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. § 435.916

Periodic renewal of Medicaid eligibility

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(a) Renewal of individuals whose Medicaid eligibility is based on modified adjusted gross income methods (MAGI). (1) Except as provided in paragraph (d) of this section, the eligibility of Medicaid beneficiaries whose financial eligibility is determined using MAGI-based income must be renewed once every 12 months, and no more frequently than once every 12 months.

(2) Renewal on basis of information available to agency. The agency must make a redetermination of eligibility without requiring information from the individual if able to do so based on reliable information contained in the individual's account or other more current information available to the agency, including but not limited to information accessed through any data bases accessed by the agency under §§ 435.948, 435.949, and 435.956. If the agency is able to renew eligibility based on such information, the agency must, consistent with the requirements of this subpart and part 431, subpart E of this subchapter, and notify the individual—

(i) Of the eligibility determination, and basis; and

(ii) That the individual must inform the agency, through any of the modes permitted for submission of applications under § 435.907(a), if any of the information contained in such notice is inaccurate, but that the individual is not required to sign and return such notice if all information provided on such notice is accurate.

(3) Use of a pre-populated renewal form. If the agency cannot renew eligibility in accordance with paragraph (a)(2) of this section, the agency must—

(i) Provide the individual with—

(A) A renewal form containing information, as specified by the Secretary, available to the agency that is needed to renew eligibility.

(B) At least 30 days from the date of the renewal form to respond and provide any necessary information through any of the modes of submission specified in § 435.907(a), and to sign the renewal form in a manner consistent with § 435.907(f);

(C) Notice of the agency's decision concerning the renewal of eligibility in accordance with part 431, subpart E of this subchapter;

(ii) Verify any information provided by the beneficiary in accordance with §§ 435.945 through 435.956;

(iii) Reconsider in a timely manner the eligibility of an individual who is terminated for failure to submit the renewal form or necessary information, if the individual subsequently submits the renewal form within 90 days after the date of termination, or a longer period elected by the State, without requiring a new application; and

(iv) Not require an individual to complete an in-person interview as part of the renewal process.

(b) Redetermination of individuals whose Medicaid eligibility is determined on a basis other than modified adjusted gross income. The agency must redetermine the eligibility of Medicaid beneficiaries excepted from modified adjusted gross income under § 435.603(j), or circumstances that may change, at least every 12 months. The agency must make a redetermination of eligibility in accordance with the provisions of paragraph (a)(2) of this section, if sufficient information is available to do so. The agency may adopt the procedures described at paragraph (a)(3) of this section for individuals whose eligibility cannot be renewed in accordance with paragraph (a)(2) of this section.

(1) The agency may consider blindness as continuing until the reviewing physician under § 435.531 determines that a beneficiary's vision has improved beyond the definition of blindness contained in the plan; and

(2) The agency may consider disability as continuing until the review team, under § 435.541, determines that a beneficiary's disability no longer meets the definition of disability contained in the plan.

(c) Procedures for reporting changes. The agency must have procedures designed to ensure that beneficiaries make timely and accurate reports of any change in circumstances that may affect their eligibility and that such changes may be reported through any of the modes for submission of applications described in § 435.907(a).

(d) Agency action on information about changes. (1) Consistent with the requirements of § 435.952, the agency must promptly redetermine eligibility between regular renewals of eligibility described in paragraphs (b) and (c) of this section whenever it receives information about a change in a beneficiary's circumstances that may affect eligibility.

(i) For renewals of Medicaid beneficiaries whose financial eligibility is determined using MAGI-based income, the agency must limit any requests for additional information from the individual to information relating to such change in circumstance.

(ii) If the agency has enough information available to it to renew eligibility with respect to all eligibility criteria, the agency may begin a new 12-month renewal period under paragraph (a) or (b) of this section.

(2) If the agency has information about anticipated changes in a beneficiary's circumstances that may affect his or her eligibility, it must redetermine eligibility at the appropriate time based on such changes.

(e) Information requests. The agency may request from beneficiaries only the information needed to renew eligibility. Requests for non-applicant information must be conducted in accordance with § 435.907(e).

(f) Consideration for other bases of eligibility and other insurance affordability programs. Determination of ineligibility and transmission of data pertaining to individuals no longer eligible for Medicaid.

(1) Prior to making a determination of ineligibility, the agency must consider all bases of eligibility, consistent with § 435.911.

(2) For individuals determined ineligible for Medicaid, the agency must determine potential eligibility for other insurance affordability programs and comply with the procedures set forth in § 435.1200(e).

(g) Renewal form and notice format. Any renewal form or notice must be accessible to persons who are limited English proficient and persons with disabilities, consistent with § 435.905(b).

