42 CFR § 435.558 — Medicaid Community Engagement Noncompliance Procedures
Represent state Medicaid agency duties governing inability to verify community engagement, noncompliance notices, opportunities to respond, continued coverage, eligibility actions, hearing safeguards, reapplication, and reconsideration.
Other Information
Status and scope: Independent statutory-and-regulatory requirements pilot issued October 23, 2026. This document renders the complete codified text of 42 CFR § 435.558 as a reusable Part 2 performance-requirements template. It is not an agency-adopted plan, a state implementation election, an individual eligibility decision, or legal advice. It contains no personal case information.Source and currency: https://www.ecfr.gov/current/title-42/section-435.558 , retrieved October 23, 2026. The eCFR page displays Title 42 as up to date October 21, 2026, with the title last amended October 13, 2026; that title-wide amendment date is not represented as a § 435.558 amendment date. A section snapshot was obtained from the eCFR versioner API for October 21, 2026. eCFR describes itself as authoritative but unofficial and not an official legal edition of the CFR. Point-in-time API source: https://www.ecfr.gov/api/versioner/v1/full/2026-10-21/title-42.xml?part=435§ion=435.558Rule provenance: Section source credits are 91 FR 33469, June 3, 2026, and 91 FR 39028, June 29, 2026. The latter correction replaced §§ 435.557 and 435.558. This rendition uses the corrected codified text, not the uncorrected initial rule or only its preamble. Correction: https://www.federalregister.gov/documents/2026/06/29/C1-2026-11094/medicaid-program-community-engagement-requirement-for-certain-individualsInferred statements: Vision, Mission, Values, goal groupings, concise noun Names, active-verb summaries, measurement dimensions, value-chain stages, and verb-based target descriptors were inferred with ChatGPT assistance. They are not quotations or official adopted statements. These interpretations create no new legal obligations. Fidelity is a principle of rendition; other values synthesize procedural protections and administrative responsibilities in the source.Responsibility: The State or agency is the performer of the duties represented here. Applicants and beneficiaries are rights-holders and potential participants in the response process. This rendition does not turn an opportunity to show compliance, deemed compliance, exclusion, or nonapplicability into an unconditional requirement for every Medicaid beneficiary to submit documentation. HourKeep or another records tool is not assigned agency eligibility-decision authority.Applicability and implementation: Applicable-individual status, exclusions, deemed compliance, optional hardship exceptions, assessed months, verification processes, implementation timing, and state elections depend on §§ 435.551–435.557 and §§ 435.559–435.560, the statute, and applicable state arrangements. This file does not independently define those conditions or convert the underlying 80-hour standard into a new target. Codified requirements are represented without deciding their application to a particular state, date, or person; implementation and any controlling legal developments require review before operational reliance.Distinct procedural stages: An inability to verify under paragraph (b) triggers the noncompliance process; it is not itself a completed determination of ineligibility. The noncompliance notice is distinct from a subsequent adverse-action notice. Application, renewal, and optional more-frequent verification have different conditions. Their alternatives are preserved without inventing a universal state default.Time semantics: Paragraph (a)(2) provides 30 calendar days beginning on receipt of the noncompliance notice. Paragraph (c)(4) presumes receipt five days after the date on the notice unless the individual shows nonreceipt within that period. The five-day rule is a rebuttable presumption, not a mailing-performance target. Neither a universal 35-day mailing-to-decision interval nor an unsupported date-counting algorithm is inferred. Receipt, the response-period end, adverse notice, hearing rights, and any later disenrollment deadline must be evaluated together.Coverage and hearings: Continued Medicaid under paragraph (a)(3), the protections incorporated by paragraph (d)(2), and any maintenance or reinstatement of services under Part 431, Subpart E are distinct. The end-of-following-month rule is not encoded as unconditional termination regardless of hearing protections. Hearing-request