Highlighting recent federal regulatory actions

The CMS’ proposed rule to streamline the Medicaid and Children’s Health Insurance (“CHIP”) eligibility processes and request for public comment on the creation of a national provider database affects states, payers, and providers. To report on the development of public comment, this article summarizes key elements of the agency’s recent releases.

Notice of Medicaid Eligibility to Develop Proposed Rules

On September 7, 2022, the Centers for Medicare and Medicaid Services (“CMS”) released a proposed rule titled “Simplifying Medicaid, Children’s Health Insurance, Basic Health Program Application, Eligibility Determination, and Enrollment and Renewal Processes” in the Federal Register.1 This proposed rule is CMS’ response to the Biden administration in April 20222 and January 20213 Executive orders to improve access to health coverage. As the title of the proposed rule implies, CMS focuses on reducing burdens for individuals applying for Medicaid, CHIP, or Basic Health Program (“BHP”) coverage and making retention of coverage easier by reducing procedural hurdles.

The proposed changes will reduce disruption to Medicaid coverage, increase predictability and stability in health plan enrollment, and support continuity of treatment. While the proposed rule affects all Medicaid, CHIP, and BHP enrollees, there are special provisions for the elderly, the blind, the disabled, and eligible beneficiaries of Medicare provision programs. If regulatory changes are finalized, they will likely require eligibility system changes, policy and potential state regulatory changes during the Public Health Emergency (“PHE”) revocation period. PHE is currently approved through January 11, 2023,4 And if PHE is not extended, advance notice must be issued by Secretary of Health and Human Services Xavier Becerra around November 12, 2022.5

Equivalence in eligibility renewal criteria for MAGI and non-MAGI residents. CMS is proposing to extend Medicaid eligibility renewal criteria for adjusted gross income (“MAGI”) eligibility groups to non-MAGI eligibility groups. This means that individuals who qualify for Medicaid because of age, blindness, or disability will be subject to renewal decisions once every 12 months; You have at least 30 days to return the pre-filled form to the state and any requested information; You are not required to attend a personal eligibility interview. In addition, states will be required to reconsider an individual’s eligibility to return a pre-filled form within ninety days of termination.

Standardize timeframes for individuals to respond to requests for additional information. Current regulations set timeframes for state Medicaid agencies to submit eligibility decisions and renewals but do not establish a standard timeframe for individuals to provide the additional information requested. The proposed rule establishes these timeframes, based on the date the application is sealed or the electronic application is sent, as follows: 15 calendar days for new applicants who apply on the basis of other than disability status; 30 calendar days for new applicants who apply on the basis of disability; and 30 days for existing beneficiaries in the process of renewal.7

Use of returned mail for loss of eligibility purposes. CMS suggests that states can no longer use returned mail or notification of an in-state or out-of-state forwarding address as evidence of Medicaid ineligibility without data checks (for example, health plan enrollee information) to verify eligibility status. States will be required to contact individuals via methods other than mail and take specific additional steps prior to termination.8

Simplify enrollment in Medicare savings programmes. The proposed rule supports simplified and increased enrollment of low-income Medicare beneficiaries in Medicare Savings Programs (“MSPs”) that, based on path of eligibility, provide Medicaid coverage to pay Medicare A and B partial premiums and share costs. To achieve this, states will be required to begin the MSP selection process based on Medicare Low Income Benefit (“LIS”) data from the Social Security Administration and limit requests for information from individuals to complete the selection process. The CMS also proposes regulations to align the revenue and resource methodologies of the MSP with those of the LIS.9

chip proposals. In addition to several proposals to streamline CHIP eligibility and renewals, CMS is proposing to eliminate the state’s option to impose a lock-up period for non-payment of premiums.10

public comment period. Public comments were due by November 7, 2022, and CMS is particularly interested in feedback on reasonable compliance timeframes for states to implement the proposed changes. For example, a CMS seeks input on the feasibility of a country’s compliance with the provisions of the final rule within 90 days, 6 months, or 12 months of the effective date.11 While the Bureau of Information and Regulatory Affairs has not yet published the consolidated fall 2022 agenda for regulatory and non-regulatory actions, the author expects to release the final rule by spring 2023.12

Request information on creating a national directory of the provider

On October 7, 2022, CMS issued a Request for Information (“RFI”).13 Solicit public comments on the creation of a unified and interoperable National Directory of Health Providers (“NDH”) to be developed and maintained by CMS.

