Financial Eligibility Verification Requirements and Flexibilities

This Center for Medicaid and CHIP Services (CMCS) Informational Bulletin (CIB) is part of a series of guidance to support states’ efforts to verify eligibility and conduct renewals in a manner that supports program integrity and continuity of coverage for eligible Medicaid and Children’s Health Insurance Program (CHIP) beneficiaries in compliance with federal regulations. This CIB reminds states about current requirements and state flexibilities in verifying financial eligibility for Medicaid and CHIP in accordance with sections 1137, 1940, and 1902(a)(46)(A) of the Social Security Act (the Act) and implementing regulations at 42 C.F.R. §§ 435.940 through 435.952 and 457.380. It contains numerous examples to illustrate application of the various verification policies. These requirements are designed to promote efficient and appropriate use of federal and state dollars in enabling individuals who meet the Medicaid and CHIP eligibility standards to enroll in and retain coverage and ensuring those who do not or no longer meet eligibility requirements can be successfully transitioned to other available coverage. Further, these requirements ease administrative burden on states by maximizing use of electronic databsources, thereby reducing the need to process documentation or other additional information from applicants and beneficiaries and reducing denial and termination of coverage for procedural reasons when an individual has not provided requested information, even if they meet all eligibility requirements. The Centers for Medicare & Medicaid Services (CMS) is committed to protecting access to health care for the individuals enrolled in Medicaid and CHIP in a manner that improves continuity of coverage and protects the integrity of these programs.

Download the Guidance Document