beneficiaries who become pregnant after enrolling in the adult group described in section 1902(a)(10)(A)(i)(VIII) of the Act and 42 C.F.R. § 435.119. Coverage provided under an Alternative Benefit Plan (ABP) under section 1937 of the Act is considered full benefits for purposes of the extended postpartum option. States must inform beneficiaries of any differences in coverage between the ABP and the benefits available to

11 While eligibility for Medicaid is not an exception to continuous eligibility during pregnancy and the extended postpartum period under ARP, it may be beneficial for a pregnant or postpartum individual to request voluntary termination of CHIP eligibility to enroll in Medicaid. As such, beneficiaries who become Medicaid eligible need to be informed about the differences between the programs, including cost sharing, benefits, provider networks, and their eligibility for extended postpartum coverage, so they can make an informed decision. 12 See CMCS Informational Bulletin “Medicaid and Children’s Health Insurance Program (CHIP) Renewal Requirements,” (December 2020) for more information on making accurate redeterminations of eligibility. Available at https://www.medicaid.gov/federal-policy-guidance/downloads/cib120420.pdf

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individuals eligible as pregnant women (including any differences in benefits, premiums, and cost sharing).

While most states provide full coverage to all pregnant Medicaid beneficiaries, some states limit the coverage available to beneficiaries who are enrolled in the group for pregnant individuals described at 42 C.F.R. § 435.116 and have income above a threshold specified by the state.13 States that have elected to provide only services related to pregnancy or a condition that may complicate pregnancy and to COVID-19 vaccines (and their administration) must submit a SPA to remove this coverage limitation while the extended postpartum coverage option is in effect.

Under CHIP, the state must continue to provide the same scope of child health assistance as defined in section 2110(a) of the Act and pregnancy-related assistance as defined in section 2112(d) of the Act during the extended postpartum period. At a minimum, states must continue to provide comprehensive benefits consistent with the benefit coverage option elected in the CHIP state plan, as described in section 2103(a) of the Act, such as benchmark or Secretary- approved coverage; however, states may elect to provide a more generous coverage option during the extended postpartum period.

State Plan Amendment Submission

States that elect the extended postpartum coverage option in Medicaid must also elect the option for a separate CHIP, unless the state only provides coverage to unborn children in its separate CHIP. In order to elect the option, states must submit a Medicaid SPA through MACPro to extend postpartum coverage under Medicaid and, as appropriate, submit a CHIP SPA in the Medicaid Model Data Lab (MMDL) to extend postpartum coverage for pregnant individuals covered in a separate CHIP. Subject to the requirements at 42 C.F.R. § 430.12, et seq. and 42 C.F.R. § 457.60, states may submit SPAs with proposed effective dates no earlier than April 1, 2022. States are strongly encouraged, but not required, to maintain their SPA through March 31, 2027, when the current statutory authority for the extended postpartum coverage option expires. CMS will work with states to identify other options to maintain extended postpartum coverage if the statutory authority to extend coverage is not reauthorized. States may contact their Medicaid state lead for technical assistance to complete the Medicaid SPA and their CHIP project officer for technical assistance to complete the CHIP SPA. Federal Financial Participation for “Newly Eligible” Individuals Receiving Extended Postpartum Coverage

Currently, many Medicaid beneficiaries (such as, but not limited to, those covered under the eligibility group for pregnant individuals described at 42 C.F.R. § 435.116) become eligible for, and transition to, the adult group described at 42 C.F.R. § 435.119, at the end of the 60-day postpartum period. Some of the individuals who transition to the adult group after their 60-day postpartum period are “newly eligible,” as defined in 42 C.F.R. § 433.204(a)(1), for purposes of the increased FMAP described in section 1905(y) of the Act (“newly eligible FMAP”).

13 Clause VII in the matter following section 1902(a)(10)(G) of the Act. Services related to pregnancy include prenatal, delivery, postpartum, and family planning services. Because the health of a pregnant individual is so intertwined with the health of the expected child, most states consider all services required for categorically needy Medicaid beneficiaries to be pregnancy-related services. The contents of this document do not have the force and effect of law and are not meant to bind the public in any way, unless specifically incorporated into a contract. This document is intended only to provide clarity to the public regarding existing requirements under the law.

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States have shared concerns that electing the extended postpartum coverage option could result in the application of a lower FMAP than the state could claim for individuals who would otherwise be determined newly eligible in the adult group, if not for the state’s adoption of the extended postpartum coverage option. States have expressed concern that, to make the extension of postpartum coverage financially possible for the state, the state would need to conduct a redetermination before the end of the 60-day postpartum period only to obtain information sufficient to determine whether the individual beneficiary qualifies as newly eligible so that the state may continue claiming the increased FMAP under section 1905(y) of the Act with respect to the individual. However, this redetermination would be unnecessary for purposes of establishing the individual’s eligibility for benefits and would be administratively burdensome for the individual and the state; its only purpose would be to support the state’s claiming of service expenditures at the applicable FMAP.

To support states interested in adopting the extended postpartum coverage option under the ARP without requiring that they conduct a redetermination that would be unnecessarily burdensome for beneficiaries and the state, states may use a proxy methodology to account for the proportion of individuals covered under the extended postpartum coverage option who would otherwise be eligible for coverage in the adult group and for the newly eligible FMAP under section 1905(y) of the Act. Under current law, states can claim the newly eligible FMAP for individuals if (1) the individual is eligible for the adult group under 42 C.F.R. § 435.119; (2) the individual is newly eligible, as defined in 42 C.F.R. § 433.204(a)(1); and (3) the individual is receiving benefits that meet the Alternative Benefit Plan requirements in section 1937 of the Act. States may claim the newly eligible FMAP for individuals receiving extended postpartum coverage if the state implements a CMS-approved proxy methodology to ascertain the proportion of medical assistance expenditures for beneficiaries receiving extended postpartum coverage that are for individuals who would be eligible for the adult group and qualify as newly eligible, if the state completed a redetermination. This option is available provided beneficiaries receiving extended postpartum coverage receive benefits satisfying the Alternative Benefit Plan requirements under section 1937 of the Act.

Similar to the resource proxy methodology set forth in 42 C.F.R. § 433.206(d), the extended postpartum coverage proxy methodology must identify the basis that would make an individual eligible for the adult group as newly eligible and must comprehensively describe the criteria used to determine the adjustment to the total medical assistance expenditures for individuals receiving extended postpartum coverage to identify the portion that may be claimed at the newly eligible FMAP under section 1905(y) of the Act. For example, if parents between 100 percent of the federal poverty level (FPL) and 133 percent of the FPL are newly eligible in a state, the state would need a reasonable, statistically valid method to identify the percentage of individuals receiving 12-month postpartum coverage who are between 100 and 133 percent FPL whom the state would otherwise transition to the adult group and claim newly eligible FMAP; and then apply that percentage to the total expenditures for individuals receiving 12-month postpartum coverage to claim at the newly eligible FMAP. The methodology must be auditable and based on statistically valid data. The proxy methodology would not apply to individuals who are enrolled in the adult group when they become pregnant and remain in that group through pregnancy and the postpartum period.

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States that adopt the extended postpartum coverage option and intend to claim the newly eligible FMAP using a proxy methodology must submit an FMAP SPA amendment that meets the requirements of 42 C.F.R. § 433.206(h), as relevant to the proxy methodology. CMS is available to provide technical assistance to states interested in developing a proxy methodology to claim the newly eligible FMAP for certain individuals during the extended postpartum coverage period. Opportunities to Improve Maternal Health

In order to realize the potential of extended postpartum coverage to improve postpartum care and advance equity in health outcomes for beneficiaries, CMS encourages states to make a concerted effort to increase awareness of the extended postpartum coverage to both providers and beneficiaries. To maximize the impact of adopting the extended postpartum coverage option, it also will be critical for states to measure and monitor utilization and quality of care in the postpartum period, and to work with health plans, providers and other stakeholders to improve maternal health care. Drawing on the experiences of states in several learning collaboratives (discussed below), CMS has developed a number of tools and strategies that states can employ and can provide technical assistance to states to support these quality measurement and improvement activities.

Care during the postpartum period involves not just a single visit but a series of encounters and a range of services tailored to the needs of the beneficiary. The American College of Obstetricians and Gynecologists (ACOG) recommends that all postpartum individuals have contact with their health care providers within the first three weeks after delivery followed by individualized ongoing care as needed.14 Coverage during an extended postpartum period gives providers opportunities to assess beneficiaries’ physical recovery from pregnancy and childbirth, and, critically, to screen for and provide care to address conditions that can lead to morbidity and mortality in the later postpartum period. High quality, comprehensive postpartum care should address chronic health conditions (e.g., diabetes or hypertension), mental health and psychological well-being (e.g., postpartum depression, interpersonal violence), and family planning (e.g., contraceptive counseling). Postpartum visits are also a time for providers to counsel individuals on nutrition, breastfeeding, tobacco and other drug use, and other preventive health issues that affect both the postpartum individual’s longer-term health and that of their infant, and to help individuals retain coverage under Medicaid or CHIP or successfully transition to other coverage at the end of the postpartum period, including enrollment in a qualified health plan available through the Health Insurance Marketplace.

States may also consider building on person-centered models of perinatal care to support individuals in the prenatal, delivery, and postpartum periods, such as doula services and home visiting. Doula support, which can be delivered in a home setting, is associated with improved health outcomes including decreased likelihood of postpartum depression and near-universal breastfeeding among low-income individuals.15 Coverage of doula services may be effectuated

14 Optimizing postpartum care. ACOG Committee Opinion No. 736. American College of Obstetricians and Gynecologists. Obset Gynecol 2018; 131:e 140-50. https://www.acog.org/clinical/clinical-guidance/committee- opinion/articles/2018/05/optimizing-postpartum-care 15 https://www.medicaid.gov/medicaid/quality-of-care/downloads/mih-expert-workgroup-recommendations.pdf

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through multiple benefit categories, including, but not limited to, preventive services, services of licensed practitioners, clinic services, and freestanding birth center services. Similarly, while there is no distinct Medicaid state plan benefit called home visiting, states may cover many of the individual component services of home visiting programs through existing Medicaid coverage authorities.16 States can utilize value-based payment arrangements to incentivize the use of innovative maternal health care delivery models and improve health outcomes. CMS is available for technical assistance to states interested in adding these coverage options to their programs.

Maternity Core Set

To support states in their maternal, perinatal, and infant health-focused quality improvement efforts, CMS identified a core set of 11 measures for voluntary reporting17 by state Medicaid and CHIP agencies. This Maternity Core Set, which consists of seven measures from CMS’s Child Core Set and four measures from the Adult Core Set, is used by CMS to measure and evaluate progress toward improvement of maternal and infant health in Medicaid and CHIP. The areas of maternal health addressed in this set include: timeliness of prenatal care, postpartum care visits, contraceptive care, elective delivery, and low-risk cesarean section births. Two of these measures, Live Births Weighing Less than 2,500 Grams and Postpartum Care, are included in the State Health System Performance pillar of the Medicaid and CHIP Scorecard.18 Additionally, several measures on the Adult Core Set measure follow-up care for conditions that are associated with maternal morbidity and mortality (e.g., controlling high blood pressure and screening for depression and follow-up plan) and to assess ongoing well-woman care (e.g. cervical and breast cancer screening).19

CMS strongly encourages states to stratify these quality measures and other metrics of interest to states by race, ethnicity, geography, language and other indicators in order to identify disparities in access to care and health outcomes and to develop targeted initiatives to improve maternal health equity.

Maternal and Infant Health Initiative

To improve access to and quality of care for pregnant and postpartum beneficiaries and their infants, CMS launched the Maternal and Infant Health Initiative (MIHI) in July 2014.20 Today, the MIHI is focused on driving improvement in three areas, each of which is associated with one or more Maternity Core Set measures:

1) Increase the use and quality of postpartum care visits; 2) Increase the use and quality of well-child visits; and

16 https://www.medicaid.gov/federal-policy-guidance/downloads/cib-03-02-16.pdf 17 Pursuant to Section 50102(b) of the Bipartisan Budget Act, reporting on the seven measures that are part of the Child Core Set will become mandatory for states beginning in 2024. Additionally, the behavioral health measures on the Adult Core Set will also become mandatory in 2024, pursuant to Section 5001 of the SUPPORT Act. 18 https://www medicaid.gov/state-overviews/scorecard/state-health-system-performance/index html 19 https://www medicaid.gov/medicaid/quality-of-care/downloads/2021-maternity-core-set.pdf 20 https://www medicaid.gov/medicaid/quality-of-care/improvement-initiatives/maternal-infant-health-care-quality/index html The contents of this document do not have the force and effect of law and are not meant to bind the public in any way, unless specifically incorporated into a contract. This document is intended only to provide clarity to the public regarding existing requirements under the law.

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3) Decrease the rates of cesarean section births in low-risk pregnancies, defined as nulliparous (first-time pregnancies), term (37 or more weeks gestation), singleton (one fetus), vertex (head facing down in the birth canal) or “NTSV births.”

These three areas of focus were selected based on input from a stakeholder workgroup, which was charged with identifying areas where Medicaid and CHIP programs had the greatest capacity to influence improvement and where CMS and states could, collectively, have the greatest impact on maternal and infant health care and outcomes.

To support state Medicaid agencies and their partners in driving improvement in these areas, CMS designs and runs learning collaboratives, which combine webinars for all states featuring best practices and effective models of care with affinity groups that provide intensive quality improvement technical assistance to state teams committed to action in these areas. Two learning collaboratives began in 2021: Postpartum Care and Infant Well-Child Visits. The third learning collaborative, focused on low-risk cesarean section births, is scheduled to begin in 2022. CMS will continue to assess the quality measurement and improvement technical assistance needs of states and will develop future opportunities and resources to address the identified needs and to facilitate shared learning across states.

CMS publishes quality measures and other data and resource materials on Medicaid.gov for states to use in their quality improvement efforts. Currently available data and resources related to improving the quality of postpartum care are included in the Appendix of this letter. CMS anticipates adding additional resources as we learn more about states’ technical assistance needs and their successes and lessons learned from postpartum care quality improvement activities. Section 1115 Demonstrations

CMS has approved several state section 1115(a) demonstrations to implement initiatives in Medicaid and CHIP aimed at immediate extension of postpartum coverage. States that extended postpartum coverage through an approved section 1115 demonstration may choose to transition the authority for their extended postpartum coverage to the new SPA option. These states, as well as states with a pending 1115 demonstration application to extend postpartum coverage, should contact their demonstration project officer to discuss their options.

In addition, CMS has previously approved section 1115 demonstration projects providing coverage of family planning and related preventive health services, authorizing evidence-based home visiting services, and incentivizing providers to demonstrate specific quality improvements and beneficiary health outcomes for maternal health. CMS supports states in submitting section 1115 proposals to test approaches that address challenges associated with maternal mortality and morbidity and stands ready to work with states on such proposals. Closing

CMS appreciates the partnership with states to ensure Medicaid and CHIP drive improvements in health outcomes and promote health equity, and CMS remains committed to collaborating with states to improve access to coverage and maternal health outcomes. CMS is available to provide technical assistance to states as they extend postpartum coverage, implement innovative The contents of this document do not have the force and effect of law and are not meant to bind the public in any way, unless specifically incorporated into a contract. This document is intended only to provide clarity to the public regarding existing requirements under the law.

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Page 12 – State Health Official payment and delivery system efforts, and engage in initiatives to measure and improve quality aimed at addressing the needs of pregnant and postpartum beneficiaries. Please submit requests for technical assistance to your CMS Medicaid state lead or CHIP Project Officer. Sincerely, Daniel Tsai Deputy Administrator and Director Cc: National Association of Medicaid Directors National Academy for State Health Policy National Governors Association American Public Human Services Association Association of State and Territorial Health Officials Council of State Governments National Conference of State Legislatures Academy Health National Association of State Alcohol and Drug Abuse Directors The contents of this document do not have the force and effect of law and are not meant to bind the public in any way, unless specifically incorporated into a contract. This document is intended only to provide clarity to the public regarding existing requirements under the law.

