Verification And Notices

How States Must Verify

Data before paperwork Before a state asks a member for anything, it has to check what it already holds. The rule lists payroll data, 12 months of Medicaid claims and encounter data, records from other state and local agencies, federal data through CMS's data services hub and the state's own eligibility files.

Self-declaration has a limit Medical frailty can rest on a member's own statement only through January 2028, and the first renewal after that has to include supporting documents.

Health plans can help, but not decide Managed care plans are allowed to contact members and point out the ones who may qualify for an exemption, but the call on eligibility or compliance is the state's alone.

Notices And The 30-Day Window

Advance outreach States owe members a first notice no later than three months, plus the length of the look-back period, ahead of the start date. A state with a one-month look-back and a January 1, 2027 start had to send it by September 1, 2026. With a three-month look-back, the cutoff moved up to July 1, 2026.

Noncompliance notice A state that can't verify compliance sends a notice. From five days after the notice date, the member has 30 calendar days to show compliance or an exemption. Enrolled members stay covered throughout.

Before coverage ends No one loses coverage until the state has looked for another Medicaid pathway they qualify under. The member also gets a written notice with fair hearing rights, along with an explanation of how losing Medicaid may affect Marketplace premium tax credits.