(h) Sunset date. The provisions of this section sunset on October 1, 2034. CMS will follow applicable rulemaking procedures to ensure that policies governing the periodic renewals of Medicaid eligibility and redeterminations based on changes in circumstances 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 33 cases (5 in the last 5 years), 1979–2025 · leading case: Blum v. Yaretsky, 457 U.S. 991 (1982).
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Blum v. Yaretsky, 457 U.S. 991 (1982). · cites it 2× “See 42 CFR § 435.916 (1981). Adjustments in benefit levels in response to a decision to discharge or transfer a patient does not constitute approval or enforcement of that decision.”
Melissa Wilson v. Darin Gordon, 822 F.3d 934 (6th Cir. 2016). · cites it 2× “42 C.F.R. § 435.916 (a)(1). However, federal regulations implementing Medicaid require that states continue to provide Medicaid to applicants while their applications for renewal are considered.”
Salazar v. Dist. of Columbia, 896 F.3d 489 (D.C. Cir. 2018). · cites it 3× “Compare 42 C.F.R. § 435.916 (2016) (prescribing "renewal" of Medicaid eligibility), with Salazar v.”
Doe v. Kidd, 501 F.3d 348 (4th Cir. 2007). · cites it 2× “" 42 C.F.R. § 435.916 (a). Likewise, with respect to services rendered under the Medicaid MD/RD Waiver program (in which Doe participated), South Carolina's Waiver agreement with Health and Human Services obligates it to "provide for an evaluation (and periodic reevaluations, at…”
Massachusetts Ass'n of Older Americans v. Alexander Sharp, Ii, Etc., 700 F.2d 749 (1st Cir. 1983). · cites it 3× “See 42 C.F.R. § 435.916 (e) (1981). They admit that they are no longer automatically eligible for Medicaid as AFDC recipients.”
Stenson v. Blum, 476 F. Supp. 1331 (S.D.N.Y. 1979). · cites it 2× “For example, 42 C.F.R. § 435.916 (c) (1979) provides that “[t]he [state] agency must promptly redetermine eligibility when it receives information about changes in a recipient’s circumstances that may affect his eligibility.”
Rosen v. Tennessee Comm'r of Fin. & Admin., 280 F. Supp. 2d 743 (M.D. Tenn. 2002). · cites it 4× “§§ 1396 (a)(8) and 1396a(19) and 42 C.F.R. §§ 435.916 and 435.930. Accordingly, because at this time it does, not appear that the uninsured and uninsura-ble coverage is provided for in the federal statutes and regulations, the Court finds that plaintiffs have failed to…”
Salazar v. Dist. of Columbia, 177 F. Supp. 3d 418 (D.D.C. 2016). · cites it 4× “See 42 C.F.R. § 435.916 . Section III of the Settlement Order does not rest on the ACA’s passive renewal model.”
Oberlander v. Perales, 740 F.2d 116 (2d Cir. 1984). “1983) (Medicaid terminations alleged to be in conflict with 42 C.F.R. § 435.916 (c) (1983)); Massachusetts General Hospital v.”
Morabito v. Blum, 528 F. Supp. 252 (S.D.N.Y. 1981). “See 42 C.F.R. § 435.916 . 24 . Defendant Blum has represented to the Court, and plaintiffs do not contest her assertion, that the MAC now includes, and has included since October 1980, Medicaid recipients among its membership.”
Ctr. for Special Needs Trust Admin., Inc. v. Olson, 676 F.3d 688 (8th Cir. 2012). “42 C.F.R. § 435.916 (requiring periodic redeterminations of Medicaid eligibility); N.”
Houghton Ex Rel. Houghton v. Reinertson, 382 F.3d 1162 (10th Cir. 2004). “Unlike a situation where a party acquires new wealth, the Sellers’ circumstances have not changed. Moreover, this regulation directly conflicts with § 1396r-5(c)(4), which shields resources belonging to the community spouse from annual reevaluation.”
Show all 33 citing cases →
42 C.F.R. § 435.916(a): 2 cases
Rosen v. Tennessee Comm'r of Fin. & Admin., 280 F. Supp. 2d 743 (M.D. Tenn. 2002). “§§ 1396 (a)(8) and 1396a(19) and 42 C.F.R. §§ 435.916 and 435.930. Accordingly, because at this time it does, not appear that the uninsured and uninsura-ble coverage is provided for in the federal statutes and regulations, the Court finds that plaintiffs have failed to…”
Eldridge v. D.C. DHS, No. 18-AA-664 (D.C. Apr. 8, 2021).
42 C.F.R. § 435.916(f)(1): 1 case
D.C. & M.L. Vs. Div. of Med. Assistance & Health Servs. (Div. of Med. Assistance & Health Servs.), 235 A.3d 1036 (N.J. Super. Ct. App. Div. 2020).
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