windows, continuation pending appeal, and exceptions require their own source review; they are linked rather than comprehensively rendered here.Reconsideration: Paragraph (f) incorporates § 435.916(a)(3)(iii). No numeric reconsideration window is guessed or conflated with either the 30-day noncompliance response period or a hearing-request window. Confirm the applicable reconsideration rule and state implementation. It applies to the described former MAGI-based enrollee, reason for disenrollment, and timely information submission.Source links and cross-references: The statutory community-engagement foundation is 42 U.S.C. § 1396a(xx), including paragraph (6). Relevant regulations include §§ 435.551–435.557, 435.905(b), 435.907(a), 435.911, 435.916, 435.917, 435.918, 435.930(b), 435.952(d), 435.1200(e), and Part 431, Subpart E. OtherInformation contains links to relevant provisions; linked text is not automatically included within the conversion scope.HourKeep comparison: Selected matching review-row anchors are supplied as external comparison aids, not legal authority or a finding that a row has been approved by a human reviewer. Review page: https://github.com/nickarrow/hourkeep/blob/main/docs/review/notices-and-fair-hearings.md . Its first 64 headings were checked for matching anchors in the retrieved review page; this document does not claim to convert or audit all HourKeep rows. The selected source-citation associations remain subject to substantive review. Quotation matching can support source traceability but does not establish correct interpretation or completeness.State discretion and error consequences: Objective OtherInformation identifies applicable triggers, qualifications, relevant state options, and potential consequences of implementation error. These consequence notes are inferred assessments, not findings that a state, person, or software project has made an error. No Colorado-specific election, approved plan, or submission workflow is presumed.Measurement and evidence: Indicators represent assessable required actions or conditions, not actual achievement. UnitOfMeasurement ... is a qualitative display convention. The one numeric target is the specified 30-calendar-day response period. No case outcomes, baselines, aggregate success rates, actual results, or inferred noncompliance are supplied. Future evidence could include de-identified process tests, notice templates, delivery-date rules, state policy documentation, and appropriately protected administrative records. Do not publish personal beneficiary data with this plan.Potential support, inferred: StratML could connect authoritative requirements, state implementation choices, reviewed policy rows, responsible actors, and evidence of performance. It could complement HourKeep’s policy review and applicant-controlled records. A Solid Pod or other evidence-storage technology is a separate implementation choice; authorization to access a personal store and legal requirements for state-held records must be assessed separately.Validation: The completed XML is validated against the Part 2 v2.2.10 XSD embedded in the user’s updated Prompting Guide ~ https://stratml.us/references/StratML-Prompting-Guide.html
Source text, contextual paragraphs, and sequence structure are checked separately. XSD validation establishes structural validity, not legal accuracy, approval by CMS or HourKeep, or fitness to decide eligibility.PublicationDate: October 24, 2026 is the issue date of this StratML rendition, not the rule’s Federal Register publication date or the effective date.
Submitter's Note: This StratML rendition has been compiled from the source by ChatGPT for the purpose of demonstrating the potential to enhance the useability of regulatory guidance by making it available as model performance plans in open, standard, machine-readable format.
🏢United States Government USG The logical jurisdiction whose federal Medicaid procedural requirements apply to administering state agencies under the applicable program and implementation arrangements.
Stakeholders:
👥 Show Hide 1 member | Source & SubmitterSource:https://www.ecfr.gov/current/title-42/section-435.558 Period: to Published: |
Vision
Accessible Medicaid notices and fair eligibility processes grounded in verified information and protected opportunities to respond.
Mission
To connect Medicaid noncompliance procedures with responsible agencies, assessable safeguards, and evidence of fulfillment.
Values
Goal 1: Verification and Notice 🔗
Apply the relevant inability-to-verify conditions and provide the required noncompliance notice.