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Appendix

Resources for Improving the Quality of Postpartum Care

The following resources to support states in improving the quality and effectiveness of postpartum coverage are available on Medicaid.gov.

- The Medicaid and CHIP Beneficiary Profile: Maternal and Infant Health provides an overview of the demographics, health status, health outcomes, risk factors, and health care utilization among reproductive age individuals, individuals with a recent live birth, and infants covered by Medicaid and CHIP.

- Quality of Maternal and Perinatal Health Care in Medicaid and CHIP: Findings from the 2019 Maternity Core Set. CMS annually releases information on state progress in reporting the Maternity Core Set measures and assesses state-specific performance for measures that are reported by at least 25 states and that met CMS standards for data quality. This resource provides information about performance on frequently-reported health care quality measures in the Maternity Core Set.

- Postpartum Care Learning Collaborative webinar recordings and slides. CMS launched the Improving Postpartum Care Learning Collaborative in January 2021. The webinar series includes presentations from experts in the field and by state Medicaid and CHIP programs on strategies for states to improve the use of postpartum care for individuals at high risk of postpartum complications, improve the continuity of coverage for postpartum individuals, and implement payment reform to incentivize changes in maternal health care practice.

- Issue Brief: Lessons Learned About Payment Strategies to Improve Postpartum Care in Medicaid and CHIP. This issue brief summarizes some of the lessons learned by states that participated in CMS’ Postpartum Care Action Learning Series. The resource includes lessons for fee-for-service delivery systems as well as alternative payment models and population-based payment.

- Issue Brief: Improving Postpartum Care: State Projects Conducted through the Postpartum Care Action Learning Series and Adult Medicaid Quality Grant Program. This issue brief presents profiles of state quality improvement projects focused on improving postpartum care and includes driver diagrams summarizing system components and activities that are associated with increasing the rate and quality of postpartum care visits.

- Resources on Strategies to Improve Postpartum Care Among Medicaid and CHIP Populations. This document compiles strategies that have been shown to be effective to improve the postpartum care visit rate and the content of care.

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The following questions and answers apply to implementation of the 12-month extended postpartum coverage option under sections 1902(e)(16) and 2107(e)(1)(J) of the Act as outlined in State Health Official (SHO) letter #21-007, “Improving Maternal Health and Extending Postpartum Coverage in Medicaid and the Children’s Health Insurance Program (CHIP).” General Requirements

Q1. Are states required to provide 12 months postpartum coverage for Medicaid and CHIP beneficiaries?

A1. No. States are not required to extend postpartum coverage in Medicaid and CHIP, but extending postpartum coverage offers opportunities to provide care that can reduce pregnancy- related death and severe maternal morbidity and improve continuity of care for chronic conditions including behavioral health conditions. States that have already expanded Medicaid eligibility to the adult group under 42 C.F.R. § 435.119, which has allowed more individuals to remain enrolled beyond the end of the month in which their 60th day postpartum occurs, report an increase in postpartum care visits, continuity in coverage, and enhanced engagement of individuals in health care.1

Q2. Are states able to extend postpartum coverage only under Medicaid or a separate CHIP?

A2. No. States that elect to extend postpartum coverage in Medicaid must also take up the option to extend postpartum coverage in their separate CHIP if they provide coverage to targeted low-income children (defined in section 2110(b) of the Act) who are pregnant and targeted low- income pregnant individuals (defined in section 2112 of the Act) in a separate CHIP. States may not adopt the option in a separate CHIP if the state does not elect to extend postpartum coverage in Medicaid.

Q3. Who is eligible for extended postpartum coverage on the effective date selected by the state?

A3. States that adopt the extended postpartum coverage option must provide 12 months of extended postpartum coverage to individuals who apply for coverage or become pregnant while enrolled in Medicaid or CHIP on or after the effective date of the state plan amendment (SPA). This includes individuals who apply for Medicaid after their pregnancy ends, but who were pregnant and received Medicaid-covered services in the state while pregnant on or after the effective date of the SPA if such services were received during a period of retroactive eligibility granted under section 1902(a)(34) of the Act and 42 C.F.R. § 435.915(a). In addition, states adopting this option must provide extended postpartum coverage to beneficiaries who are

1 Gordon, S.H., B.D. Sommers, I. Wilson, O. Galarraga, and A.N. Trivedi. “The Impact of Medicaid Expansion on Continuous Enrollment: A Two-State Analysis.” Journal of General Internal Medicine, vol. 34, no. 9, 2019, pp. 1919–1924.

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For example, a state elects to extend postpartum coverage beginning April 1, 2022. Julie is enrolled in Medicaid on April 1, 2022, and had given birth while enrolled on November 15, 2021. The state must provide Julie with continuous extended postpartum coverage through the end of the month in which her 12-month postpartum period ends (November 30, 2022).

Q4. Do states have the option to provide extended postpartum coverage under the state plan for a period of less than 12 months?

A4. No. The state plan option provides 12 months of postpartum coverage. States extending postpartum coverage under the state plan option do not have the flexibility to establish a different postpartum period.

Q5. Can a state implement the 12-month extended postpartum coverage SPA option before April 1, 2022?

A5. No. States may only elect the 12-month extended postpartum coverage SPA option with an effective date on or after April 1, 2022.

However, states that wish to implement extended postpartum coverage before April 2022 may work with CMS to propose a section 1115 demonstration project for Medicaid and/or CHIP. Eligibility for Extended Postpartum Coverage

Q6. Does the American Rescue Plan (ARP) establish a new optional eligibility group in order for states to provide 12 months postpartum coverage in Medicaid?

A6. No, the ARP does not establish a new eligibility group. Individuals who receive the 12- month postpartum extension remain in the eligibility group in which they were enrolled when pregnant for the duration of the postpartum period. For additional information on Federal Medical Assistance Percentage (FMAP) and coverage in the adult group, see questions Q21-22, below.

Q7. Is an individual entitled to extended postpartum coverage if they enroll in Medicaid or CHIP during the postpartum period?

A7. No. To be eligible for extended postpartum coverage, the individual must have been eligible for and enrolled in Medicaid or CHIP while pregnant (including during a period of retroactive eligibility in Medicaid). Individuals who apply for and are enrolled in Medicaid or CHIP after a pregnancy ends are not entitled to continuous eligibility for the remainder of their 12-month postpartum period because they were not enrolled under the Medicaid or CHIP state plan while pregnant. For additional information on eligibility for extended postpartum coverage granted during a period of retroactive eligibility, see question Q10, below.

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Q8. Is an individual entitled to an additional 12-month postpartum period in Medicaid or CHIP if they become pregnant during the extended postpartum period?

A8. Yes. An individual who becomes pregnant during an initial extended postpartum period and therefore is enrolled in Medicaid or CHIP during such pregnancy would be entitled to an extended 12-month postpartum period following the end of the subsequent pregnancy. The individual in this case would receive continuous coverage through the end of 12th month after the subsequent pregnancy ends consistent with section 1902(e)(16) or 2107(e)(1)(J) of the Act.

For example, Emily is enrolled in Medicaid while pregnant. Her pregnancy ends in May 2022, and an extended 12-month postpartum coverage period begins. Seven months later, Emily becomes pregnant again in December 2022, while she is still eligible for and enrolled in coverage. Emily’s subsequent pregnancy ends in September 2023. At that point, a new 12- month extended postpartum period will begin, and Emily will remain continuously eligible through the end of the subsequent extended postpartum period (through September 2024). In September 2024, the state will need to conduct a redetermination of eligibility and determine whether Emily remains eligible for Medicaid under the same or another eligibility group.

Q9: Do individuals who qualify as medically needy with a spenddown while pregnant have to continue to meet their spenddown each budget period to be eligible for the coverage available under the 12-month postpartum option?

A9: No. An individual who attained Medicaid eligibility through a spenddown while pregnant is eligible for the extended postpartum coverage even if the individual does not have sufficient incurred medical or remedial care expenses to meet their spenddown in any subsequent budget period during the pregnancy or extended postpartum period. For example, if a pregnant individual applies for Medicaid in January in a state that has adopted the 12-month postpartum option and covers medically needy individuals, and the individual establishes eligibility by meeting their spenddown in February, the state must maintain the individual’s Medicaid coverage through the remainder of the individual’s pregnancy and the end of the month in which the 12-month postpartum period ends. The individual will not have to meet a spenddown again until the end of continuous 12-month postpartum period.

Q10. Are individuals eligible for extended postpartum coverage if they enroll in Medicaid during their postpartum period but were pregnant during a period of retroactive eligibility?

A10. Yes, individuals who received Medicaid services and met Medicaid eligibility requirements while pregnant during a period of retroactive eligibility must be provided extended postpartum coverage.

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Q11. Do pregnant individuals who receive Medicaid or CHIP coverage under the “CHIPRA 214 option” qualify for extended postpartum coverage?

A11. Yes. A state that has elected to cover lawfully residing pregnant individuals in Medicaid and CHIP under the option provided for at sections 1903(v)(4)(A)(i) and 2107(e)(1)(O), and has also elected the extended postpartum coverage option, must provide 12 months of extended postpartum coverage to such individuals under the option described at 1902(e)(16) and/or 2107(e)(1)(J) of the Act. Sections 1903(v)(4)(A) and 2107(e)(1)(O) of the Social Security Act provide states the option to provide full Medicaid and/or CHIP coverage to lawfully residing children and pregnant individuals, if they otherwise meet eligibility requirements under the state’s program (e.g., income and state residency requirements). This option is commonly referred to as “the CHIPRA 214 option.”

Section 1902(e)(16) of the Act, added by section 9812 of the ARP, and section 2107(e)(1)(J) of the Act, added by section 9822 of the ARP, provide states with an option to provide coverage during an extended 12-month postpartum period for individuals who, while pregnant, were eligible for and received Medicaid or CHIP under the state plan, or a waiver of such plan. If this option is elected, states cannot offer extended postpartum coverage to only some individuals enrolled in Medicaid or CHIP while pregnant, but must provide extended postpartum coverage to all such individuals. Thus, in a state which has elected both the CHIPRA 214 option for pregnant individuals in Medicaid and CHIP and also elects the option to provide 12 months of extended postpartum coverage under sections 1902(e)(16) and 2107(e)(1)(J) of the Act, lawfully residing adolescents who become pregnant while enrolled in Medicaid or CHIP and pregnant individuals covered under the Medicaid or CHIP state plan (or waiver of the state plan) during pregnancy would be eligible for the extended 12-month postpartum coverage.2 Continuous Eligibility for Individuals During Pregnancy and the Postpartum Period

Q12. Does the ARP require states that elect the option to provide 12 months postpartum coverage to provide continuous eligibility to individuals in Medicaid and CHIP during the pregnancy and extended postpartum period?

A12. Yes. Individuals who are eligible for extended postpartum coverage in Medicaid and CHIP are entitled to continuous eligibility throughout the pregnancy and postpartum period until the last day of the month in which the 12-month postpartum period ends. Pregnant and postpartum individuals in states that elect the ARP option remain eligible regardless of changes

2 A list of which states have elected to cover lawfully residing children and pregnant women in Medicaid and CHIP, is available at https://www.medicaid.gov/medicaid/enrollment-strategies/medicaid-and-chip-coverage-lawfully-residing-children-pregnant- women

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The contents of this document do not have the force and effect of law and are not meant to bind the public in any way, unless specifically incorporated into a contract. This document is intended only to provide clarity to the public regarding existing requirements under the law. in circumstances that may affect eligibility such as a change in household composition, a change in categorical eligibility (e.g., reaching an age milestone, eligibility conferred through receipt of other program benefits). States must ensure that individuals eligible for extended postpartum coverage, who would otherwise lose eligibility due to a change in circumstances, remain enrolled in Medicaid or CHIP until the end of the 12-month postpartum period, unless: (1) the individual requests voluntary termination, (2) the individual ceases to be a state resident, (3) the agency determines that eligibility was determined incorrectly at the most recent determination or redetermination of eligibility because of agency error or fraud, abuse, or perjury attributed to the individual, or (4) the individual dies.

Q13. Does the ARP require states to provide continuous eligibility to pregnant individuals in Medicaid regardless of changes in circumstances, even if the state does not extend postpartum coverage?

A13. In states that do not extend postpartum coverage, pregnant individuals enrolled in Medicaid are entitled to continuous eligibility through the last day of the month in which a 60- day period, beginning on the last day of pregnancy, ends, regardless of changes in income that would otherwise result in a loss of eligibility, as required at 42 C.F.R. § 435.170. States that provide postpartum coverage consistent with 42 C.F.R. § 435.170 must act on changes in circumstances that may affect eligibility, other than changes in income, while the individual is pregnant or in their 60-day postpartum period. In states that do not provide extended postpartum coverage, we believe changes in circumstances that may affect eligibility for pregnant and postpartum individuals are rare, and may include, for example, a change affecting categorical eligibility or a change in immigration status.

Q14. Does the ARP require states to provide continuous eligibility to pregnant individuals enrolled in a separate CHIP if the state does not adopt the option to provide 12 months of extended postpartum coverage?

A14. No. Section 2107(e)(1)(J) of the Act provides that section 1902(e)(5), which requires continuous eligibility for pregnant individuals in Medicaid, applies to separate CHIPs only if the state has adopted the extended postpartum option in section 1902(e)(16). There is not a continuous eligibility requirement for pregnant individuals enrolled in CHIP unless the state adopts the option in sections 1902(e)(16) and 2107(e)(1)(J) of the Act.

Q15. Are states required to transition individuals enrolled in CHIP who become eligible for Medicaid during the continuous extended postpartum period?

A15. No. Section 2107(e)(1)(J) applies paragraphs 5 and 16 of section 1902(e) of the Act equally to CHIP, which requires that if an individual was eligible for CHIP and receiving services while pregnant, they are entitled to continuous eligibility throughout their pregnancy and postpartum period. Therefore, states must keep individuals enrolled in CHIP for the duration of their pregnancy and extended postpartum period, even if they become eligible for Medicaid, unless one of the allowable exceptions to the continuous eligibility period (as discussed in Q12) is applicable. However, we note that if an individual voluntarily elects to end their CHIP enrollment during their extended postpartum period, the individual would not be entitled to continuous eligibility for the remainder of their 12-month postpartum period in Medicaid. In

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Page 19 – FAQs

Q16. In a separate CHIP, may states disenroll individuals for non-payment of premiums during their pregnancy or extended postpartum period?

A16. No. Section 2107(e)(1)(J) of the Act applies the requirements of section 1902(e)(16) of the Act to CHIP, which requires that an individual who was eligible under the state plan while pregnant remain eligible until the last day of the 12th month after the pregnancy ends, regardless of changes that may affect eligibility. Because the individual met all CHIP requirements during the pregnancy, they are entitled to continuous eligibility in CHIP for the entire duration of their pregnancy and extended postpartum period even if they do not pay premiums. Renewals for Individuals Receiving Extended Postpartum Coverage

Q17. When should states conduct renewals for pregnant and postpartum individuals?

A17. Pregnant individuals enrolled in Medicaid and CHIP in a state that elects to provide 12- months postpartum coverage are entitled to continued coverage through the end of the 12-month extended postpartum period regardless of changes in circumstances, except in the case of a change in state residency, voluntary termination, an erroneous determination of eligibility, or death. For almost all pregnant individuals, the end of the postpartum period will occur after the individual’s regular renewal date. States that adopt the 12-month extended postpartum option will not need to conduct a redetermination or renewal prior to the end of the extended postpartum period. The state will need to complete a full renewal, consistent with 42 C.F.R. § 435.916 and § 457.343, at the end of the extended postpartum period.

