C.F.R. » Title 42 » CHAPTER IV—CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES › SUBCHAPTER C—MEDICAL ASSISTANCE PROGRAMS › PART 435—ELIGIBILITY IN THE STATES, DISTRICT OF COLUMBIA, THE NORTHERN MARIANA ISLANDS, AND AMERICAN SAMOA › Subpart J—Eligibility in the States and District of Columbia

42 C.F.R. § 435.912

Timely determination of eligibility

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(a) For purposes of this section—

(1) Timeliness standards refer to the maximum period of time in which every applicant is entitled to a determination of eligibility, subject to the exceptions in paragraph (e) of this section.

(2) Performance standards are overall standards for determining eligibility in an efficient and timely manner across a pool of applicants, and include standards for accuracy and consumer satisfaction, but do not include standards for an individual applicant's determination of eligibility.

(b) Consistent with guidance issued by the Secretary, the agency must establish in its State plan timeliness and performance standards for promptly and without undue delay—

(1) Determining eligibility for Medicaid for individuals who submit applications to the single State agency or its designee.

(2) Determining potential eligibility for, and transferring individuals' electronic accounts to, other insurance affordability programs pursuant to § 435.1200(e).

(3) Determining eligibility for Medicaid for individuals whose accounts are transferred from other insurance affordability programs, including at initial application as well as at a regularly-scheduled renewal or due to a change in circumstances.

(c)(1) The timeliness and performance standards adopted by the agency under paragraph (b) of this section must cover the period from the date of application or transfer from another insurance affordability program to the date the agency notifies the applicant of its decision or the date the agency transfers the individual to another insurance affordability program in accordance with § 435.1200(e) and must comply with the requirements of paragraph (c)(2) of this section, subject to additional guidance issued by the Secretary to promote accountability and consistency of high quality consumer experience among States and between insurance affordability programs.

(2) Timeliness and performance standards included in the State plan must account for—

(i) The capabilities and cost of generally available systems and technologies;

(ii) The general availability of electronic data matching and ease of connections to electronic sources of authoritative information to determine and verify eligibility;

(iii) The demonstrated performance and timeliness experience of State Medicaid, CHIP and other insurance affordability programs, as reflected in data reported to the Secretary or otherwise available; and

(iv) The needs of applicants, including applicant preferences for mode of application (such as through an internet website, telephone, mail, in-person, or other commonly available electronic means), as well as the relative complexity of adjudicating the eligibility determination based on household, income or other relevant information.

(3) Except as provided in paragraph (e) of this section, the determination of eligibility for any applicant may not exceed—

(i) 90 days for applicants who apply for Medicaid on the basis of disability; and

(ii) 45 days for all other applicants.

(d) The agency must inform applicants of the timeliness standards adopted in accordance with this section.

(e) The agency must determine eligibility within the standards except in unusual circumstances, for example—

(1) When the agency cannot reach a decision because the applicant or an examining physician delays or fails to take a required action; or

(2) When there is an administrative or other emergency beyond the agency's control.

(3) When the agency is unable to meet the standards for applicants who are provided a notice of noncompliance to demonstrate community engagement due to the 30-calendar day period that States must provide for the individual to respond to such notice at § 435.558.

(f) The agency must document the reasons for delay in the applicant's case record.

(g) The agency must not use the time standards—

(1) As a waiting period before determining eligibility; or

(2) As a reason for denying eligibility (because it has not determined eligibility within the time standards).

(h) The provisions of this section sunset on October 1, 2034. CMS will follow applicable rulemaking procedures to ensure that policies governing timeliness standards for Medicaid eligibility are implemented and effective on October 1, 2034, replacing the policies scheduled to sunset on that date.

