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

Regularly scheduled renewals of Medicaid eligibility

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(a) Frequency of renewals. Except as provided in § 435.919:

(1) The eligibility of all Medicaid beneficiaries not described in paragraph (a)(2) of this section must be renewed once every 12 months, and no more frequently than once every 12 months.

(2) The eligibility of qualified Medicare beneficiaries described in section 1905(p)(1) of the Act must be renewed at least once every 12 months, and no more frequently than once every 6 months.

(b) Renewals of eligibility—(1) Renewal on basis of information available to agency. The agency must make a redetermination of eligibility for all Medicaid beneficiaries 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 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 subpart E of part 431 of this chapter, 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.

(2) Renewals requiring information from the individual. If the agency cannot renew eligibility for beneficiaries in accordance with paragraph (b)(1) of this section, the agency—

(i) Must provide the individual with—

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

(B) At least 30 calendar days from the date the agency sends 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 under penalty of perjury in a manner consistent with § 435.907(f).

(C) Notice of the agency's decision concerning the renewal of eligibility in accordance with this subpart and subpart E of part 431 of this chapter.

(ii) Must verify any information provided by the beneficiary in accordance with §§ 435.945 through 435.956.

(iii) If the individual subsequently submits the renewal form or other needed information within 90 calendar days after the date of termination, or a longer period elected by the State, must treat the renewal form as an application and reconsider the eligibility of an individual whose coverage is terminated for failure to submit the renewal form or necessary information in accordance with the application time standards at § 435.912(c)(3) without requiring a new application.

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

(v) 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).

(3) Special rules related to beneficiaries whose Medicaid eligibility is determined on a basis other than modified adjusted gross income. (i) 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

(ii) 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) Timeliness of renewals. The agency must complete the renewal of eligibility in accordance with this section by the end of the beneficiary's eligibility period described in paragraph (a) of this section and in accordance with the time standards in § 435.912(c)(4).

(d) 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) Prior to terminating coverage for individuals determined ineligible for Medicaid, the agency must determine eligibility or potential eligibility for other insurance affordability programs and comply with the procedures set forth in § 435.1200(e).

(e) Accessibility of renewal forms and notices. Any renewal form or notice must be accessible to persons who are limited English proficient and persons with disabilities, consistent with § 435.905(b).

[89 FR 22869, Apr. 2, 2024]
Notes of Decisions
Cited in 33 cases (5 in the last 5 years), 1979–2025 · leading case: Blum v. Yaretsky
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Blum v. Yaretsky (1982) scotus · 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 (2016) ca6 · 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 (2018) cadc · cites it 3× “Compare 42 C.F.R. § 435.916 (2016) (prescribing "renewal" of Medicaid eligibility), with Salazar v.”
Doe v. Kidd (2007) ca4 · 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 Association of Older Americans v. Alexander Sharp, Ii, Etc. (1983) ca1 · 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 (1979) nysd · 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 Commissioner of Finance & Administration (2002) tnmd · 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. District of Columbia (2016) dcd · 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 (1984) ca2 “1983) (Medicaid terminations alleged to be in conflict with 42 C.F.R. § 435.916 (c) (1983)); Massachusetts General Hospital v.”
Morabito v. Blum (1981) nysd “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.”
Center for Special Needs Trust Administration, Inc. v. Olson (2012) ca8 “42 C.F.R. § 435.916 (requiring periodic redeterminations of Medicaid eligibility); N.”
Houghton Ex Rel. Houghton v. Reinertson (2004) ca10 “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 Commissioner of Finance & Administration (2002) tnmd “§§ 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 (2021) dc
— 42 C.F.R. § 435.916(f)(1) — 1 case
D.C. AND M.L. VS. DIVISION OF MEDICAL ASSISTANCE AND HEALTH SERVICES (DIVISION OF MEDICAL ASSISTANCE AND HEALTH SERVICES (2020) njsuperctappdiv
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