Other Information
Sources: § 435.558(a)(1) and (b). Governing trigger: (a) Provision of notice of noncompliance. If a State is unable to verify that an applicable individual has met the requirement to demonstrate community engagement under §§ 435.552 and 435.556, or is deemed compliant under § 435.553 or, if applicable, § 435.555, as specified in paragraph (b) of this section, the State must: Verification definition: (b) Defining “unable to verify” community engagement. The agency is considered to be unable to verify that an applicable individual is compliant with the requirement to demonstrate community engagement as follows: (1) At application, the agency is unable to verify compliance with community engagement when it does not have sufficient information after reviewing the information provided by the individual at application and the reliable information available to the State to determine that the individual has demonstrated or is deemed to have demonstrated community engagement for the number of months required under the State plan. (2) As part of a renewal under section 1902(e)(14)(L) of the Act and § 435.916, the agency is unable to verify compliance with community engagement when it does not have sufficient information to determine that the individual has demonstrated or is deemed to have demonstrated community engagement for the number of months required under the State plan, after— (i) Reliable information available to the State accessed at renewal consistent with § 435.916(a)(2) are not sufficient to verify compliance with the community engagement requirement; or (ii) The renewal form provided to the beneficiary in accordance with § 435.916(a)(3) for those whose eligibility cannot be renewed based on reliable information under § 435.916(a)(2) is not returned or the information returned on the renewal form is not sufficient to verify compliance with community engagement. (3) If applicable, as part of the more frequent verification of compliance under § 435.557(d), the agency is unable to verify compliance with the community engagement requirement when it does not have sufficient information to determine that the individual has demonstrated or is deemed to have demonstrated community engagement for the number of months required under the State plan after— (i) Accessing reliable information in accordance with § 435.557(d) and information is not sufficient; or (ii) Accessing reliable information in accordance with § 435.557(d) and following the State's procedures under § 435.952(d) to request information from the individual, when the requested information is not returned or the information returned is not sufficient.Required prior verification and exclusion checks are governed by § 435.557 and other incorporated provisions. They must not be bypassed by a simple software label of noncompliance.
Objective 1.1: Application Verification 🔗
Apply the application inability-to-verify condition only when information from the application and reliable information available to the state remains insufficient to establish demonstrated or deemed compliance for the required months.
Other Information
Source: 42 CFR § 435.558(b)(1). https://www.ecfr.gov/current/title-42/section-435.558#p-435.558%28b%29%281%29Source text (verbatim with whitespace normalized): (1) At application, the agency is unable to verify compliance with community engagement when it does not have sufficient information after reviewing the information provided by the individual at application and the reliable information available to the State to determine that the individual has demonstrated or is deemed to have demonstrated community engagement for the number of months required under the State plan.State choices: The assessed months depend on the applicable state plan and § 435.556. No number of months or documentation default is inferred here. Potential error consequence, inferred: bypassing required information checks could trigger an unnecessary noncompliance process.Cross-reference links: https://www.ecfr.gov/current/title-42/section-435.557 ; https://www.ecfr.gov/current/title-42/section-435.556HourKeep comparison row(s), review status not independently established: https://github.com/nickarrow/hourkeep/blob/main/docs/review/notices-and-fair-hearings.md#unable-to-verify-at-application
Performance Indicators
1.1.1: Application Verification
| Type | Start Date | End Date | ... | Status | Description |
|---|---|---|---|---|---|
| Target | Applied | Apply the application inability-to-verify condition only when information from the application and reliable information available to the state remains insufficient to establish demonstrated or deemed compliance for the required months. |
Other Information
The target condition derives from 42 CFR § 435.558(b)(1). Measurement dimension and completion descriptor are editorial representations. The ... unit is a qualitative display convention. No actual result or individual eligibility outcome is asserted. Applicability, source conditions, and incorporated safeguards must be checked before assessing performance.
Objective 1.2: Renewal Verification 🔗
Apply the renewal inability-to-verify condition after the applicable reliable-information or renewal-form process described in paragraph (b)(2), for the required months.