[91 FR 33480, June 3, 2026]
Notes of Decisions
Cited in 30 cases (5 in the last 5 years), 1984–2025 · leading case: Melissa Wilson v. Darin Gordon, 822 F.3d 934 (6th Cir. 2016).
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Melissa Wilson v. Darin Gordon, 822 F.3d 934 (6th Cir. 2016). · cites it 3× “42 C.F.R. § 435.912 (c)(3). The Medicaid statute additionally requires that states must “provide for granting an opportunity for a fair hearing before the State agency to any individual whose claim for medical assistance under the plan is denied or is not acted upon with…”
Roselyn Ford v. Dep't of Health & Human Servs., 931 N.W.2d 571 (Mich. 2019). · cites it 2× “The hypothetical trust provides that the third-party trustee must not make any distribution to the community spouse until after the Department has made a determination on the institutionalized spouse’s eligibility (which must be made within 45 days from the date of application,…”
Derek Waskul v. Washtenaw Cnty. Cmty. Mental Health, 979 F.3d 426 (6th Cir. 2020). “And the regulations make clear that the standard for “reasonable promptness” is within at least forty-five or ninety days, depending on the basis for an individual’s application.”
Guggenberger ex rel. Guggenberger v. State, 198 F. Supp. 3d 973 (D. Minn. 2016). “14 Regulations also require the state to establish time standards to determine an individual’s eligibility for Medicaid in no more than ninety days and to “[fjurnish Medicaid promptly to beneficiaries without any delay caused by the agency’s administrative proce *1007 dures.”
Salazar v. Dist. of Columbia, 896 F.3d 489 (D.C. Cir. 2018). “With exceptions not relevant here, both federal and local law have long required the District of Columbia to make Medicaid eligibility determinations within 45 days of an application for benefits, 42 C.F.R. § 435.912 (c)(3) ; D.C. Code § 4-205.”
Salazar v. Dist. of Columbia, 177 F. Supp. 3d 418 (D.D.C. 2016). · cites it 4× “The Parties disagree as to the scope of the problems that developed; however, it is clear that thousands of Medicaid beneficiaries were affected by (1) the District’s failure to process Medicaid applications *427 within 45 days in violation of 42 C.F.R. § 435.912 (c)(3) and D.C.…”
Rivera v. Kent, 37 Cal. App. 5th 529 (Cal. Ct. App. 2019). · cites it 4× “(See 42 C.F.R. § 435.912 (e).) 10 The term "unusual circumstances" *476 is defined illustratively in federal regulation 435.”
Lisnitzer v. Zucker, 983 F.3d 578 (2d Cir. 2020). “See 42 C.F.R. § 435.912 (c)(3)(ii). 6 1 In New York, a Medicaid applicant who is denied benefits by a local 2 agency may appeal to DOH for a fair hearing to contest the denial.”
Koss v. Norwood, 305 F. Supp. 3d 897 (E.D. Ill. 2018). · cites it 7× “The court enters a preliminary injunction requiring defendants to presume that applicants for long-term care Medicaid benefits be presumptively eligible after the expiration of the deadlines to decide their applications set forth in governing federal regulations.”
Ability Ctr. v. Lumpkin, 808 F. Supp. 2d 1003 (N.D. Ohio 2011). “See also 42 C.F.R. § 435.912 (the agency must send each applicant a written notice of the agency’s decision on his application, and, if eligibility is denied, the reasons for the action, the specific regulation supporting the action, and an explanation of his or her right to…”
Kessler v. Blum, 591 F. Supp. 1013 (S.D.N.Y. 1984). “10 (a)(4), nor its re-codification in the Medicaid regulations at 42 C.F.R. § 435.912 , requires notices to be given upon approvals of prior approval requests.”
Padron v. Feaver, 180 F.R.D. 448 (S.D. Fla. 1998). · cites it 2× “” 42 C.F.R. § 435.912 . Furthermore, applicants must be provided with an opportunity for a fair hearing if their application is not acted on with reasonable promptness.”
Show all 30 citing cases →
42 C.F.R. § 435.912(c)(3): 1 case
Koss v. Eagleson, No. 1:17-cv-02762 (N.D. Ill. Mar. 29, 2018).
42 C.F.R. § 435.912(c)(3)(i): 1 case
Genesis Healthcare v. Delaware Dep't of Health & Soc. Servs., No. N17A-11-001 AML (Del. Super. Ct. June 22, 2018).
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