For example, Sydney applies for Medicaid in June 2022 and is enrolled in the eligibility group for pregnant individuals under 42 C.F.R. § 435.116 in a state that elects to provide 12-months postpartum coverage under section 1902(e)(16) of the Social Security Act. Sydney’s 12-month eligibility period for purposes of regular renewals, described at 42 C.F.R. § 435.916(a)(1), extends from June 1, 2022, to May 31, 2023. But because Sydney is eligible and enrolled in Medicaid while pregnant, she is entitled to continuous eligibility through the end of the month in which her 12-month postpartum period ends. Sydney’s pregnancy ends December 15, 2022. Her 12-month postpartum period ends December 31, 2023, which is after the end of her regular 12-month eligibility period (May 31, 2023). Because Sydney is eligible for continuous eligibility through the end of the extended 12-month postpartum period, the agency does not need to complete a renewal by May 31, 2023, and may not act on changes in circumstances until she reaches the end of her postpartum period (December 31, 2023).

Q18. Are states required to move pregnant and postpartum individuals between Medicaid eligibility groups during a period of continuous eligibility? What if the individual is enrolled in the adult group under 42 C.F.R. § 435.119 and becomes pregnant?

A18. No. A redetermination of eligibility is required to move individuals between eligibility groups, but because pregnant individuals are entitled to continuous eligibility, states electing to provide 12 months of extended postpartum coverage do not need to complete a renewal or act on

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Page 20 – FAQs

Q19. May states complete periodic renewals of eligibility based on available information during a period of continuous eligibility?

A19. Yes. A state may, but is not required to, conduct redeterminations and periodic renewals of eligibility based on available information without requesting information from the individual during a period of continuous eligibility, and if appropriate, move the individual to a new eligibility group as long as the transition to the new group would not result in a loss of or reduction in coverage (e.g., reduction in benefits, increase in premiums or cost sharing). However, states may not send a renewal form or request additional information from the individual in order to complete a renewal or redetermination based on a change in circumstances, unless the state has information indicating the individual is no longer a state resident or is deceased. A state may also not request additional information or terminate coverage for an individual whose eligibility is renewed based on available information during a period of continuous eligibility if the individual responds to the renewal notice to inform the state that the information used to determine eligibility is not correct.

Q20. May a state redetermine eligibility at the end of the 60-day postpartum period described at 1902(e)(5) of the Social Security Act for individuals eligible for extended postpartum coverage who are enrolled in a group for which pregnancy status is a factor of eligibility?

A20. A state may, but is not required to, redetermine eligibility based on available information for individuals enrolled in an eligibility group where pregnancy status is a factor of eligibility who are eligible for extended postpartum coverage at the end of the month in which the 60th postpartum day occurs. Individuals determined eligible at application for the group for pregnant individuals described at 42 C.F.R. § 435.116 must be provided a 12-month eligibility period in accordance with requirements for renewals for MAGI-based individuals at 42 C.F.R. § 435.916(a)(1). For individuals enrolled in the group for pregnant individuals or a group where pregnancy status is a factor of eligibility, the end of the 60-day postpartum period represents a change in circumstances that impacts their eligibility for the group. At the end of the 60-day postpartum period, states typically must act on the end of the 60-day postpartum period as a change in circumstances, consistent with 42 C.F.R. § 435.916(d)(1), and transition the individual to another group for which the state is able to determine the individual is eligible. In states that have adopted the extended postpartum coverage under section 1902(e)(16) of the Act, the state must provide continuous coverage for 12 months postpartum under the group for pregnant individuals if the state is unable, at the end of the 60-day postpartum period, to determine that the beneficiary is eligible for another group conferring full Medicaid benefits without requesting any information from the beneficiary.

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Page 21 – FAQs

Because Jane is eligible for extended postpartum coverage, the state does not need to redetermine eligibility at the end of Jane’s 60-day postpartum period or complete a renewal of eligibility until the end of her 12-month postpartum period (August 31, 2023), and she may remain enrolled in the group for pregnant individuals through the remainder of her extended postpartum period. However, if the state does not have any information indicating Jane’s income has changed since application when she reaches the end of the 60-day postpartum period (October 31, 2022), it is permissible for the state to shift Jane’s coverage to the eligibility group for parents and caretaker relatives effective November 1, 2022. The state will need to complete Jane’s next regular renewal at the end of her extended postpartum period. Federal Financial Participation

Q21. What FMAP applies to individuals enrolled in the adult group who become pregnant?

A21. States are not required to track the pregnancy status of beneficiaries enrolled in the adult group and are not required to move them to the eligibility group for pregnant individuals if the state becomes aware of their pregnancy. Beneficiaries who become pregnant must be given the option of moving to the pregnancy-related coverage category. States must inform beneficiaries of the differences in coverage between the adult group and pregnancy-related coverage (including any differences in benefits, premiums, and cost sharing), and if the state covers any additional benefits for pregnant individuals under 42 C.F.R. § 440.250(p) not provided to other individuals eligible under the state plan, such benefits also must be provided to pregnant individuals enrolled in the adult group in an alternative benefit package. If an individual enrolled in the adult group who becomes pregnant does not elect to switch groups and remains enrolled in the adult group, the individual’s status for FMAP purposes (as newly eligible or not) is unchanged until such time the individual is determined eligible for another group, which would in no case be sooner than the end of the 12-month postpartum period.

Q22. Is increased FMAP related to the adult group available to states for individuals covered in the extended postpartum coverage option who might otherwise qualify for the adult group?

A22. Yes. Increased FMAP is available for beneficiaries receiving coverage during an extended 12-month postpartum period who would meet the requirements for coverage in the adult group described in 42 C.F.R. § 435.119 and the definition of “newly eligible” in 42 C.F.R. §433.204(a)(1).

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Page 22 – FAQs

The contents of this document do not have the force and effect of law and are not meant to bind the public in any way, unless specifically incorporated into a contract. This document is intended only to provide clarity to the public regarding existing requirements under the law. For individuals who would otherwise transition to the adult group after the 60-day postpartum period, the state would typically determine whether they meet the requirements for coverage under the adult group and the newly eligible criteria under 42 C.F.R. § 433.204(a)(1) for the purpose of the increased FMAP. However, because a state adopting the option to provide 12 months of postpartum coverage does not need to conduct a redetermination of eligibility until the end of the extended postpartum period, the state might not conduct the determination under Subpart E of Part 433 for adult group FMAP. Instead, states seeking to claim the increased FMAP for newly eligible individuals enrolled in the adult group may adopt a proxy methodology to determine the percentage of beneficiaries who would have transitioned to alternative benefit package coverage as newly eligible beneficiaries in the adult group for whom newly eligible FMAP is available. Once the methodology is approved by CMS, the state would apply the relevant percentage to medical assistance expenditures for the entire extended postpartum population to claim the increased FMAP for the proportion of newly eligible individuals determined under the proxy methodology.

If a state chooses to conduct renewals based on available information as discussed in Q19 and Q20, this will have implications on whether and how a state develops a proxy methodology to claim newly eligible FMAP. CMS will provide additional technical assistance on the possibility of using a proxy methodology to states in this circumstance. SPAs and Capitation Rate Amendments

Q23. Are states required to submit separate state plan amendments (SPA) to provide extended postpartum coverage in Medicaid and its separate CHIP?

A23. Yes. States must submit a Medicaid SPA as well as a CHIP SPA in order to make the election in both programs. CMS will make a Medicaid SPA template available in MACPro and a CHIP SPA template available in MMDL.

Q24. Are states required to create new managed care capitation rates for a 12-month postpartum period?

A24. Capitation rates paid by states to Medicaid managed care plans must be actuarially sound in accordance with 42 C.F.R. § 438.4, including that the capitation rates are appropriate for the populations to be covered and the services to be furnished under the contract between the state and plan. Therefore, the state’s actuary must evaluate if programmatic changes to the managed care program, such as a change in eligibility and coverage, impact the development of actuarially sound capitation rates or require a rate amendment if the programmatic change occurs after the development of the capitation rates for the applicable rating period. The state and its actuary should ensure that the rate development standards and documentation expectations outlined in the Medicaid Managed Care Rate Development Guide are met within the rate certification.

(26-001)SHO #26-001, Implementation of Section 71109 Alien Medicaid Eligibility of Public Law 119-21 (April 8, 2026)#

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SHO #26-001 RE: Implementation of Section 71109 “Alien Medicaid Eligibility” of the Working Families Tax Cut Legislation (Public Law 119-21) April 8, 2026 Dear State Health Official: This letter is one of a series that provides guidance on the implementation of Public Law (P.L.) 119- 21, which the Centers for Medicare & Medicaid Services (CMS) refers to as the “Working Families Tax Cut” (WFTC) legislation. The purpose of this State Health Official (SHO) letter is to provide Medicaid and Children’s Health Insurance Program (CHIP) policy and operational guidance to states1 related to implementation of section 71109 of the WFTC legislation, “Alien Medicaid Eligibility.” Beginning October 1, 2026, sections 1903(v)(5) and 2107(e)(1)(R) of the Social Security Act (the Act), as added and amended, respectively, by section 71109 of the WFTC legislation, generally limit federal financial participation (FFP) for medical assistance (Medicaid) and child or pregnancy-related health assistance (CHIP), with limited exceptions, to U.S. citizens and U.S. nationals, lawful permanent residents (LPRs), Cuban/Haitian entrants, and Compact of Free Association (COFA) migrants. This letter discusses in more detail the limitations on FFP and potential impacts on eligibility and availability of coverage, the implications for current beneficiaries, and the changes states may need to make to their systems and processes prior to October 1, 2026, to comply with the statutory changes made by section 71109 of the WFTC legislation. States should make any such changes to state systems and operations to protect program integrity, make accurate eligibility determinations, and ensure proper claiming of FFP, in accordance with sections 1903(v)(5) and 2107(e)(1)(R) of the Act. 1 For the purposes of this letter, “states” refers to the 50 states, the District of Columbia, and the United States (U.S.) territories of American Samoa, Commonwealth of the Northern Mariana Islands (CNMI), Guam, Puerto Rico, and the U.S. Virgin Islands, unless otherwise specified. DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop S2-26-12 Baltimore, Maryland 21244-1850

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Page 2 – State Health Official Letter Contents Background .............................................................................................................................................3 Overview of Section 71109 of the WFTC Legislation ...........................................................................3 Implementation Date for Section 71109 of the WFTC Legislation ....................................................5 Interaction between Section 71109 of the WFTC Legislation and PRWORA ...................................5 Impact on Noncitizens Dually Eligible for Medicare and Medicaid ..................................................7 Implementation Requirements at Application and for Current Medicaid and CHIP Beneficiaries ........8 Considerations for Applicants and Current Beneficiaries who are Not FFP-Eligible Noncitizens ..10 Operational Considerations for States and Territories .......................................................................... 11 Updates to Applications, Renewal Forms, and Other Materials for Medicaid and CHIP ................12 Verification of Immigration Status or Category ................................................................................13 Considerations for Medicaid Managed Care Programs ....................................................................16 Medicaid and CHIP Information Technology (IT) Systems Costs and Upgrades ................................16 Financial Systems and Proper Claiming ...........................................................................................18 Transformed-Medicaid Statistical Information System (T-MSIS) ...................................................18 Federal Medical Assistance Percentage (FMAP) .................................................................................19 FMAP for Full Medicaid and CHIP Benefits (including under the CHIPRA 214 Option) ..............19 FMAP for Emergency Medicaid .......................................................................................................19 State Plan Amendment (SPA) Submission ............................................................................................20 Territory Considerations .......................................................................................................................21 Closing .................................................................................................................................................22 APPENDIX A - Details Regarding Qualified Noncitizen Coverage in Medicaid and CHIP Before and After Implementation of Section 71109 of the WFTC Legislation ................................................23 APPENDIX B - Summary of Hub Changes in Accordance with Section 71109 of the WFTC Legislation.............................................................................................................................................29

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Page 3 – State Health Official Letter Background Under the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (PRWORA) (P.L. 104-193), certain “qualified aliens,” defined under Medicaid and CHIP as “qualified noncitizens”2 (e.g., LPRs, refugees, and asylees), are eligible for federal public benefits, including full Medicaid and CHIP coverage,3 if they meet all other eligibility requirements in the state (e.g., residency, income). Other federal statutes require other categories of individuals – including certain victims of human trafficking4 and certain Afghan5 and Ukrainian6 parolees – to be treated as “refugees,” and therefore they are eligible for full Medicaid or CHIP coverage if they meet all other eligibility requirements in the state. In accordance with PRWORA, many qualified noncitizens are subject to a five-year waiting period before becoming eligible for full Medicaid or CHIP coverage, but some noncitizens (e.g., refugees and asylees) are exempted from the five-year waiting period.7 The Children’s Health Insurance Program Reauthorization Act of 2009 (CHIPRA) (P.L. 111-3) authorized an option for states to provide full Medicaid and CHIP coverage to children (up to age 21 for Medicaid and up to age 19 for CHIP) and pregnant women who are lawfully residing in the U.S., without having to meet the five-year waiting period, if otherwise applicable (often referred to as the “CHIPRA 214 option”).8 Overview of Section 71109 of the WFTC Legislation Beginning October 1, 2026, section 1903(v)(5) of the Act (added by section 71109 of the WFTC legislation and made applicable to CHIP through section 2107(e)(1)(R) of the Act), restricts, with limited exceptions, FFP for non-emergency medical assistance under title XIX (i.e., medical assistance that is not necessary for treatment of an emergency medical condition, as defined in section 1903(v)(3) of the Act), and for child and pregnancy-related health assistance under title XXI to the following groups, provided that the individual is a resident9 of one of the 50 states, the District

2 “Qualified noncitizen” is defined at 42 C.F.R. § 435.4 for Medicaid and cross-referenced at 42 C.F.R. § 457.320(c) for CHIP. “Qualified noncitizen” includes: (1) noncitizens who are considered “qualified aliens” under 8 U.S.C. § 1641(b) and (c); and (2) noncitizens who are treated as refugees under other federal statutes. 3 PRWORA was enacted in 1996, prior to the establishment of CHIP through the Balanced Budget Act of 1997 (P.L. 105- 33). The U.S. Department of Health and Human Services (HHS) identified CHIP as a “federal public benefit,” as defined at 8 U.S.C. § 1611(c), for the purposes of applying eligibility limitations at 8 U.S.C. § 1611 (HHS, Notice with comment period, “Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (PRWORA); Interpretation of ‘Federal Public Benefit’ (63 Fed. Reg. 41658), Aug. 4, 1998, available at: https://www.govinfo.gov/content/pkg/FR-1998- 08-04/pdf/98-20491.pdf). The five-year waiting period applies to CHIP in accordance with 8 U.S.C. § 1613. See SHO letter, (issued Jan. 14, 1998), available at: https://www.medicaid.gov/Federal-Policy-Guidance/downloads/sho011498.pdf. 4 8 U.S.C. § 1101(a)(15)(T)(i)-(ii); 22 U.S.C. § 7105(b)(1)(A) and (C); 8 U.S.C. § 1641(c)(4). 5 Section 2502 of the Extending Government Funding and Delivering Emergency Assistance Act (P.L. 117-43 as amended, enacted Sept. 30, 2021) and Section 1501 of the Consolidated Appropriations Act, 2023, (P.L. 117-328). 6 Section 401 of the Additional Ukraine Supplemental Appropriations Act (P.L. 117-128 as amended, enacted May 21, 2022), as amended by Section 301 of the Ukraine Security Supplemental Appropriations Act, 2024 (P.L. 118-50). 7 8 U.S.C. § 1613. The five-year waiting period is commonly referred to as the “five-year bar.” 8 Sections 1903(v)(4)(A) and 2107(e)(1)(Q) of the Act. 9 42 C.F.R. §§ 435.403 and 457.320(e).