Other Information
Source: 42 CFR § 435.558(b)(2). https://www.ecfr.gov/current/title-42/section-435.558#p-435.558%28b%29%282%29Source text (verbatim with whitespace normalized): (2) As part of a renewal under section 1902(e)(14)(L) of the Act and § 435.916, the agency is unable to verify compliance with community engagement when it does not have sufficient information to determine that the individual has demonstrated or is deemed to have demonstrated community engagement for the number of months required under the State plan, after— (i) Reliable information available to the State accessed at renewal consistent with § 435.916(a)(2) are not sufficient to verify compliance with the community engagement requirement; or (ii) The renewal form provided to the beneficiary in accordance with § 435.916(a)(3) for those whose eligibility cannot be renewed based on reliable information under § 435.916(a)(2) is not returned or the information returned on the renewal form is not sufficient to verify compliance with community engagement.State choices: Preserve the alternative processes and their connection to the state’s renewal arrangements. Do not silently impose a universal selection or infer inability solely from an unanswered notice about unrelated eligibility factors. Potential error consequence, inferred: treating an earlier stage as a completed inability-to-verify finding could shorten the proper process.Cross-reference links: https://www.ecfr.gov/current/title-42/section-435.916HourKeep comparison row(s), review status not independently established: https://github.com/nickarrow/hourkeep/blob/main/docs/review/notices-and-fair-hearings.md#renewal-notice-with-renewal-form ; https://github.com/nickarrow/hourkeep/blob/main/docs/review/notices-and-fair-hearings.md#renewal-notice-after-renewal-form-period
Performance Indicators
1.2.1: Renewal Verification
| Type | Start Date | End Date | ... | Status | Description |
|---|---|---|---|---|---|
| Target | Applied | Apply the renewal inability-to-verify condition after the applicable reliable-information or renewal-form process described in paragraph (b)(2), for the required months. |
Other Information
The target condition derives from 42 CFR § 435.558(b)(2). Measurement dimension and completion descriptor are editorial representations. The ... unit is a qualitative display convention. No actual result or individual eligibility outcome is asserted. Applicability, source conditions, and incorporated safeguards must be checked before assessing performance.
Objective 1.3: Interim Verification 🔗
Apply the inability-to-verify condition for more-frequent checks only when the state uses that option and the applicable information-check or information-request process leaves insufficient evidence for the required months.
Other Information
Source: 42 CFR § 435.558(b)(3). https://www.ecfr.gov/current/title-42/section-435.558#p-435.558%28b%29%283%29Source text (verbatim with whitespace normalized): (3) If applicable, as part of the more frequent verification of compliance under § 435.557(d), the agency is unable to verify compliance with the community engagement requirement when it does not have sufficient information to determine that the individual has demonstrated or is deemed to have demonstrated community engagement for the number of months required under the State plan after— (i) Accessing reliable information in accordance with § 435.557(d) and information is not sufficient; or (ii) Accessing reliable information in accordance with § 435.557(d) and following the State's procedures under § 435.952(d) to request information from the individual, when the requested information is not returned or the information returned is not sufficient.State choice: More-frequent verification is optional under § 435.557(d). Paragraph (b)(3) preserves its two specified process alternatives. Potential error consequence, inferred: inventing a mandatory check or skipping required process could impose unsupported demands or premature action.Cross-reference links: https://www.ecfr.gov/current/title-42/section-435.557#p-435.557(d)HourKeep comparison row(s), review status not independently established: https://github.com/nickarrow/hourkeep/blob/main/docs/review/notices-and-fair-hearings.md#more-frequent-check-notice-after-data-check ; https://github.com/nickarrow/hourkeep/blob/main/docs/review/notices-and-fair-hearings.md#more-frequent-check-notice-after-information-request
Performance Indicators
1.3.1: Interim Verification
| Type | Start Date | End Date | ... | Status | Description |
|---|---|---|---|---|---|
| Target | Applied if Option Used | Apply the inability-to-verify condition for more-frequent checks only when the state uses that option and the applicable information-check or information-request process leaves insufficient evidence for the required months. |
Other Information
The target condition derives from 42 CFR § 435.558(b)(3). Measurement dimension and completion descriptor are editorial representations. The ... unit is a qualitative display convention. No actual result or individual eligibility outcome is asserted. Applicability, source conditions, and incorporated safeguards must be checked before assessing performance.
Objective 1.4: Noncompliance Notice 🔗
Provide the individual with the paragraph (c) noncompliance notice when the state is unable to verify demonstrated or deemed compliance under the paragraph (b) conditions.