The CMS recognizes the costs and burdens to providers, payers, and patients that result from provider directory requirements that vary in the type of information collected, frequency of updates, and formats available. Provider directories are an essential resource for measuring and monitoring the adequacy of provider networks across health insurance programs, and errors are well documented.14 CMS is asking for comment on the following:

  • NDH’s technical platform and standards to simplify the validation, verification, and interoperability of provider directory information, such as the HL7® Fast Healthcare Interoperability Resources (“FHIR”) and Application Programming Interface (“API”) and integration of provider data from other CMS systems.
  • Incentives and policies to support timely and accurate data reporting and use of NDH.16
  • Standard Provider Directory data items, including information on social determinants of health.17
  • Considerations for implementation, including stakeholder involvement, technical and policy requirements and potential risks or challenges.18

public comment period. Public comments are due by December 6, 2022, and commenters can selectively comment on questions raised by the RFI content management system.19


These two opportunities for public comment should be of interest to the broad community of healthcare stakeholders. The Medicaid eligibility rule, as proposed, removes procedural hurdles that could cause coverage disruptions or delays affecting continuity of health care services and health plan enrollment in Medicaid managed care situations. Inaccuracy of Provider Directory information across coverage programs has been the subject of numerous studies and a long-term management challenge for both payers and providers. Public input received on several of the key areas identified by CMS will inform agency actions with regard to future rule-making for the creation of a national provider directory.


1: Department of Health and Human Services; Centers for Medicare and Medicaid Services, “Simplifying Medicaid, Children’s Health Insurance Program, Basic Health Program Application, Eligibility Determination, Enrollment, and Renewal Processes,” Federal Register Vol. 87, no. 172 (7 Sept. 2022): 54,760, https://www.govinfo.gov/content/pkg/FR-2022-09-07/pdf/2022-18875.pdf.

2: “Executive Order 14070 of April 5, 2022, Continuing to Promote Americans’ Access to Affordable, Quality Health Coverage,” Federal Register Vol. 87, no. 68 (April 8, 2022): 20689, https://www.govinfo.gov/content/pkg/FR-2022-04-08/pdf/2022-07716.pdf.

3: “Executive Order 14009 of January 28, 2021, Strengthening Medicaid and the Affordable Care Act,” Federal Register Vol. 86, no. 20 (2 Feb 2021): 7793, https://www.govinfo.gov/content/pkg/FR-2021-02-02/pdf/2021-02252.pdf.

4: Strategic Preparedness and Response Department, Secretary Xavier Becerra, “Reinventing Design with a Public Health Emergency” (October 13, 2022), https://aspr.hhs.gov/legal/PHE/Pages/covid19-13Oct2022.aspx.

5: Department of Health and Human Services, Office of the Assistant Secretary for Preparedness and Response, “Letter to Governors on the COVID-19 Response.” (January 21, 2022), https://aspr.hhs.gov/legal/PHE/Pages/Letter-to-Governors-on-the-COVID-19-Response.aspx.

6: See note 1 on pp. 54780-54786.

7: See note 1 on pp. 54786-54791.

8: See note 1 on pp. 54791-54794.

9: See note 1 on pp. 54763-54776.

10: See note 1 on pp. 54813-54814.

11: See footnote 1 on pp. 54760-54763.

12: The current consolidated agenda for regulatory and deregulatory actions is available at https://www.reginfo.gov/public/do/eAgendaMain.

13: Centers for Medicare and Medicaid Services, “Requesting Information; National Directory of Health Care Providers,” (October 7, 2022), Available here. https://www.federalregister.gov/public-inspection/2022-21904/request-for-information-national-directory-of-healthcare-providers-and-servisis.

14: See, for example, Centers for Medicare & Medicaid Services, “Online Providers Directory Review Report,” (last accessed Oct. 31, 2022), https://www.cms.gov/Medicare/Health-Plans/ManagedCareMarketing/Downloads/Provider_Directory_Review_Industry_Report_Round_2_Updated_1-31-18.pdf.

15: See note 13 on pp. 61023-61025.

16: See footnote 13 on p.61024.

17: See note 13 on pp. 61025-61026.

18: See footnote 13 on p.61028.

19: See footnote 13 on p.61018.

Copyright © 2022. The opinions expressed herein are those of the author(s) and are not necessarily those of FTI Consulting, Inc. or its management, subsidiaries, affiliates, or other professionals.

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