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Page 4 – State Health Official Letter of Columbia, or a U.S. territory, and meets all other applicable eligibility criteria in the respective jurisdiction: • U.S. citizens and U.S. nationals, • LPRs/“green card holders,”10 • Cuban/Haitian entrants,11 and • COFA migrants.12 In other words, generally, FFP is not available for full Medicaid benefits, for non-emergency Medicaid services provided to a limited-benefit eligibility group (such as the family planning eligibility group13), or for CHIP coverage for individuals unless they are in one of the groups in the bulleted list above or meet one of the discrete exceptions listed below. Throughout this letter, we refer to this Medicaid and CHIP coverage for which section 1903(v)(5) of the Act limits the availability of FFP as “full Medicaid and CHIP benefits,”14 and we refer to LPRs, Cuban/Haitian entrants, and COFA migrants, as described in section 1903(v)(5)(B)(ii)-(iv) of the Act, as “FFP-eligible noncitizens.” Given these changes, beginning October 1, 2026, with limited exceptions, FFP will no longer be available for full Medicaid or CHIP benefits furnished to qualified noncitizens who are not also FFP- eligible noncitizens (e.g., asylees, refugees, parolees, or victims of trafficking) unless they have another immigration status or category15 that meets the definition of an FFP-eligible noncitizen.16 See Appendix A for more information on the availability of coverage, by immigration status or category, for qualified noncitizens prior to and following the applicability date of section 71109 of the WFTC legislation.

10 Section 1903(v)(5)(B)(ii) of the Act describes an individual who is lawfully admitted for permanent residence as an immigrant under the Immigration and Nationality Act (INA), as defined by sections 101(a)(15) and 101(a)(20) of the INA (8 U.S.C. § 1101(a) et seq.); 8 U.S.C. § 1641(b)(1). 11 Section 1903(v)(5)(B)(iii) of the Act describes an individual who has been granted the status of Cuban/Haitian entrant as defined under section 501(e) of Refugee Education Assistance Act of 1980; 8 U.S.C. §§ 1612(b)(2)(A)(i)(IV), 1613(b)(1)(D), and 1641(b)(7). 12 Section 1903(v)(5)(B)(iv) of the Act describes an individual who lawfully resides in the U.S. in accordance with a COFA referred to in section 402(b)(2)(G) of PRWORA. 8 U.S.C. §§ 1612(b)(2)(G), 1613(b)(3), and 1641(b)(8). Medicaid coverage of COFA migrants is optional for territories. As of April 2026, CNMI and Guam have elected this option in Medicaid. 13 Section 1902(a)(10)(A)(ii)(XXI) of the Act and 42 C.F.R. § 435.214. 14 The term “full Medicaid and CHIP benefits” refers to full Medicaid benefits, partial or limited Medicaid benefits (e.g., only family planning services, Medicare Savings Programs (MSPs)), and CHIP coverage; it excludes Medicaid payment for the limited coverage of an emergency medical condition (“emergency Medicaid”) authorized under section 1903(v)(2) of the Act. Emergency Medicaid coverage does not apply to separate CHIPs. 15 The term “category” is used for certain noncitizens (i.e., Cuban/Haitian entrants described at 8 U.S.C. § 1641(b)(7); see also https://www.uscis.gov/save/resources/information-for-save-users-cuban-haitian-entrants) and relates to eligibility for certain federal public benefits, including Medicaid, rather than to a specific immigration status. 16 42 C.F.R. §§ 435.406(a)(2) and 457.320(b)(6) require coverage of qualified noncitizens who have provided verified, satisfactory documentary evidence of their declared qualified noncitizen status and meet all other eligibility requirements in the state. We acknowledge that these requirements will not be aligned with the FFP limitations at section 1903(v)(5) of the Act beginning October 1, 2026. We plan to update Medicaid and CHIP regulations in future notice and comment rulemaking for consistency with sections 1903(v)(5) and 2107(e)(1)(R) of the Act.

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Page 5 – State Health Official Letter Section 1903(v)(5) of the Act describes only three exceptions to these FFP limitations: (1) care and services necessary for the treatment of an emergency medical condition as described in section 1903(v)(3) of the Act, (often referred to as “emergency Medicaid”), per section 1903(v)(2) of the Act; (2) coverage under the CHIPRA 214 option, per section 1903(v)(4) of the Act;17 and (3) Health Services Initiatives (HSIs), which are programs that are designed to improve the health of low- income children, authorized under section 2105(a)(1)(D)(ii) of the Act.18 The FFP limitations described in section 1903(v)(5) of the Act do not apply to Medicaid or CHIP expenditures provided under these three exceptions. We note that section 1903(v)(5) of the Act did not make any changes to coverage of emergency Medicaid authorized under section 1903(v)(2) of the Act nor to coverage under the CHIPRA 214 option (if a state elects such option) authorized under section 1903(v)(4) of the Act. In the sections below, we describe implementation of section 71109 of the WFTC legislation, the interaction between the statutory changes made by section 71109 of the WFTC legislation and PRWORA, and the impact on noncitizens dually eligible for Medicare and Medicaid. Implementation Date for Section 71109 of the WFTC Legislation For applicants determined eligible for Medicaid or CHIP on and after October 1, 2026, and for beneficiaries enrolled in Medicaid or CHIP on and after October 1, 2026, states must ensure they appropriately claim FFP in accordance with sections 1903(v)(5) and 2107(e)(1)(R) of the Act, including under an exception specified at sections 1903(v)(2), 1903(v)(4), or 2105(a)(1)(D)(ii) of the Act. Thus, states will need to implement any systems and operational changes necessary to ensure such proper FFP claiming by October 1, 2026. Interaction between Section 71109 of the WFTC Legislation and PRWORA PRWORA establishes a statutory framework limiting eligibility of noncitizens for federal public benefits, including for full Medicaid and CHIP benefits, to “qualified aliens,” as defined in 8 U.S.C. § 1641.19 Section 403 of PRWORA subjects many qualified noncitizens to a five-year waiting period before becoming eligible for full Medicaid or CHIP benefits20 (e.g., LPRs) and provides for exceptions to this five-year waiting period for other specified qualified noncitizens21 (e.g., Cuban/Haitian entrants). Under section 402 of PRWORA, states are required to provide full Medicaid benefits to certain qualified noncitizens, if they otherwise meet all eligibility

17 Applicable to CHIP through a cross-reference to section 1903(v)(4) of the Act at section 2107(e)(1)(Q) of the Act. 18 Section 2107(e)(1)(R) of the Act. For general background on HSIs, see the Center for Medicaid and CHIP Services (CMCS) Frequently Asked Questions (FAQs), “Health Services Initiative,” (Jan. 12, 2017), available at: https://www.medicaid.gov/federal-policy-guidance/downloads/faq11217.pdf. 19 8 U.S.C. § 1611(a). For discussion on PRWORA’s applicability to CHIP, see footnote 3. 20 8 U.S.C. § 1613(a). See U.S. Department of Justice (DOJ), Notice of interim guidance with request for comments, “Interim Guidance on Verification of Citizenship, Qualified Alien Status and Eligibility Under Title IV of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996,” 62 Fed. Reg 61344, 61349-50, 61414-16, Attachment 7 (Nov. 17, 1997), available at: https://www.govinfo.gov/content/pkg/FR-1997-11-17/pdf/97-29851.pdf. 21 8 U.S.C. § 1613(b).

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Page 6 – State Health Official Letter requirements.22 For example, states must provide full Medicaid benefits to Cuban/Haitian entrants for seven years after their grant date of Cuban/Haitian entrant status if they meet all other eligibility requirements in the state,23 and states have the option to provide full Medicaid benefits to Cuban/Haitian entrants beyond the seven year period.24 While section 1903(v)(5) of the Act places limits on the availability of FFP for full Medicaid and CHIP benefits for certain noncitizens beginning on October 1, 2026, the WFTC legislation did not amend: the definition of qualified alien in PRWORA;25 the limitation in PRWORA that eligibility for federal public benefits, including full Medicaid and CHIP benefits, is restricted to qualified aliens;26 or the applicability of the five-year waiting period (and exceptions thereto) to certain qualified aliens.27 States must continue to apply relevant eligibility rules in 8 U.S.C. §§ 1613 (for Medicaid and CHIP) and 1612 (for Medicaid, only) to those qualified noncitizens who are also FFP-eligible noncitizens. Therefore, on and after October 1, 2026, states must continue to apply the five-year waiting period to LPRs in accordance with 8 U.S.C. § 1613(a), unless an exception provided in 8 U.S.C. §§ 1613(b) or (d)(1) applies (e.g., LPRs who are veterans or active-duty armed forces service members or certain family members of such an individual28). States must continue to except Cuban/Haitian entrants and COFA migrants from the five-year waiting period.29 Similarly, states must continue to provide full Medicaid benefits to FFP-eligible noncitizens in accordance with 8 U.S.C. § 1612(b) (e.g., states must provide full Medicaid benefits to LPRs who have worked, or can be credited with, 40 qualifying quarters, and may elect to provide full Medicaid benefits to all LPRs30). Specifically, in accordance with 8 U.S.C. § 1612(b)(2), states must not apply additional eligibility limitations to certain FFP-eligible noncitizens (e.g., certain Indians who are LPRs31 and COFA migrants32). Section 71109 of the WFTC legislation did not amend the description in 8 U.S.C. § 1612(b)(2) of the populations to which states must provide full Medicaid benefits, nor did it amend the description or scope of the populations in section 1902 of the Act to which states are required to provide medical assistance33 (e.g., individuals to whom supplemental security income (SSI) benefits are being paid).

22 8 U.S.C. § 1612(b) specifies that it applies to Medicaid as a “designated federal program” defined at 8 U.S.C. § 1612(b)(3)(C). Since CHIP has never been identified as a “designated federal program,” we do not interpret the provisions of 8 U.S.C. § 1612(b) as applicable to separate CHIPs. 23 8 U.S.C. § 1612(b)(2)(A)(i)(IV). 24 8 U.S.C. § 1612(b)(1). 25 8 U.S.C. §§ 1641(b) and 1641(c). 26 8 U.S.C. § 1611(a). 27 8 U.S.C. § 1613. 28 8 U.S.C. § 1613(b)(2). 29 8 U.S.C. § 1613(b)(1)(D); 8 U.S.C. § 1613(b)(3). 30 8 U.S.C. § 1612(b)(2)(B). In accordance with 8 U.S.C. § 1613, LPRs must also meet the five-year waiting period, unless an exception applies. 31 8 U.S.C. § 1612(b)(2)(E). 32 8 U.S.C. § 1612(b)(2)(G). 33 In particular, states are required to provide medical assistance that includes at least the care and services described in sections 1905(a)(1)-(5), (13)(B), (17), (21), (28), (29), and (30) of the Act to individuals listed at section 1902(a)(10)(A) of the Act. (Section 1902(a)(10)(A) of the Act.)

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Page 7 – State Health Official Letter At the same time, neither the text of section 71109 of the WFTC legislation nor its legislative history demonstrates a clear Congressional intent to require that states provide full Medicaid benefits to qualified noncitizens without receiving federal matching funds for that coverage. Under these circumstances and consistent with relevant case law,34 beginning October 1, 2026, CMS will not require states to provide state-only funded health coverage to qualified noncitizens for whom FFP is not available for full Medicaid benefits under 1903(v)(5) of the Act (e.g., asylees, refugees, parolees, or victims of trafficking who are not also FFP-eligible noncitizens), including populations listed at section 1902 of the Act. Moreover, because section 71109 of the WFTC legislation did not clearly and unambiguously alter the fundamental structure of the Medicaid program, whose “cornerstone” is “financial contribution by both the Federal Government and the participating State,”35 we would not consider health coverage that a state opts to continue to provide with 100 percent state-only funds to be Medicaid, notwithstanding the fact that 8 U.S.C. § 1612(b)(2) still describes coverage that will no longer be eligible for federal matching funds beginning October 1, 2026 as “Medicaid,” and notwithstanding the fact that section 1902 of the Act still describes mandatory Medicaid coverage that (when provided to certain populations) will no longer be eligible for federal matching funds beginning October 1, 2026. Therefore, beginning October 1, 2026, a noncitizen must be an FFP- eligible noncitizen or meet one of the statutory exceptions listed in section 1903(v)(5) of the Act to have “satisfactory immigration status” for full Medicaid benefits (including for purposes of section 1137(d) of the Act). See Appendix A for more information on the availability of FFP for coverage by immigration status or category prior to and following the applicability date of the statutory changes made by section 71109 of the WFTC legislation. While PRWORA does not describe any populations who must be eligible for CHIP, the same reasoning identified above for Medicaid applies to CHIP. Specifically, neither the text of section 71109 of the WFTC legislation nor its legislative history demonstrates a clear Congressional intent to require that states provide CHIP benefits to qualified noncitizens without receiving federal matching funds for that coverage, and we do not consider coverage that a state might opt to continue providing with 100 percent state-only funds to be “CHIP.” Impact on Noncitizens Dually Eligible for Medicare and Medicaid The term “dually eligible beneficiaries” generally describes beneficiaries who are eligible for both Medicare and Medicaid. The term includes beneficiaries enrolled in Medicare Part A, Part B, or both, who receive either full Medicaid benefits or assistance with Medicare premiums and often cost- sharing through a Medicare Savings Program (MSP) eligibility group.36 Sections 1903(v)(5) and 1899C of the Act, as added by section 71109 and section 71201 of the WFTC legislation, respectively, both impact noncitizens who are dually eligible for Medicare and Medicaid. Section 1899C of the Act limits Medicare eligibility for noncitizens to the same groups for which section

34 See, e.g., Pennhurst State Sch. & Hosp. v. Halderman, 451 U.S. 1, 17-18 (1981); Harris v. McRae, 448 U.S. 297, 308- 09 (1980); see also Detgen ex rel. Detgen v. Janek, 945 F. Supp. 2d 746, 759 (N.D. Tex. 2013), aff'd, 752 F.3d 627 (5th Cir. 2014). 35 McRae, 448 U.S. at 308. 36 Federal Coordinated Health Care Office Fact Sheet, “Dual Eligibility Categories,” (Jan. 15, 2025), available at: https://www.cms.gov/files/document/dual-eligible-categories-01152026.pdf.

