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Page 20 – 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. changes in circumstances, with limited exceptions (see Q17), until the end of the individual’s 12- month postpartum period. Therefore, Medicaid beneficiaries may remain in the eligibility group in which they are enrolled during pregnancy through the 12-month postpartum period, including individuals enrolled in the adult group under 42 C.F.R. § 435.119 who become pregnant after enrollment in the adult group and were not transitioned to another group during the course of their pregnancy.

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.