Other Information
Source: 42 CFR § 435.558(a)(1). https://www.ecfr.gov/current/title-42/section-435.558#p-435.558%28a%29%281%29Source text (verbatim with whitespace normalized): (1) Provide such individual with the notice of noncompliance described in paragraph (c) of this section;Trigger: Read with the paragraph (a) introduction and prior verification requirements. Potential error consequence, inferred: omitting the notice could remove the required chance to respond.HourKeep comparison row(s), review status not independently established: https://github.com/nickarrow/hourkeep/blob/main/docs/review/notices-and-fair-hearings.md#send-notice-of-noncompliance
Performance Indicators
1.4.1: Noncompliance Notice
| Type | Start Date | End Date | ... | Status | Description |
|---|---|---|---|---|---|
| Target | Provided | Provide the individual with the paragraph (c) noncompliance notice when the state is unable to verify demonstrated or deemed compliance under the paragraph (b) conditions. |
Other Information
The target condition derives from 42 CFR § 435.558(a)(1). Measurement dimension and completion descriptor are editorial representations. The ... unit is a qualitative display convention. No actual result or individual eligibility outcome is asserted. Applicability, source conditions, and incorporated safeguards must be checked before assessing performance.
Goal 2: Notice Content and Delivery 🔗
Provide the required clear notice content, accessible delivery, and correctly applied receipt rule.
Other Information
Source: § 435.558(c). All applicable notice elements must be assessed together. The optional-hardship element is conditional on state election; electronic delivery conditions apply when that format is used.
Objective 2.1: Compliance Instructions 🔗
Include clear instructions identifying the months to be assessed, how to show demonstrated community engagement, and how to show deemed compliance under the applicable mandatory or elected hardship provisions.
Other Information
Source: 42 CFR § 435.558(c)(1)(i). https://www.ecfr.gov/current/title-42/section-435.558#p-435.558%28c%29%281%29%28i%29Source text (verbatim with whitespace normalized): (i) How to make a satisfactory showing of compliance with the community engagement requirement, including: (A) Which month(s) will be assessed by the State in accordance with § 435.556(a); (B) How to show the individual demonstrated community engagement under § 435.552; and (C) How to show the individual should be deemed to have demonstrated community engagement as specified at § 435.553 or, if applicable, § 435.555;Governing context: (c) Content and form of noncompliance notice. A notice of noncompliance— (1) Must include clear statements containing the following information— The paragraph contains three required sub-elements (A)–(C). Potential error consequence, inferred: missing assessed months or deemed-compliance routes could cause unnecessary work or an inadequate response.HourKeep comparison row(s), review status not independently established: https://github.com/nickarrow/hourkeep/blob/main/docs/review/notices-and-fair-hearings.md#notice-says-how-to-show-compliance
Performance Indicators
2.1.1: Compliance Instructions
| Type | Start Date | End Date | ... | Status | Description |
|---|---|---|---|---|---|
| Target | Included | Include clear instructions identifying the months to be assessed, how to show demonstrated community engagement, and how to show deemed compliance under the applicable mandatory or elected hardship provisions. |
Other Information
The target condition derives from 42 CFR § 435.558(c)(1)(i). Measurement dimension and completion descriptor are editorial representations. The ... unit is a qualitative display convention. No actual result or individual eligibility outcome is asserted. Applicability, source conditions, and incorporated safeguards must be checked before assessing performance.
Objective 2.2: Nonapplicability Instructions 🔗
Include clear instructions on showing that the community-engagement requirement does not apply, including applicable-individual and specified-exclusion criteria.