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Page 8 – State Health Official Letter 1903(v)(5) of the Act permits FFP for full-benefit Medicaid coverage (i.e., LPRs, Cuban/Haitian entrants, and COFA migrants). Section 1899C of the Act applies 18 months after the date of enactment of the WFTC legislation. Section 1899C of the Act otherwise applies immediately to limit entitlement to, or enrollment for, Medicare after July 4, 2025. We expect to provide more information on section 1899C of the Act in forthcoming guidance. Implementation Requirements at Application and for Current Medicaid and CHIP Beneficiaries States will need to implement changes by October 1, 2026, to comply with the FFP limitations outlined in section 1903(v)(5) of the Act with respect to individuals who apply for coverage on and after October 1, 2026, and to beneficiaries who are enrolled in Medicaid or CHIP on October 1, 2026. Beginning October 1, 2026, states must ensure proper FFP claiming by limiting determinations of eligibility for full Medicaid and CHIP benefits to only those individuals for whom FFP is available for that coverage under sections 1903(v)(5) and 2107(e)(1)(R) of the Act. States will need to implement these new requirements when verifying citizenship or satisfactory immigration status, as required under sections 1137 and 2105(c)(9) of the Act, and implementing regulations at 42 C.F.R. §§ 435.406, 435.956, and 457.380(b). See the section of this letter entitled Verification of Immigration Status or Category for more information. Potential changes to states’ Medicaid and CHIP applications and to eligibility and enrollment and other systems necessitated by the implementation of sections 1903(v)(5) and 2107(e)(1)(R) of the Act are discussed in the sections of this letter entitled Updates to Applications, Renewal Forms, and Other Materials for Medicaid and CHIP and Medicaid and CHIP Information Technology (IT) Systems Costs and Upgrades. Because section 1903(v)(5) of the Act affects certain individuals’ eligibility for federally funded coverage and because CMS does not consider health coverage to be Medicaid or CHIP coverage unless federal matching funds are available, CMS interprets section 1903(v)(5) of the Act as a statutory change that potentially may affect an individual’s eligibility for Medicaid or CHIP coverage. Similarly, CMS interprets section 1903(v)(5) of the Act as affecting an individual’s “satisfactory immigration status” for full Medicaid or CHIP benefits for purposes of section 1137(d) of the Act. Thus, in accordance with 42 C.F.R. §§ 435.916(d) (2023) and 457.343,37 states must promptly act on this statutory change and assess whether certain beneficiaries continue to be in a satisfactory

37 Section 71102 of the WFTC legislation imposed a moratorium prohibiting CMS from implementing, administering, or enforcing certain amendments made by a CMS final rule entitled “Streamlining the Medicaid, Children’s Health Insurance Program, and Basic Health Program Application, Eligibility Determination, Enrollment, and Renewal Processes” (89 Fed. Reg. 22780 (Apr. 2, 2024)) (the “2024 Eligibility and Enrollment (E&E) Final Rule”) available at: https://www.govinfo.gov/content/pkg/FR-2024-04-02/pdf/2024-06566.pdf. The moratorium applies to certain provisions of the 2024 E&E Final Rule that have a compliance date after July 4, 2025, the date the WFTC legislation was enacted, and ends on September 30, 2034. To comply with the moratorium, in this SHO letter, CMS refers to the renewal requirements and the requirements for acting on changes in circumstances at 42 C.F.R. § 435.916, including those cross- referenced at 42 C.F.R. § 457.343, in effect as of 2023, available at: https://www.ecfr.gov/on/2024-06-02/title-42/chapter- IV/subchapter-C/part-435 and https://www.ecfr.gov/on/2024-06-02/title-42/chapter-IV/subchapter-D/part-457. For more information on the moratorium, see the CIB “Working Families Tax Cut” Legislation, Public Law 119-21: Summary of Medicaid and Children’s Health Insurance Program (CHIP) Related Provisions,” (Nov. 18, 2025), available at: https://www.medicaid.gov/federal-policy-guidance/downloads/cib11182025.pdf.

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Page 9 – State Health Official Letter immigration status that confers full Medicaid and CHIP benefits. States must attempt to redetermine satisfactory immigration status without the involvement of the beneficiary, if possible, and must contact the beneficiary if they are unable to reverify the satisfactory immigration status without additional information, consistent with 42 C.F.R. §§ 435.952(a)-(d) and 457.380(f). When addressing this statutory change, states must first attempt to identify all potentially affected beneficiaries (i.e., beneficiaries enrolled in and receiving full Medicaid or CHIP benefits who are not U.S. citizens or U.S. nationals, and whose immigration status or category is not LPR, Cuban/Haitian entrant, or COFA migrant, or who are not lawfully residing children or pregnant women in states that have elected the CHIPRA 214 option).38 Once the state identifies the potentially affected beneficiaries, the state must redetermine eligibility based on available information, if possible. States must first attempt to reverify a beneficiary’s satisfactory immigration status through electronic data sources (i.e., Department of Homeland Security’s (DHS’s) Systematic Alien Verification for Entitlements (SAVE) program39) before attempting to contact the beneficiary. If the state is unable to verify a beneficiary’s satisfactory immigration status electronically, the state must request information from the beneficiary in accordance with 42 C.F.R. §§ 435.952(c)-(d) and 457.380(f) and give the beneficiary a reasonable period of time to provide information prior to the state taking adverse action.40 The state must consider all information and documentation submitted by the beneficiary as the state redetermines eligibility. If the beneficiary responds with additional information about their current immigration status, including a new declaration of satisfactory immigration status, and the state is unable to verify such status, the state must provide the beneficiary with a 90-day reasonable opportunity period (ROP), as required by sections 1137(d), 1902(a)(46), 1902(ee), 1903(x), and 2105(c)(9) of the Act.41 If the state verifies that the beneficiary continues to have a satisfactory immigration status for the coverage in which they are enrolled, the beneficiary will retain coverage, and the state should notify the beneficiary that they continue to be eligible for the coverage in which they are enrolled. If information or documentation provided by the beneficiary demonstrates the individual no longer has satisfactory immigration status for the coverage in which they are enrolled, or if the beneficiary does not respond to the state’s request within the time specified by the state, the state must comply with requirements at 42 C.F.R. §§ 435.916(f) (2023), 457.343, and 457.350 to consider all bases of

38 States that are unable to individually identify all potentially affected beneficiaries will need to reverify the satisfactory immigration status for a broader population of noncitizens enrolled in Medicaid or CHIP (the scope may depend on state systems). For example, a state that does not retain data on the specific, verified immigration status or category for a beneficiary but, instead, retains a general designation of verified qualified noncitizen, may need to redetermine eligibility for all qualified noncitizens. A state that retains only the immigration status for those who are LPRs would need to redetermine eligibility for any other noncitizens receiving full Medicaid or CHIP benefits, with the exception of those beneficiaries receiving full Medicaid or CHIP benefits under a state’s election of the CHIPRA 214 option. 39 See https://www.uscis.gov/save; also discussed in the Verification of Immigration Status section of this letter. 40 Regardless of the source of information, 42 C.F.R. §§ 435.916(d)(1)(i) (2023) and 457.343 require that states limit requests for information from beneficiaries whose eligibility is based on modified adjusted gross income (MAGI) methodology to information related to the potential change in circumstances (which, here, is the statutory change that potentially affected their satisfactory immigration status). 41 42 C.F.R. §§ 435.956(b) and 457.380(b)(1).

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Page 10 – State Health Official Letter eligibility (e.g., under a state’s election under the CHIPRA 214 option and emergency Medicaid) and must provide advance notice of adverse action, including the right to a Medicaid fair hearing or CHIP review, before terminating coverage or reducing benefits.42 Considerations for Applicants and Current Beneficiaries who are Not FFP-Eligible Noncitizens When states determine eligibility for applicants and current beneficiaries who are not FFP-eligible noncitizens, states must evaluate whether an individual is eligible for full Medicaid or CHIP benefits on any basis under the state plan, including under the CHIPRA 214 option (if the state elects such option).43 If an applicant, who is not an FFP-eligible noncitizen, is a lawfully residing child or pregnant woman (e.g., a refugee) and meets all other eligibility requirements in the state, the applicant can be determined eligible for full Medicaid or CHIP benefits under the state’s CHIPRA 214 option. If the state identifies that a current beneficiary is eligible for full Medicaid or CHIP benefits under the state’s CHIPRA 214 option, the state would maintain full Medicaid or CHIP benefits for such beneficiary.44 States may need to update their systems to accurately evaluate eligibility for Medicaid or CHIP coverage under CHIPRA 214 for applicants and current beneficiaries who are currently eligible for full Medicaid or CHIP benefits but who will not be FFP-eligible noncitizens beginning October 1, 2026. For a list of specifically affected populations, see Appendix A. For Medicaid applicants and current Medicaid beneficiaries who are not FFP-eligible noncitizens and are not eligible under a state’s election of the CHIPRA 214 option, FFP remains available for emergency Medicaid coverage for such individuals in accordance with section 1903(v)(5) of the Act on and after October 1, 2026.45 For current Medicaid beneficiaries in a continuous eligibility period or continuous postpartum coverage,46 the state must apply the FFP limitation under section

42 42 C.F.R. §§ 435.917, 435.918, and 42 C.F.R Part 431 Subpart E for Medicaid (which require at least ten days advance notice of the proposed termination and an opportunity for a fair hearing) and 42 C.F.R. §§ 457.340(e), 457.1130(a), and 457.1180 (2023) for CHIP (which require a timely and adequate written notice of the proposed termination and an opportunity for review). (See: https://www.ecfr.gov/on/2024-06-02/title-42/chapter-IV/subchapter-D/part-457 and footnote 37.) 43 As of publication of this letter, 39 states, the District of Columbia, and three territories have elected the CHIPRA 214 option, see: https://www.medicaid.gov/medicaid/enrollment-strategies/medicaid-and-chip-coverage-lawfully-residing- children-pregnant-individuals. 44 Qualified noncitizens are considered “lawfully residing” for purposes of the CHIPRA 214 option. Section 1903(v)(4)(A) of the Act, (cross-referenced at section 2107(e)(1)(Q) of the Act for CHIP), specifies that coverage to lawfully residing children and/or pregnant women authorized under the CHIPRA 214 option is provided notwithstanding sections 401(a), 402(b), and 403 of PRWORA (8 U.S.C. §§ 1611(a), 1612(b), 1613). These limitations would not apply to the CHIPRA 214 population that the state has elected to cover in accordance with section 1903(v)(4) of the Act. CMCS SHO letter #10-006, “Medicaid and CHIP Coverage of “Lawfully Residing” Children and Pregnant Women,” (July 1, 2010), available at: https://www.medicaid.gov/federal-policy-guidance/downloads/SHO10006.pdf. 45 Section 1903(v)(2) of the Act; 8 U.S.C. § 1611(b)(1)(A). 46 This includes children in a continuous eligibility period under the state plan or section 1115 demonstrations under section 1902(e)(12) of the Act; individuals covered during a period of continuous postpartum coverage under the state plan or section 1115 demonstrations under section 1902(e)(16) of the Act; and individuals receiving authority for an expanded continuous eligibility period under the terms of a section 1115 demonstration. CMS reminds states that we do not anticipate approving new state proposals or extending existing state section 1115 demonstration expenditure authority that allow for expanded continuous eligibility beyond what is required or available under the Medicaid and CHIP statutes. CMS letter “Section 1115 Demonstration Authority for Continuous Eligibility Initiatives,” (July 17, 2025), available at:

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Page 11 – State Health Official Letter 1903(v)(5) of the Act. We remind states that availability of FFP is limited to payment for emergency Medicaid coverage during the remainder of the continuous eligibility period under sections 1902(e)(12) or 1902(e)(16) of the Act for such Medicaid beneficiaries who are not FFP-eligible noncitizens or eligible under a state’s election of the CHIPRA 214 option.47 For CHIP applicants and current CHIP beneficiaries who are not FFP-eligible noncitizens and are not eligible for CHIP coverage under a state’s election of the CHIPRA 214 option, no FFP is available on and after October 1, 2026, as there is no authorization for coverage of emergency services in a separate CHIP. Beginning October 1, 2026, FFP will no longer be available for current CHIP beneficiaries in a continuous eligibility period under sections 2107(e)(1)(L) or 2107(e)(1)(K) of the Act who are not FFP-eligible noncitizens,48 unless the state has elected the CHIPRA 214 option for these populations. Thus, states would terminate separate CHIP eligibility for such beneficiaries after providing required sufficient notice and review rights.49 Operational Considerations for States and Territories The changes made to the availability of FFP for Medicaid and CHIP in sections 1903(v)(5) and 2107(e)(1)(R) of the Act could require states to update eligibility determination processes for new applicants and current beneficiaries. We expect these updates would include changes to eligibility systems and related operational processes. Below we address key operational considerations for states when implementing these changes, including updates to applications and other materials, verification of immigration status or category, and considerations for managed care plans.50 As states make system and operational changes by October 1, 2026 to ensure proper FFP claiming and accurate Medicaid and CHIP eligibility determinations consistent with section 1903(v)(5) of the Act, states are also reminded that they should take appropriate measures to ensure erroneous payments are not made as a result of eligibility errors in accordance with section 1903(u)(1) of the Act, as amended by section 71106 of the WFTC legislation.51

https://www.medicaid.gov/resources-for-states/downloads/contin-elig-ltr-to-states.pdf. CMS expects to provide additional technical assistance to states about the potential impact of section 1903(v)(5) of the Act for currently approved section 1115 demonstrations. 47 CMCS SHO letter #25-001, “Section 5112 Requirement for all States to Provide Continuous Eligibility to Children in Medicaid and CHIP under the Consolidated Appropriations Act, 2023,” (Jan. 15, 2025), available at: https://www.medicaid.gov/federal-policy-guidance/downloads/sho25001.pdf. 48 This includes children in a continuous eligibility period under the state plan or section 1115 demonstrations under section 2107(e)(1)(L) of the Act; individuals covered during a period of continuous postpartum coverage under the state plan or section 1115 demonstrations under section 2107(e)(1)(K) of the Act, (but not for individuals covered through an HSI under section 2105(a)(1)(D)(ii) of the Act); and individuals receiving authority for an expanded continuous eligibility period under the terms of a section 1115 demonstration. For additional discussion of applicability to section 1115 demonstrations, see footnotes 46 and 47. 49 42 C.F.R. §§ 457.340(e), 457.1130(a), and 457.1180 (2023). 50 The term “managed care plan” in this guidance refers to managed care organizations (MCOs), prepaid inpatient health plans (PIHPs) and prepaid ambulatory health plans (PAHPs) as defined in 42 C.F.R. § 438.2. 51 This provision is applicable beginning fiscal year 2030.

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Page 12 – State Health Official Letter Updates to Applications, Renewal Forms, and Other Materials for Medicaid and CHIP To be determined eligible for full Medicaid or CHIP benefits, an individual must declare to be a U.S. citizen or U.S. national or have satisfactory immigration status in accordance with sections 1137(d), 1902(a)(46)(B), 1902(ee), 1903(x), and 2105(c)(9) of the Act, and 42 C.F.R. §§ 435.406 and 457.320(d). Applicants who attest to having satisfactory immigration status may, but are not required to, provide additional information to support electronic verification, such as document type, and, at state option, noncitizen immigration status (e.g., attesting to LPR status). To effectuate the FFP limitations in sections 1903(v)(5) and 2107(e)(1)(R) of the Act, states may need to update their Medicaid and CHIP applications. CMS anticipates that the application modifications needed to effectuate these statutory changes may vary among states. Some states may need to remove or modify existing questions or response options. For example, some states’ applications request the type of satisfactory immigration status or document type by prompting applicants to identify the immigration status or document from a list (e.g., a list presented in a drop-down or via radio buttons in an online application). In such cases, states may need to modify the lists to account for the changes described in this letter. States may also need to revise state-specific instructions or help text included in applications (e.g., to provide the immigration statuses and categories for which FFP is available for full Medicaid and CHIP benefits beginning October 1, 2026). In states that have elected to cover lawfully residing children and/or pregnant women under the CHIPRA 214 option, the changes described herein may be more limited as the application must continue to collect the necessary information to determine eligibility for this population. As a reminder, per 42 C.F.R. §§ 435.907(e)(1) and 457.330, applications may only require an applicant to submit information needed to determine their Medicaid or CHIP eligibility. Revising help text or instructions and modifying questions to remove information that is no longer applicable to eligibility determinations does not necessitate submission of a state plan amendment (SPA). As such, states are not required to submit a SPA to CMS to make these changes to their single streamlined applications. CMS staff are available to provide technical assistance as needed. In addition to evaluating changes to Medicaid and CHIP applications, states may need to revise their renewal forms. For example, if a renewal form or instructions include a comprehensive list of immigration statuses and/or document types that qualified an individual for full Medicaid or CHIP benefits prior to October 1, 2026, that list might need to be revised. States may also need to update other Medicaid or CHIP materials, such as policy and procedure manuals, eligibility worker training materials, call center scripts, and website language, to reflect the changes described in this letter and for consistency with the statutory changes made by section 71109 of the WFTC legislation. CMS continues to evaluate whether changes may be needed to the single, streamlined application developed by the Secretary, as described at 42 C.F.R. §§ 435.907(a) and (b)(1) and 457.330, to effectuate these statutory changes.

