QUESTION

I just got a notice that my Medicaid benefits are being terminated in less than 10 days. How can I make sure I don’t have a gap in insurance?

Transitions from Medicaid to Private Insurance | Transitions from Medicaid to Private Insurance |
ANSWER

You will need to act quickly to ensure you do not have a gap in insurance.

You may have received a termination notice because your Medicaid agency did not receive the information needed to renew your coverage. If you received a renewal notice in the mail but did not submit the required documentation as directed, you have 90 days from the date of termination to submit your renewal paperwork to your Medicaid agency. If you are still eligible for Medicaid, your Medicaid agency is required to reinstate your coverage once your renewal is processed. If it has been more than 90 days since your termination, you may reapply for Medicaid benefits at any time. In most states, in either situation, your coverage can be made retroactive up to three months if you received services that would be covered by Medicaid during that time, and met eligibility requirements at the time you received such services. (42 U.S.C. § 1396a(a)(34); 45 C.F.R. §§ 435.915, 435.916)

If you submitted the required renewal information on time and believe you received a termination notice in error or if you believe the state made a mistake in determining you ineligible, you have the right to appeal the state’s decision through a fair hearing. The termination notice you received should include information about how to request a hearing. You can do so by mail, in person, by telephone, or online. If you decide to request a hearing, you have at most 90 days from the day the termination notice was mailed to you to do so—some states may have shorter time frames within which you must request a hearing, so it is in your best interest to proceed by following the steps specified on your termination letter as soon as possible. If you need assistance, please reach out to the legal services organization in your area. (42 C.F.R. Part 431, Subpart E)

If your employer offers health insurance: Once you are found ineligible for Medicaid, federal law requires your employer to offer you a 60-day window to enroll in your employer’s group plan. Your employer should ensure that your enrollment in the group plan begins no later than the first day of the month following your request for a special enrollment opportunity. (Children’s Health Insurance Program Reauthorization Act of 2009, Pub. L. No. 111-3)

If you do not have access to an employer-sponsored plan: You may be eligible for a Marketplace health plan with premium subsidies. To find out if you qualify for a Marketplace plan with premium tax credits or cost-sharing subsidies, go to HealthCare.gov and select your state of residence. The Marketplace also provides trained Navigators and insurance brokers who can help advise you on your options. You can find one near you by visiting the Find Local Help page on your state Marketplace’s website.

Every Marketplace offers an opportunity to enroll in the Marketplace beginning 60 days before (and up to 60 days after) your Medicaid terminates. If you sign up during that window, most Marketplaces will ensure that your insurance starts on the first of the month following your plan selection. For example, if you learn that your Medicaid benefits will terminate at the end of April and sign up for a Marketplace plan at any point during the month of April, your Marketplace plan benefits will be effective on May 1, in most states.

If you live in a state that uses HealthCare.gov, and your last date of Medicaid coverage occurs between March 31, 2023 and July 31, 2024, you will be able to enroll beyond the 60-day timeframe following your loss of coverage (and up until July 31, 2024). After you submit an application and receive a determination that you are eligible for this “special enrollment” opportunity, you will have 60 days from the date of your application to select a plan, and your plan will become effective the first day of the following month after the plan selection is made. If you live in a state that does not use HealthCare.gov, check with your Marketplace to see if a similar opportunity is available. (CMS, Temporary Special Enrollment Period (SEP) for Consumers Losing Medicaid or the Children’s Health Insurance Program (CHIP) Coverage Due to Unwinding of the Medicaid Continuous Enrollment Condition– Frequently Asked Questions (FAQ))

Be careful about trying to buy health insurance online through a site that is not HealthCare.gov or your state’s own health insurance Marketplace. These government-run sites are the only places you can buy health insurance guaranteed to offer all of the Affordable Care Act protections. They are also the only sites where you can access subsidies to reduce your premiums and/or cost-sharing.

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