Other Information
Source: 42 CFR § 435.558(c)(1)(ii). https://www.ecfr.gov/current/title-42/section-435.558#p-435.558%28c%29%281%29%28ii%29Source text (verbatim with whitespace normalized): (ii) How to make a satisfactory showing that the community engagement requirement does not apply to the individual on the basis that the individual does not meet the definition of an applicable individual at § 435.551, including because the individual meets the criteria for one or more of the categories of a specified excluded individual under § 435.554;Governing context: (c) Content and form of noncompliance notice. A notice of noncompliance— (1) Must include clear statements containing the following information— Do not require excluded individuals to prove an 80-hour activity requirement instead of permitting the nonapplicability showing. Potential error consequence, inferred: omitting exclusions could impose unnecessary obligations.Cross-reference links: https://www.ecfr.gov/current/title-42/section-435.551 ; https://www.ecfr.gov/current/title-42/section-435.554HourKeep comparison row(s), review status not independently established: https://github.com/nickarrow/hourkeep/blob/main/docs/review/notices-and-fair-hearings.md#notice-says-how-to-show-not-applicable
Performance Indicators
2.2.1: Nonapplicability Instructions
| Type | Start Date | End Date | ... | Status | Description |
|---|---|---|---|---|---|
| Target | Included | Include clear instructions on showing that the community-engagement requirement does not apply, including applicable-individual and specified-exclusion criteria. |
Other Information
The target condition derives from 42 CFR § 435.558(c)(1)(ii). Measurement dimension and completion descriptor are editorial representations. The ... unit is a qualitative display convention. No actual result or individual eligibility outcome is asserted. Applicability, source conditions, and incorporated safeguards must be checked before assessing performance.
Objective 2.3: Response Deadline 🔗
Include a clear statement of the deadline for providing the compliance or nonapplicability information to the state.
Other Information
Source: 42 CFR § 435.558(c)(1)(iii). https://www.ecfr.gov/current/title-42/section-435.558#p-435.558%28c%29%281%29%28iii%29Source text (verbatim with whitespace normalized): (iii) The deadline for providing the information under paragraph (c)(1)(i) or (ii) of this section to the State;Governing context: (c) Content and form of noncompliance notice. A notice of noncompliance— (1) Must include clear statements containing the following information— Read with the 30-calendar-day period and receipt rule. Potential error consequence, inferred: an incorrect date could shorten the protected response period.HourKeep comparison row(s), review status not independently established: https://github.com/nickarrow/hourkeep/blob/main/docs/review/notices-and-fair-hearings.md#notice-states-the-deadline
Performance Indicators
2.3.1: Response Deadline
| Type | Start Date | End Date | ... | Status | Description |
|---|---|---|---|---|---|
| Target | Included | Include a clear statement of the deadline for providing the compliance or nonapplicability information to the state. |
Other Information
The target condition derives from 42 CFR § 435.558(c)(1)(iii). Measurement dimension and completion descriptor are editorial representations. The ... unit is a qualitative display convention. No actual result or individual eligibility outcome is asserted. Applicability, source conditions, and incorporated safeguards must be checked before assessing performance.
Objective 2.4: Submission Methods 🔗
Describe clearly how the required information may be submitted through any of the modalities described in § 435.907(a).
Other Information
Source: 42 CFR § 435.558(c)(1)(iv). https://www.ecfr.gov/current/title-42/section-435.558#p-435.558%28c%29%281%29%28iv%29Source text (verbatim with whitespace normalized): (iv) A description of how the information under paragraph (c)(1)(i) or (ii) of this section may be submitted to the State through any of the modalities described in § 435.907(a);Governing context: (c) Content and form of noncompliance notice. A notice of noncompliance— (1) Must include clear statements containing the following information— The allowed modalities require the cross-reference; a software-only submission route is not invented. Potential error consequence, inferred: restricting methods could impede a valid response.Cross-reference links: https://www.ecfr.gov/current/title-42/section-435.907#p-435.907(a)HourKeep comparison row(s), review status not independently established: https://github.com/nickarrow/hourkeep/blob/main/docs/review/notices-and-fair-hearings.md#notice-says-how-to-submit
Performance Indicators
2.4.1: Submission Methods
| Type | Start Date | End Date | ... | Status | Description |
|---|---|---|---|---|---|
| Target | Described | Describe clearly how the required information may be submitted through any of the modalities described in § 435.907(a). |
Other Information
The target condition derives from 42 CFR § 435.558(c)(1)(iv). Measurement dimension and completion descriptor are editorial representations. The ... unit is a qualitative display convention. No actual result or individual eligibility outcome is asserted. Applicability, source conditions, and incorporated safeguards must be checked before assessing performance.