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Page 13 – State Health Official Letter Verification of Immigration Status or Category States must electronically verify an individual’s immigration status or category for all individuals who have declared to have a satisfactory immigration status, in accordance with section 1137(d)(3) of the Act and 42 C.F.R. §§ 435.956(a)(2) and 457.380(b).52 State electronic verification of immigration status or category occurs through DHS/USCIS’s SAVE program. In this section, we describe how states can access the DHS/USCIS’s SAVE program and use the SAVE response data to verify a noncitizen’s immigration status or category, as well as the upcoming changes to the Federal Data Services Hub (the “Hub”) to comply with the FFP limitations described in sections 1903(v)(5) and 2107(e)(1)(R) of the Act. DHS/USCIS’s SAVE Program, the Federal Data Services Hub, and the Graphical User Interface (GUI) CMS and DHS/USCIS make available three pathways to states to access SAVE: 1. the Hub Verify Lawful Presence (VLP) service; 2. a direct connection between the state’s eligibility system and SAVE; or 3. SAVE’s web-based GUI. States can also use a combination of these three SAVE pathways. DHS/USCIS’s SAVE program provides data to accurately reflect the current immigration status or category of a noncitizen for a new verification request based on the most up-to-date data available. The SAVE verification responses may include some combination of the following immigration information, depending on which of the three SAVE pathways the state uses (as described more below): Eligibility Statement Code (ESC)/Major codes, Class of Admission (COA) codes, Employment Authorization Document (EAD) Category codes, and grant date of verified immigration status or category. When redetermining eligibility for potentially affected beneficiaries, states would submit a new SAVE verification request for these beneficiaries to receive a response based on the most up-to-date immigration data available for the beneficiary. SAVE provides “point in time” verification and does not update past SAVE verification responses when there is a change in immigration status or category. Potentially affected beneficiaries may have applied for and been granted adjustment of status to that of an LPR or may have another qualifying immigration status or category (for example, could be considered a Cuban/Haitian entrant) such that they may be considered an FFP-eligible noncitizen for full Medicaid or CHIP benefits. Alternatively, potentially affected beneficiaries may be lawfully residing for purposes of Medicaid or CHIP eligibility under a state’s election of the CHIPRA 214 option.

52 Section 1137(d)(3) of the Act directs states “to verify with the Immigration and Naturalization Service the individual’s immigration status through an automated or other system (designated by the Service for use with States).” See also 42 C.F.R. §§ 435.956(a) and 457.380(b)(1)(i). DHS’s U.S. Citizenship and Immigration Services (USCIS) now performs this function, see: https://www.uscis.gov/save/about-save/save-governing-laws.

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Page 14 – State Health Official Letter Hub VLP Service v37.1, Version 2 The Hub interprets the immigration codes received from SAVE to help states determine Medicaid and CHIP eligibility based on qualified noncitizen status under PRWORA and lawful presence status for purposes of the CHIPRA 214 option. The Hub currently transmits indicators to states reflecting the following: • citizenship (for individuals with naturalized or derived citizenship); • lawful presence (used for Marketplace53 and the CHIPRA 214 option); • qualified noncitizen; • if the five-year waiting period is applicable (only for qualified noncitizens); • if the five-year waiting period is met (only for qualified noncitizens, when applicable); and • the underlying immigration codes received from SAVE. The Hub will continue to transmit to states all current indicators, listed above, as these indicators will not be impacted by implementation of section 1903(v)(5) of the Act. In 2026, in addition to the current indicators, the Hub will transmit a new indicator to states reflecting FFP-eligible noncitizen status for full Medicaid and CHIP benefits in accordance with sections 1903(v)(5) and 2107(e)(1)(R) of the Act for each noncitizen verified by the Hub. See the following examples of Hub responses with the new indicator: • When a state submits a verification request for an asylee, the Hub would return: o “Yes” for qualified noncitizen status indicator, o “No” for eligible noncitizen54 status indicator, o “No” for whether the five-year waiting period is applicable, and o “Not Applicable” whether the five-year waiting period has been met. • When the state submits a verification request for an LPR, the Hub would return: o “Yes” for qualified noncitizen status indicator, o “Yes” for eligible noncitizen status indicator, o “Yes”/“No” for whether the five-year waiting period is applicable (depending on whether the individual met an exception from the five-year waiting period), and o “Yes”/“No”/“Not Applicable” for whether the five-year waiting period has been met. See Appendix B for a summary of the Hub changes to verify FFP-eligible noncitizen status, including the applicable ESCs, COA codes, and EAD Category codes returned by SAVE.

53 Similar to the FFP limitations added by section 71109, section 71301 of the WFTC legislation added limits on eligibility for premium tax credits to noncitizens who are “eligible aliens” (i.e., LPRs, Cuban/Haitian entrants, and COFA migrants), beginning January 1, 2027. 54 The Hub will use a simplified term of “eligible noncitizen” for the new indicator, which has the same meaning as the “FFP-eligible noncitizen” term used in this letter (i.e., LPRs, Cuban/Haitian entrants, and COFA migrants).

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Page 15 – State Health Official Letter Direct Connections with SAVE and the GUI States that connect directly with SAVE through a direct web services connection or through the GUI would read and interpret the underlying immigration codes and other responses from SAVE to verify and determine FFP-eligible noncitizen status. SAVE returns a different set of codes (e.g., ESC/Major codes, COA codes, and EAD codes) depending on which of the pathways the state uses: • Direct Connection – SAVE returns the same ESC/Major codes, COA codes, and EAD codes to states with a direct web services connection as it does to the Hub. • GUI – SAVE returns the same COA and EAD codes to the GUI as it does to the Hub. States may need to update their eligibility logic to utilize the codes received from SAVE to correctly determine if an individual is an FFP-eligible noncitizen. For example, states that use the GUI or direct web services connection with SAVE would receive data confirming an individual’s LPR status and grant date; these states would apply their own eligibility logic to determine whether the five-year waiting period applies and, if so, whether the five-year waiting period has been met. States that use the Hub would receive data confirming LPR status and grant date, along with the following Hub indicators: (1) confirm FFP-eligible noncitizen, (2) whether the five-year waiting period applies, and (3) if so, whether the five-year waiting period has been met. Since the ESC/Major codes, COA codes, and EAD codes returned to states using a direct web services connection or the GUI are the same as those returned to the Hub, states using a direct web services connection or the GUI can use the Hub verification logic to inform their system updates (see Appendix B - Summary of Hub Changes in Accordance with Section 71109 of the WFTC Legislation). Reasonable Opportunity Period (ROP) when Unable to Verify U.S. Citizenship or Satisfactory Immigration Status If, during initial verification of an applicant’s attested U.S. citizenship or satisfactory immigration status or during a redetermination of a beneficiary’s attested U.S. citizenship or satisfactory immigration status, the state is not able to verify an individual’s citizenship or immigration status or category promptly through electronic data sources and the individual meets all other eligibility requirements for Medicaid or CHIP in the state, the state is required to furnish benefits during the 90- day ROP, for individuals declaring to be U.S. citizens or in a satisfactory immigration status to obtain documentation or where the agency itself needs more time to verify the individual’s citizenship or immigration status or category.55 Before discontinuing coverage provided during the ROP, states must provide such individuals with advance written notice of the proposed termination and an opportunity for a fair hearing or review, consistent with the applicable Medicaid or CHIP requirements.56

55 Sections 1137(d), 1902(a)(46), 1902(ee), 1903(x), and 2105(c)(9) of the Act and 42 C.F.R. §§ 435.956 and 457.380(b)(1). The 90-day ROP may be extended for individuals declaring to be in a satisfactory immigration status if the agency determines that the individual is making a good faith effort to obtain any necessary documentation or the agency needs more time to verify the individual's status, in accordance with 42 C.F.R. § 435.956(b)(2)(ii)(B). 56 42 C.F.R. §§ 435.917, 435.918, and 42 C.F.R Part 431 Subpart E for Medicaid (which require at least ten days advance notice of the proposed termination and an opportunity for a fair hearing) and 42 C.F.R. §§ 457.340(e), 457.1130(a), and

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Page 16 – State Health Official Letter Considerations for Medicaid Managed Care Programs States must ensure their Medicaid managed care programs comply with section 1903(v)(5) of the Act, as added by section 71109 of the WFTC legislation. States and their actuaries should evaluate whether implementation of section 1903(v)(5) of the Act necessitates adjustments to Medicaid capitation rate development or constitutes a material adjustment requiring an amended rate certification.57 States must also ensure that all Medicaid managed care contracts comply with all applicable federal and state laws, including section 1903(v)(5) of the Act.58 To ensure clarity, states should assess their Medicaid managed care contracts and consider revisions to make explicit that payment for medical assistance under the contract is limited to expenditures for which FFP is available under section 1903(v) of the Act and that the limitations on FFP in section 1903(v)(5) of the Act apply to Medicaid capitation rates.59 CMS reminds states that CMS published the State Medicaid Director (SMD) letter #25-003 entitled “Medicaid Managed Care Payments and Emergency Medical Condition Coverage for Aliens Ineligible for Full Medicaid Benefits” on September 30, 2025.60 This guidance announced a change in the agency’s interpretation of section 1903(v) of the Act and how it applies to Medicaid managed care payments to improve program and fiscal integrity in the Medicaid program. As outlined in SMD letter #25-003, for rating periods beginning on or after September 30, 2026, states can either provide coverage and claim FFP for emergency Medicaid in the FFS delivery system or by contracting with PIHPs and PAHPs on a non-risk basis. Additionally, if a state uses state-only funding to provide health coverage for noncitizens for whom FFP is not available for full Medicaid benefits under section 1903(v)(5) of the Act, the state must utilize a separate and distinct contract and payment with any managed care plan it contracts with to provide state-funded services. State-only funded services for noncitizens who are not FFP-eligible noncitizens may not be included in the state’s contracts and payments to Medicaid managed care plans. Medicaid and CHIP Information Technology (IT) Systems Costs and Upgrades To support the implementation of sections 1903(v)(5) and 2107(e)(1)(R) of the Act, as described above, states may need to modify their eligibility and enrollment system and/or their Medicaid Management Information System (MMIS) to accurately determine Medicaid and CHIP eligibility and provide the appropriate scope of coverage (i.e., full Medicaid or CHIP benefits or emergency Medicaid coverage), including to ingest the new Hub indicators or apply new eligibility logic to immigration codes and other responses from SAVE.

457.1180 (2023) for CHIP (which require a timely and adequate written notice of the proposed termination and an opportunity for review). 57 42 C.F.R. §§ 438.5(b)(4), 438.5(f), 438.7(b)(4), and 438.7(c)(2). 58 42 C.F.R. § 438.3(f). 59 42 C.F.R. § 438.812(a). 60 CMCS SMD letter # 25-003, “Medicaid Managed Care Payments and Emergency Medical Condition Coverage for Aliens Ineligible for Full Medicaid Benefits” (Sept. 30, 2025), available at: https://www.medicaid.gov/federal-policy- guidance/downloads/smd25003.pdf.

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Page 17 – State Health Official Letter To expand on such system modifications, for example, states may need to update eligibility determination logic to reflect those immigration statuses and categories for which FFP remains available for full Medicaid and CHIP benefits and to revise logic for those immigration statuses and categories for which FFP is available for emergency Medicaid only. See Appendix A for a list of these impacted immigration statuses and categories. As discussed above, depending on how a state implements emergency Medicaid coverage, state systems may recognize such impacted beneficiaries as either eligible only for payment for emergency Medicaid services or as ineligible for full Medicaid benefits and, subsequently, determine their eligibility again if the individual needs treatment of an emergency medical condition for which Medicaid coverage is available pursuant to section 1903(v)(2) of the Act. Additionally, depending on which of the three pathways a state uses to verify immigration status or category, states may need to either: (1) update schema to accept new Hub indicators for eligible noncitizen codes (in states that use the VLP service through the Hub); or (2) update verification logic to interpret SAVE codes to determine who is an FFP-eligible noncitizen (in states with a direct connection to SAVE or that use the GUI). States should ensure that these interconnected policy and system requirements function seamlessly together. Equally important is ensuring the vendors supporting the implementation clearly understand their role and expectations. Without proper alignment between policy design and technological capabilities, states may create administrative burdens that undermine program effectiveness and cost- efficiency. When establishing state-specific policies, states should consult with their system implementation teams to ensure policies can be operationalized in their systems. CMS recognizes the program changes could require significant IT system work to fulfill policy implementation. State Medicaid agency IT system costs necessary to support requirements may be eligible for enhanced FFP. Approval of enhanced FFP requires the submission of an Advanced Planning Document (APD). A state may submit an APD requesting approval for a 90/10 enhanced match for the design, development, and installation of its Medicaid Enterprise Systems (MES) initiatives contributing to the economic and efficient operation of the program. States should refer to 45 C.F.R. Part 95 Subpart F entitled “Automatic Data Processing Equipment and Services-Conditions for FFP” for the specifics related to APD submission and to 42 C.F.R § 433.112 entitled “FFP for design, development, installation or enhancement of mechanized processing and information retrieval systems” for specifics related to enhanced match. States may also request a 75/25 enhanced match for ongoing operations of CMS approved systems. States should refer to 42 C.F.R. Part 433 Subpart C entitled “Mechanized Claims Processing and Information Retrieval Systems” for the specifics related to systems approval. Receipt of these enhanced funds is conditioned upon states meeting a series of standards and conditions to ensure investments are efficient and effective. To the extent these system costs are attributable to a state’s CHIP (Medicaid expansion CHIP (MCHIP) or separate CHIP), cost-allocation methodologies set forth in 45 C.F.R. Part 75 apply. For the CHIP-funded portion of the cost, states

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Page 18 – State Health Official Letter can claim at a state’s CHIP enhanced FMAP (EFMAP), available under section 2105(b) of the Act. CHIP administrative funding is limited to 10 percent of either a state’s total computable allotments for a fiscal year or its total expenditures reported for a fiscal year, whichever is lower.61 Other activities, such as state development of eligibility policy and outreach in response to the changes at section 1903(v)(5) of the Act, may be claimed under Medicaid at the 50 percent administrative match, in accordance with regular claiming policies for such administrative activities.62 Financial Systems and Proper Claiming States should continue to ensure proper claiming and expenditure reporting on the quarterly budget and expenditure reports in the Medicaid and CHIP Budget and Expenditure System (MBES/CBES). States that provide state-only funded coverage to noncitizens for whom, beginning October 1, 2026, FFP will not be available for full Medicaid and CHIP benefits under sections 1903(v)(5) and 2107(e)(1)(R) of the Act must implement controls to limit claims for FFP to expenditures for emergency Medicaid. For this reason, states may also need to make edits or add controls to their MMIS and/or other accounting systems to ensure accurate claiming of related expenditures. States must be able to identify and isolate costs directly related to the administration of the Medicaid program (and if applicable, to CHIP) from any state-only health program costs incurred to ensure accurate reporting of claims for FFP and to implement allocation methodologies in accordance with the authority to claim administrative costs, (e.g., approved Public Assistance Cost Allocation Plan (PACAPs), Medicaid Administrative Claiming Plans (MACs), and APDs). Upon certification of the Form CMS-64, states are required to have all documentation in a readily reviewable form. States should report all claims for FFP related to emergency Medicaid on the Form CMS-64 Line 27 to reduce the risk of overclaiming FFP. CMS has conducted focused financial oversight of eight states with state-only funded programs that provide health coverage for noncitizens regardless of immigration status and has identified approximately $1.8B in questionable expenditures reported by states relating to services provided to noncitizens for whom FFP is available only for emergency Medicaid and not for full Medicaid benefits. CMS intends to continue conducting oversight to ensure state claims for FFP related to emergency Medicaid comply with federal requirements. Transformed-Medicaid Statistical Information System (T-MSIS) For consistency with the statutory changes made by section 71109 of the WFTC legislation that are applicable beginning October 1, 2026, states will need to update Medicaid and CHIP data submitted to T-MSIS to accurately report information about who is an FFP-eligible noncitizen and, in Medicaid, who is eligible for emergency Medicaid coverage only. We plan to provide additional information on T-MSIS data reporting, including updates to the T-MSIS Data Guide,63 in forthcoming guidance.

