When the COVID-19 pandemic hit, the government put handcuffs on eligibility enforcement for Medicaid, spiking enrollment to 100 million—including millions of ineligible enrollees.
In 2023, states were able to restart efforts to clean up their Medicaid rolls and remove ineligible people from the program. Unsurprisingly, these efforts to shore up the integrity of Medicaid are being met with resistance and schemes from the Biden administration.
A new report from the Foundation for Government Accountability exposes the ways in which the Centers for Medicare & Medicaid Services (CMS) is working to keep Medicaid enrollment and retention as high as possible—and what states can do to fight back.
Here’s some of what CMS has been up to:
1. CMS is removing state options for determining Medicaid eligibility.
A new CMS rule prohibits states from checking eligibility more than once per year, with the goal of growing the Medicaid program and keeping enrollment high. CMS estimates the rule will add an additional 1.3 million people to the rolls and cost nearly $59 billion over five years. The true cost will likely be much higher.
2. CMS is pushing multi-year continuous eligibility waivers.
Section 1115 waivers allow states to obtain permission from CMS to alter their protocols from the typical Medicaid rules. During the Trump administration, states used waivers to pass work requirements and enhance program integrity. However, President Biden’s CMS canceled state waivers for work requirements and is encouraging states to implement waivers that allow for continuous Medicaid eligibility for multiple years.
3. CMS is accepting self-attestation and post-enrollment income verification.
CMS allows for self-attestation without proof for some eligibility criteria. It also allows for proof of income after a person has already enrolled in the program, opening a door to fraud and abuse.
4. CMS is politically targeting states that are disenrolling ineligible Medicaid recipients.
In April 2023, states were allowed to begin performing Medicaid redeterminations for the first time in more than three years. Rather than applauding the efforts of states to ensure that only eligible people remain on the rolls, CMS sent warning letters to reprimand nine states—all with Republican governors—for disenrolling people whose applications were incomplete.
5. CMS is delaying a return to normal eligibility rules and processes after the pandemic.
While states were supposed to complete the redetermination process for all Medicaid enrollees by June 2024, CMS extended this deadline to December 2024 and then again to June 2025—more than five years after the start of the pandemic. While these delays continue, millions of ineligible individuals will continue to receive Medicaid.
This includes waivers allowing states to reenroll individuals at or below 100 percent of the federal poverty level in March 2019 without formal income verification. That means these individuals’ incomes have not been verified for up to six years, and many may no longer be eligible for Medicaid.
While CMS pursues sneaky strategies to surge Medicaid enrollment, states and Congress must implement safeguards to ensure that resources are preserved for the truly needy.
For specific examples of CMS schemes hurting state budgets (and suggestions for how to resist federal pressure and safeguard program integrity), read the full paper here.