61 42 C.F.R. § 457.618(e)(1). 62 Section 1903(a)(7) of the Act and 42 C.F.R. § 433.15(b)(7). 63 The T-MSIS Data Guide is available at: https://www.medicaid.gov/tmsis/dataguide/.

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Page 19 – State Health Official Letter Federal Medical Assistance Percentage (FMAP) In this section, we describe the applicable FMAP for those individuals for whom, beginning October 1, 2026, FFP is available for full Medicaid and CHIP benefits under sections 1903(v)(5) and 2107(e)(1)(R) of the Act and under the CHIPRA 214 option, in accordance with sections 1903(v)(4) and 2107(e)(1)(Q) of the Act, as well as the applicable FMAP for emergency Medicaid, including the impact of section 71110 of the WFTC legislation on FMAP claiming. FMAP for Full Medicaid and CHIP Benefits (including under the CHIPRA 214 Option) Section 71109 of the WFTC legislation made no changes to the Act’s FMAP provisions, but it did affect for whom FFP can be claimed for full Medicaid and CHIP coverage beginning October 1, 2026.64 Beginning October 1, 2026, the FMAP for expenditures for full Medicaid and CHIP benefits and expenditure reporting for FFP-eligible noncitizens (i.e., for LPRs, Cuban/Haitian entrants, and COFA migrants) would generally remain the same as prior to October 1, 2026. Expenditures for FFP- eligible noncitizens enrolled in the state’s: • Medicaid program are claimed at the state’s regular FMAP under section 1905(b) of the Act, or other applicable FMAPs as provided in statute, on the Form CMS-64 series of expenditure reports in the MBES/CBES and are funded by title XIX for Medicaid. • CHIP program: o MCHIP are claimed under section 1905(u)(2) of the Act (including FFP- eligible noncitizens who are children up to age 19) at the state’s EFMAP on the Form CMS 64.21U series of expenditure reports and are funded by title XXI CHIP Allotments. As applicable for all MCHIP expenditures, states continue to have the option under section 115 of CHIPRA to claim their MCHIP expenditures at the regular FMAP funded by title XIX for Medicaid.65 o Separate CHIP are claimed under title XXI at the state’s EFMAP on the Form CMS-21 series of expenditure reports and are funded by title XXI CHIP Allotments. FMAP for Emergency Medicaid Because the availability of FFP for full Medicaid and CHIP benefits for certain noncitizens will be more limited beginning October 1, 2026, states may, in fact, experience an overall total increase in the number of expenditures for emergency Medicaid only coverage beginning October 1, 2026. In general, emergency Medicaid is claimed at the applicable FMAP. We note that section 71110 of the WFTC legislation added a new subsection (kk) to section 1905 of the Act that limits, beginning

64 CMCS SHO letter #10-006, “Medicaid and CHIP Coverage of “Lawfully Residing” Children and Pregnant Women” (July 1, 2010), available at: https://www.medicaid.gov/federal-policy-guidance/downloads/SHO10006.pdf. 65 CMCS SHO letter #10-005, “Applicability of Federal Matching Rates in CHIP and Medicaid” (Mar. 2, 2010), available at: https://www.medicaid.gov/federal-policy-guidance/downloads/SHO10005.pdf.

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Page 20 – State Health Official Letter October 1, 2026, the FMAP for emergency Medicaid services provided to noncitizens to no greater than the state’s regular FMAP determined under section 1905(b) of the Act. This impacts expenditure claims for services provided to individuals in the adult group at section 1902(a)(10)(A)(i)(VIII) of the Act and other applicable eligibility groups, such as the Optional Breast and Cervical Cancer Treatment group. Therefore, beginning October 1, 2026, the FMAP for expenditures related to services provided to individuals receiving emergency Medicaid coverage (including individuals in the adult group) will be matched at the state’s regular FMAP under section 1905(b) of the Act. States should report expenditures for emergency Medicaid services only on Line 27 of the appropriate Form CMS-64 expenditure report. CMS is working to modify the MBES/CBES to reflect the appropriate FMAP under section 1905(kk) of the Act as applicable October 1, 2026. The FMAP applicable to expenditures for prior period adjustments should be the FMAP at which the original expenditure was claimed, for both private and governmental providers. States should ensure accurate claiming on Line 27 of the appropriate Form CMS-64 for noncitizens who are not FFP-eligible noncitizens, or they may be at risk of over-claiming. With CMS approval, some states claim FFP for a portion of supplemental payments at the increased adult group FMAP rates specified in sections 1905(y) and (z) of the Act. States should update any supplemental payment allocation methodology for emergency Medicaid services to reflect the new FMAP limitation under section 1905(kk) of the Act. The result should be that a greater portion of a supplemental payment will be allocated to and claimed at the state’s regular FMAP under section 1905(b) of the Act, and a lesser portion of the supplemental payment will be claimed at the increased adult group FMAP rates. States should submit an updated allocation methodology to CMS prior to October 1, 2026, specifying the method used to identify the emergency Medicaid services portion of the supplemental payment(s) and ensuring that, on and after October 1, 2026, such amounts are claimed for the adult group at the match rate under section 1905(b) of the Act (and are not claimed at an increased FMAP under section 1905(y) or (z) of the Act). CMS plans to provide states with further details on specific updates needed to their supplemental payment allocation methodology document(s). Additionally, CMS is working to modify functionality in the Medicaid and CHIP Financial System (MACFin) to reflect the appropriate FMAP under section 1905(kk) of the Act for supplemental payments and intends to provide technical instructions to states regarding appropriate reporting of supplemental payments tied to emergency Medicaid services on the Form CMS-64.66 State Plan Amendment (SPA) Submission CMS expects all states, territories, and the District of Columbia to submit a Medicaid SPA to update their state plan to be consistent with section 1903(v)(5) of the Act. Medicaid SPAs must be submitted to CMS no later than December 31, 2026, for an effective date of October 1, 2026. Similarly, CMS expects all states with a separate CHIP to submit a CHIP SPA to update their state plan to be consistent with section 2107(e)(1)(R) of the Act. For states that have not elected the CHIPRA 214

66 CMCS SMD letter # 21-006, “New Supplemental Payment Reporting and Medicaid Disproportionate Share Hospital Requirements under the Consolidated Appropriations Act, 2021” (Dec. 10, 2021), available at: https://www.medicaid.gov/federal-policy-guidance/downloads/smd21006.pdf.

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Page 21 – State Health Official Letter option for all covered populations in their separate CHIP, these SPAs will effectively restrict eligibility, thus the submission timeframe at 42 C.F.R. § 457.65(b), requiring states to submit SPAs by no later than 60 days after the effective date of the proposed SPA, applies. Therefore, these states are required to submit CHIP SPAs to CMS by no later than November 30, 2026, after sufficient public notice. For states with a separate CHIP that have elected the CHIPRA 214 option for all populations within their separate CHIP, the state will need to submit the SPA within the state fiscal year in which October 1, 2026, falls. CMS is making revisions to the “Citizenship and Non-Citizen Eligibility” SPA Reviewable Unit, which each state and the District of Columbia must complete and submit through the Medicaid and CHIP Program MACPro portal for Medicaid, including MCHIP, and to the “CS 18: Non-Financial Eligibility-Citizenship” state plan template submitted in OneMAC for separate CHIPs. Territories must submit a SPA through MACPro or amend their paper state plan. We plan to provide additional information about the revised Medicaid and CHIP SPA templates in forthcoming guidance. Territory Considerations The FFP limitations described in section 1903(v)(5) of the Act apply to the U.S. territories. We note that section 402(b)(2)(G) of PRWORA, as added by section 208 of the Consolidated Appropriations Act, 2021 (CAA, 2021), provides an option for the U.S. territories to provide full Medicaid benefits to COFA migrants who are lawfully residing in the territory.67 Section 71109 of the WFTC legislation did not make changes to section 402(b)(2)(G) of PRWORA; therefore Medicaid coverage of COFA migrants in the territories will remain optional after the October 1, 2026, applicability date.68

67 8 U.S.C. § 1612(b)(2)(G). 68 CMCS SHO letter #21-005, “Medicaid Eligibility for COFA Migrants” (Oct. 18, 2021), available at: https://www.medicaid.gov/federal-policy-guidance/downloads/sho21005.pdf. As of April 2026, the territories of CNMI and Guam have approved SPAs to provide coverage to COFA migrants in Medicaid.

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Page 22 – State Health Official Letter Closing CMS is committed to working with states and territories as they implement the policy and operational changes in their Medicaid programs and CHIPs for compliance with the statutory changes made by section 71109 of the WFTC legislation. CMS staff are available to provide technical assistance regarding the changes discussed in this letter. Questions regarding the Medicaid and CHIP policies discussed in this letter may be directed to MedicaidReforms@cms.hhs.gov. Sincerely, /s/ Dan Brillman Deputy Administrator, CMS Director, Center for Medicaid and CHIP Services

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APPENDIX A - Details Regarding Qualified Noncitizen Coverage in Medicaid and CHIP Before and After Implementation of Section 71109 of the WFTC Legislation This table lists all immigration statuses and categories that are considered “qualified noncitizens,” as defined at 42 C.F.R. § 435.4 for Medicaid and cross-referenced at 42 C.F.R. § 457.320(c) for CHIP. For each immigration status or category, the table shows availability of FFP for full Medicaid and CHIP benefits before and after the October 1, 2026, applicability date for the statutory changes made by section 71109 of the WFTC legislation, as well as the availability of FFP for emergency Medicaid. This table applies to both full Medicaid and CHIP benefits, unless otherwise indicated. In states that have elected to cover children (up to age 21 for Medicaid and up to age 19 for CHIP) and/or pregnant women who are lawfully residing in the U.S. under the CHIPRA 214 option, these individuals can receive full Medicaid or CHIP benefits, depending on the election by the state in their state plan. While we have not included detailed information regarding the CHIPRA 214 option in this table, we provide key information on how certain noncitizen pregnant women and/or children are covered under a state’s CHIPRA 214 option before and after October 1, 2026. NOTE: This table is not intended to be comprehensive of all immigration statuses or categories for purposes of Medicaid and CHIP coverage and availability of FFP for certain noncitizens.

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TABLE 1. Medicaid and CHIP Coverage by Immigration Status or Category, before and after Section 71109 Implementation Immigration Status/Category Before 10/1/26 On and After 10/1/26 Before, On, and After 10/1/26 Eligible for Full Medicaid & CHIP Benefits FFP for Full Medicaid & CHIP Benefits1 FFP for Emergency Medicaid Only1 FFP for Full Medicaid & CHIP Benefits under the CHIPRA 214 Option2 Lawful Permanent Residents (LPRs)3 Section 101(a)(15) and 101(a)(20) of INA; An individual who is lawfully admitted for permanent residence under the INA. (8 U.S.C. § 1641(b)(1))

• LPRs not subject to the 5-year waiting period 8 U.S.C. § 1613 YES YES n/a YES • LPRs subject to the 5-year waiting period

o Who have not met the 5-year waiting period NO NO YES YES o Who have met the 5-year waiting period YES YES n/a YES Cuban/Haitian entrants4,5 Section 501(e) of Refugee Education Assistance Act of 1980. (8 U.S.C. § 1641(b)(7)) YES YES n/a YES COFA migrants5,6 8 U.S.C. §§ 1613(b)(3) and 1641(b)(8) YES YES n/a YES Refugees4,5 A refugee who is admitted to the U.S. under section 207 of INA. (8 U.S.C. § 1641(b)(3)) YES NO YES YES Asylees4,5 An individual who is granted asylum under section 208 of the INA. (8 U.S.C. § 1641(b)(2)) YES NO YES YES

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Immigration Status/Category Before 10/1/26 On and After 10/1/26 Before, On, and After 10/1/26 Eligible for Full Medicaid & CHIP Benefits FFP for Full Medicaid & CHIP Benefits1 FFP for Emergency Medicaid Only1 FFP for Full Medicaid & CHIP Benefits under the CHIPRA 214 Option2 Noncitizens paroled in the U.S. for at least one year An individual who is paroled into the U.S. under section 212(d)(5) of INA for a period of at least one year. (8 U.S.C. § 1641(b)(4)) YES NO YES YES Noncitizens granted withholding of deportation4,5 Section 241(b)(3) of the INA, as amended. (8 U.S.C. § 1641(b)(5)) YES NO YES YES Noncitizens granted conditional entry prior to April 1, 1980 An individual is granted conditional entry pursuant to section 203(a)(7) of INA as in effect prior to Apr. 1, 1980. (8 U.S.C. § 1641(b)(6)) YES NO YES YES Noncitizens subject to battery or extreme cruelty by their U.S. citizen or LPR relative, including their noncitizen spouse, child(ren), or parent(s) As qualified under the Violence Against Women Act (VAWA), an individual who has been battered or subjected to extreme cruelty in the U.S. by a spouse or a parent, or by a member of the spouse’s or parent’s family residing in the same household as the alien, but only if (in the opinion of the agency providing such benefits) there is a substantial connection between such battery or cruelty and the need for the benefits to be provided (8 U.S.C. § 1641(c)). This also includes noncitizen parents of battered children (8 U.S.C. § 1641(c)(2)) and noncitizen children of a battered parent (8 U.S.C. § 1641(c)(3)). YES NO YES YES

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Immigration Status/Category Before 10/1/26 On and After 10/1/26 Before, On, and After 10/1/26 Eligible for Full Medicaid & CHIP Benefits FFP for Full Medicaid & CHIP Benefits1 FFP for Emergency Medicaid Only1 FFP for Full Medicaid & CHIP Benefits under the CHIPRA 214 Option2 Noncitizens granted nonimmigrant status as a victim of trafficking (VoT) or who have a pending application that sets forth a prima facie case for eligibility for such immigration status 8 U.S.C. § 1101(a)(15)(T)(i), 22 U.S.C. § 7105(b)(1)(A). (8 U.S.C. § 1641(c)(4)) YES NO YES YES Noncitizens who are “victim[s] of a severe form of trafficking in persons” and certain family members 8 U.S.C. § 1101(a)(15)(T)(ii); 22 U.S.C. § 7105(b)(1)(A) and (C). (8 U.S.C. § 1641(c)(4)) YES NO YES YES Amerasian immigrants4,5 Section 204(f) of the INA; Section 584 of the Foreign Operations, Export Financing, and Related Programs Appropriations Act, 1988 (P.L. 100–202, as amended, enacted Dec. 22, 1987); as amended by the 9th proviso under Migration and Refugee Assistance in title II of the Foreign Operations, Export Financing, and Related Programs Appropriations Act, 1989 (P.L. 100–461, as amended, enacted Oct. 1, 1988). (8 U.S.C. § 1612(b)(2)(A)(i)(V)) YES NO7 YES YES Lawfully residing veterans/active-duty servicemembers and certain family members5 (8 U.S.C. § 1612(b)(2)(C)) YES NO YES YES

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Immigration Status/Category Before 10/1/26 On and After 10/1/26 Before, On, and After 10/1/26 Eligible for Full Medicaid & CHIP Benefits FFP for Full Medicaid & CHIP Benefits1 FFP for Emergency Medicaid Only1 FFP for Full Medicaid & CHIP Benefits under the CHIPRA 214 Option2 American Indians born in Canada8 or American Indians who are members of a federally recognized tribe Section 289 of the INA. (8 U.S.C. § 1612(b)(2)(E)) NOTE: This FFP exclusion would only apply to American Indians born in Canada and who are members of a federally recognized tribe who are not U.S. citizens. YES NO YES YES Certain Afghan parolees4 Section 2502 of the Extending Government Funding and Delivering Emergency Assistance Act (P.L. 117-43 as amended, enacted Sept. 30, 2021); as amended by Section 1501 of Title V of Division M of the Consolidated Appropriations Act (CAA), 2023, (P.L. 117-328). YES NO YES YES Certain Ukrainian parolees4 Section 401 of the Additional Ukraine Supplemental Appropriations Act (P.L. 117-128 as amended, enacted May 21, 2022); as amended by Section 301 of the Ukraine Security Supplemental Appropriations Act, 2024, (P.L. 118-50). YES NO YES YES Other lawfully residing noncitizens9 NO NO YES YES Table 1 Footnotes: 1. Excludes eligibility for the other lawfully present immigration statuses or categories under the CHIPRA 214 option not included in this table. See CMCS SHO #10-006, “Medicaid and CHIP Coverage of “Lawfully Residing” Children and Pregnant Women,” (July 1, 2010), available at https://www.medicaid.gov/federal-policy-guidance/downloads/SHO10006.pdf. 2. Under the CHIPRA 214 option, states can elect to provide full Medicaid and CHIP benefits to children (up to age 21 in Medicaid and up to age 19 in CHIP) and/or pregnant women who are lawfully residing in the U.S. A list of states that

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have elected the option is available at: https://www.medicaid.gov/medicaid/enrollment-strategies/medicaid-and-chip- coverage-lawfully-residing-children-pregnant-individuals. See the sections of this letter entitled Background and Interaction between Section 71109 of the WFTC Legislation and the CHIPRA 214 Option for more information. 3. Some states elect under their Medicaid state plan to limit eligibility of LPRs for full Medicaid benefits to LPRs who have 40 qualifying work quarters (8 U.S.C. § 1612(b)(2)(B)). See the sections of this letter entitled Background and Interaction between Section 71109 of the WFTC Legislation and PRWORA for more information. 4. Some states elect under their Medicaid state plan to limit eligibility for full Medicaid benefits to seven years for certain noncitizens (8 U.S.C. § 1612(b)(2)(A)(i)). See the sections of this letter entitled Background and Interaction between Section 71109 of the WFTC Legislation and PRWORA for more information. 5. Under 8 U.S.C. § 1613(b), certain specified qualified noncitizens have an exception from the five-year waiting period (described at 8 U.S.C. § 1613(a)). See the sections of this letter entitled Background and Interaction between Section 71109 of the WFTC Legislation and PRWORA for more information. 6. Medicaid coverage of COFA migrants is optional for the U.S. territories. 7. This row displays information for Amerasian immigrants who have not adjusted to LPR status since the programs are open indefinitely (https://www.uscis.gov/policy-manual/volume-7-part-p-chapter-9). Amerasians are exempt from the five-year waiting period (8 U.S.C. § 1613(b)(1)(E)). Many Amerasian immigrants have been admitted or adjusted to LPR status and thus would be considered FFP-eligible noncitizens under section 1903(v)(5) of the Act, exempt from the five-year waiting period. (see applicable rows in Table 1 on LPRs). 8. CHIP coverage is not applicable for this status or category. 9. See CMCS SHO #10-006, “Medicaid and CHIP Coverage of “Lawfully Residing” Children and Pregnant Women,” (July 1, 2010), available at: https://www.medicaid.gov/federal-policy-guidance/downloads/SHO10006.pdf. Individuals with deferred action under the Deferred Action for Childhood Arrivals (DACA) process are not eligible for full Medicaid and CHIP benefits under the CHIPRA 214 option; see CMCS SHO letter #12-002, “Individuals with Deferred Action for Childhood Arrivals,” (Aug. 28, 2012), available at: https://www.medicaid.gov/federal-policy- guidance/downloads/SHO-12-002.pdf.

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APPENDIX B - Summary of Hub Changes in Accordance with Section 71109 of the WFTC Legislation As described previously in the section entitled Verification of Immigration Status, the Hub VLP v37.1 v2 service applies translation logic to the DHS SAVE program response data and provides the following response indicators to verify immigration and citizenship status: • Naturalized or Derived Citizenship (U.S. Citizen Code) • Lawful Presence Verified (LPV) • Eligible Noncitizen (ENC) Status69 • Qualified Noncitizen (QNC) Status* • Five-Year Bar Applicable (5Yr Bar Apply) • Five-Year Bar Met (5Yr Bar Met) For each of these immigration and citizenship indicators, the Hub returns indicators set to either: Y (for Yes), N (for No), P (for Pending), or X (for Not Applicable). The Hub will return two ENC indicators: (1) for APTC/CSR eligibility (APTC ENC) entitled “APTCEligibleNonCitizenCode,” and (2) for FFP availability in Medicaid/CHIP (MC ENC) entitled “MCEligibleNonCitizenCode.” The APTC ENC and MC ENC are new indicators added to the Hub VLP v37.1 v2 service. The values returned for the APTC ENC and MC ENC indicators will be identical and can be used to verify that an applicant or beneficiary is an LPR, Cuban/Haitian entrant, or COFA migrant. As described previously in this letter, all FFP-eligible noncitizens (i.e., MC ENCs) are QNCs and considered lawfully present. *NOTE: Due to the statutory changes made by the WFTC legislation, the QNC indicator will have limited usage beginning October 1, 2026, for Medicaid and CHIP. TABLE 2. Overview of Hub Indicator Logic, by FFP-Eligible Noncitizen Status/Category Description LPV ENC (APTC & MC) QNC 5Yr Bar Apply 5Yr Bar Met LPR Y Y Y Y/N/P Y/N/P/X Cuban/Haitian entrant Y Y Y N X COFA migrant Y Y Y N X

69 If the “Eligible Noncitizen (ENC) Status” is Yes (“Y”), then the noncitizen has been verified by DHS SAVE program to be either a Lawful Permanent Resident (LPR), a Cuban/Haitian entrant, or a COFA migrant and, therefore, in an immigration status or category for which the state can receive FFP for full Medicaid or CHIP benefits in accordance with section 1903(v)(5) of the Act.

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The following table provides a summary of the Hub indicators for each immigration status or category code that SAVE returns to the Hub. This table only reflects the Hub indicator logic for SAVE Step 1 (Initial Verification step). In addition to the Hub indicators and the SAVE response data, the Hub also returns an “Agency Action” field to states to identify any next steps, where necessary, to verify immigration status or category. In some cases, states will need to proceed to Step 2 (Additional Verification) and/or Step 3 (Third Verification) to verify an individual’s immigration status or category. For additional information, including Step 2 and Step 3 Hub logic, please refer to the Hub’s “Verify Lawful Presence (VLP) v37.1 v2 Business Service Definition” (BSD).70 NOTE: For any instances where the Hub indicator is set to “P” (for pending) or instances where the table lists multiple Hub indicator responses, please consult the Hub VLP v37.1 v2 BSD. For example, these indicators may require additional information (e.g., documentation and confirmation of an individual’s Cuban/Haitian entrant status) or may be dependent on additional DHS SAVE response data (e.g., grant date). TABLE 3. Hub Indicator Logic by ESC, Step 1 ESC COA Code or Condition LPV ENC (APTC & MC) QNC 5Yr Bar Apply 5Yr Bar Met 1 AS6, AS7, AS8, GA6, GA7, GA8, 2D, 4A, 4-A, 4B, 4C, 4D, 4F, 6, 6A3, C7P, HH6, IC6, IC7, K9, K10, P75, R86, RE6, RE7, RE8, RE9, REF, RRA, Y11, Y12, Y13, Y14, Y16, Y4, Y5, Y64, Y7, Y9, NC6, NC7, NC8, NC9, A16, A17, A31, A32, A33, A36, A37, A38, AM1, AM2, AM3, AM6, AM7, SQ1, SQ2, SQ3, SQ6, SQ7, SQ8, SI1, SI2, SI3, SI6, SI7, SI8, ST0, ST1, ST7, ST8, ST9, SW1, SW2, SW3, S13, HF, LR6, LR7, LR8, LR9, YY, ZZ, NAI, SI9, A19 Y Y Y N X 1 CNP, CU0, CU6, CU7, CU8, CU9, CUP, HA6, HA7, HA8, HA9, HB6, HB7, HB8, HB9, HC6, HC7, HC8, HC9, HD6, HD7, HD8, HD9, HE6, HE7, HE8, HE9 Y Y Y N X

70 The Hub “Verify Lawful Presence (VLP) v37.1v2 Business Service Definition” (BSD) is available in zONE. Please contact cmsvlpsupport@hcgov.us for questions related to the Hub VLP v37.1v2 BSD and for assistance accessing zONE.

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ESC COA Code or Condition LPV ENC (APTC & MC) QNC 5Yr Bar Apply 5Yr Bar Met 1 CB1, CB2, CB6, CH6 Y Y Y P P 1 ST6 Y Y Y N/P X/P 1 COA other than: AS6, AS7, AS8, GA6, GA7, GA8, 2D, 4A, 4-A, 4B, 4C, 4D, 4F, 6, 6A3, C7P, HH6, IC6, IC7, K9, K10, P75, R86, RE6, RE7, RE8, RE9, REF, RRA, Y11, Y12, Y13, Y14, Y16, Y4, Y5, Y64, Y7, Y9, NC6, NC7, NC8, NC9, A16, A17, A31, A32, A33, A36, A37, A38, AM1, AM2, AM3, AM6, AM7, SQ1, SQ2, SQ3, SQ6, SQ7, SQ8, SI1, SI2, SI3, SI6, SI7, SI8, ST0, ST1, ST7, ST8, ST9, SW1, SW2, SW3, S13, HF, LR6, LR7, LR8, LR9, YY, ZZ, NAI, SI9, A19, CNP, CU0, CU6, CU7, CU8, CU9, CUP, HA6, HA7, HA8, HA9, HB6, HB7, HB8, HB9, HC6, HC7, HC8, HC9, HD6, HD7, HD8, HD9, HE6, HE7, HE8, HE9, CB1, CB2, CB6, CH6, ST6 Y Y Y Y Y/N/P 1 No COA Y Y Y P P 10 (dependent on EAD Category Code) Y/N/P Y/N/P Y/N/P Y/N/P/X Y/N/P/X 128 COA other than FSM, MIS, PAL, T1, PI Y N N X X 128 FSM, MIS, PAL Y Y Y N X 128 T1 Y N Y N/P X/P 128 COA = PI or No COA and no EAD Category Code Y P P P P 128 No COA but EAD category code exists Y/N/P Y/N/P Y/N/P Y/P/X Y/N/P/X 13, 328, 386 DE, EXC N N N X X 13, 328, 386 T2, T3, T4, T5, T6 Y N Y N X 13, 328, 386 FSM, MIS, PAL Y Y Y N X 13, 328, 386 PI, CC, CH, DT, ML, OP, or No COA Code Y P P P P

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ESC COA Code or Condition LPV ENC (APTC & MC) QNC 5Yr Bar Apply 5Yr Bar Met 13, 328, 386 CP Y N/P P P P 13, 328, 386 IN, PR Y P Y P P 13, 328, 386 CM Y N Y Y Y/N/P 13, 328, 386 Any COA other than: DE, EXC, T2, T3, T4, T5, T6, FSM, MIS, PAL, CP, IN, PR, CM, PI, CC, CH, DT, ML, OP Y N N X X 15, 368, 369, 374, 385 Country code = CUB or HTI Y/P P P P P 189 Country code = CUB or HTI Y P P P P 15, 189, 369, 374 Country code other than CUB or HTI (or empty) Y N N X X 368 Country code other than CUB or HTI (or empty) N/P N N/P X/P X/P 385 Country code other than CUB or HTI (or empty) P N N X X 18, 20 Country code = CUB or HTI Y P Y N X 18, 20 Country code other than CUB or HTI (or empty) Y N Y N X 188, 376, 387 N/A N N N X X 22, 122, 168, 372, 373, 375, 380, 382, 384 N/A Y N N X X 228 N/A P N N X X 248, 249 CQ1, CQ2, CQ3 Y Y Y N X 248, 249 COA other than CQ1, CQ2, CQ3, or No COA Y Y Y Y Y/N/P 250 COA = WHP; Country code = CUB or HTI Y Y Y N X 250 COA = WHP; Country code is empty Y P P P P 250 COA = WHP; Country code other than CUB or HTI Y N Y/N/P Y/P/X Y/N/P/X 250, 288, 381, 401, 402 HHP, CHP, RCU, RHT Y Y Y N X 250, 288, 381, 401, 402 SQ4, SQ5, OAR Y N Y/P N/P X/P 250, 288, 381, 401, 402 UHP; Country code = UKRAI, UKR, or UP Y N Y/P N/P X/P

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ESC COA Code or Condition LPV ENC (APTC & MC) QNC 5Yr Bar Apply 5Yr Bar Met 250, 288, 381, 401, 402 PAR, DT; Country code = AFGHA, AFG, AF, UKRAI, UKR, or UP Y N Y/P N/P X/P 250, 288, 381, 401, 402 PAR, DT; Country code = CUB or HTI Y P Y/P P P 250, 288, 381, 401, 402 PAR, DT; Country code other than AFGHA, AFG, AF, UKRAI, UKR, UP, CUB, or HTI Y N Y/N/P Y/P/X Y/N/P/X 250, 288, 381, 401, 402 COA other than HHP, CHP, RCU, RHT with Cuban/Haitian Entrant attestation P P P P P 250, 288, 381, 401, 402 COA other than HHP, CHP, RCU, RHT, SQ4, SQ5, OAR, UHP, PAR, DT without Cuban/Haitian Entrant attestation; Country code = CUB or HTI Y P Y/P P P 250, 288, 381, 401, 402 COA other than HHP, CHP, RCU, RHT, SQ4, SQ5, OAR, UHP, PAR, DT without Cuban/Haitian Entrant attestation; Country code other than CUB or HTI (or empty) Y N Y/N/P Y/P/X Y/N/P/X 250, 288, 381, 401, 402 COA code is missing Y P P P P 251, 371, 383 N/A Y N Y N X 377, 378, 379 N/A Y/P N Y Y P 4 N/A Y Y Y N X 5, 39, 44, 370 N/A P P P P P

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For ESC 10 or 128, the Hub uses the EAD Category Code when determining the Hub indicators. This logic will not apply to any other ESCs returned on Step 1. See the following table for Hub indicator logic as related to EAD Category Codes for ESC 10 and 128. TABLE 4. Hub Indicator Logic using EAD Category Codes for ESC 10 and 128, Step 1 EAD Category Code Condition LPV ENC (APTC & MC) QNC 5Yr Bar Apply 5Yr Bar Met A02, A04, C08, C09, C09P, C091, C11, C19 Country code CUB or HTI Y P P P P A02, C08, C09, C09P, C091, C19 Country code not CUB or HTI (or empty) Y N N X X A03, A05, A10 Country code CUB or HTI Y P Y N X A03, A05, A10 Country code not CUB or HTI (or empty) Y N Y N X A04, C11 Country code not CUB or HTI (or empty) Y N P P P A06, A07, A09, A11, A12, A13, A15, A17, A18, A19, A20, C01, C011, C012, C02, C03A, C03B, C03C, C031, C032, C033, C034, C04, C041, C042, C05, C06, C07, C10, C12, C14, C16, C16P, C171, C172, C173, C18, C20, C21, C22, C24, C26 N/A Y N N X X A08 N/A Y Y Y N X A14, C33 N/A N N N X X A16 (dependent on grant date) Y N Y P P C13, C151, C152 N/A P P P P P C25 N/A Y N Y N X C27, C28, C29, C30 N/A Y N P P P C31 N/A Y N Y Y P C35, C36 N/A P N N X X C40 (If C40 is received, Hub will set these indicators regardless of the ESC or COA code.) Y N Y P P

(10-006)SHO #10-006 (State Health Official letter, July 1, 2010)#

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(12-002)SHO #12-002 (State Health Official letter, August 28, 2012)#

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(21-007)SHO #21-007, Improving Maternal Health and Extending Postpartum Coverage (December 7, 2021)#

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