Objective 2.5: Consequences 🔗
Describe clearly the consequences of community-engagement noncompliance and failure to respond for Medicaid eligibility and eligibility for advance premium tax credits and premium tax credits for Exchange coverage.
Other Information
Source: 42 CFR § 435.558(c)(1)(v). https://www.ecfr.gov/current/title-42/section-435.558#p-435.558%28c%29%281%29%28v%29Source text (verbatim with whitespace normalized): (v) A description of the consequences of noncompliance with the community engagement requirement and failure to respond to the notice of noncompliance for Medicaid eligibility and eligibility for advance payments of the premium tax credit (APTC) and the premium tax credit (PTC) used to pay for coverage through a Health Insurance Exchange;Governing context: (c) Content and form of noncompliance notice. A notice of noncompliance— (1) Must include clear statements containing the following information— This is a notice-content duty, not this rendition’s independent determination of tax-credit eligibility. Potential error consequence, inferred: inaccurate consequences could misdirect coverage decisions.HourKeep comparison row(s), review status not independently established: https://github.com/nickarrow/hourkeep/blob/main/docs/review/notices-and-fair-hearings.md#notice-says-consequences-including-premium-tax-credit
Performance Indicators
2.5.1: Consequences
| Type | Start Date | End Date | ... | Status | Description |
|---|---|---|---|---|---|
| Target | Described | Describe clearly the consequences of community-engagement noncompliance and failure to respond for Medicaid eligibility and eligibility for advance premium tax credits and premium tax credits for Exchange coverage. |
Other Information
The target condition derives from 42 CFR § 435.558(c)(1)(v). Measurement dimension and completion descriptor are editorial representations. The ... unit is a qualitative display convention. No actual result or individual eligibility outcome is asserted. Applicability, source conditions, and incorporated safeguards must be checked before assessing performance.
Objective 2.6: Reapplication Instructions 🔗
Explain clearly how the individual may reapply for medical assistance after an application denial or disenrollment, as applicable.
Other Information
Source: 42 CFR § 435.558(c)(1)(vi). https://www.ecfr.gov/current/title-42/section-435.558#p-435.558%28c%29%281%29%28vi%29Source text (verbatim with whitespace normalized): (vi) How such individual may reapply for medical assistance under the State plan (or a waiver of such plan) if the individual's application is denied or the individual is disenrolled from coverage under the State plan or waiver, as applicable; andGoverning context: (c) Content and form of noncompliance notice. A notice of noncompliance— (1) Must include clear statements containing the following information— Potential error consequence, inferred: missing or misleading instructions could deter reapplication or extend a coverage gap.HourKeep comparison row(s), review status not independently established: https://github.com/nickarrow/hourkeep/blob/main/docs/review/notices-and-fair-hearings.md#notice-says-how-to-reapply
Performance Indicators
2.6.1: Reapplication Instructions
| Type | Start Date | End Date | ... | Status | Description |
|---|---|---|---|---|---|
| Target | Explained | Explain clearly how the individual may reapply for medical assistance after an application denial or disenrollment, as applicable. |
Other Information
The target condition derives from 42 CFR § 435.558(c)(1)(vi). Measurement dimension and completion descriptor are editorial representations. The ... unit is a qualitative display convention. No actual result or individual eligibility outcome is asserted. Applicability, source conditions, and incorporated safeguards must be checked before assessing performance.
Objective 2.7: Hardship Information 🔗
Include the short-term-hardship-event information described in § 435.555(c) when the state has elected to provide that exception.
Other Information
Source: 42 CFR § 435.558(c)(1)(vii). https://www.ecfr.gov/current/title-42/section-435.558#p-435.558%28c%29%281%29%28vii%29Source text (verbatim with whitespace normalized): (vii) For States that have elected to provide the short-term hardship exception under § 435.555, the information about short-term hardship events described in § 435.555(c).Governing context: (c) Content and form of noncompliance notice. A notice of noncompliance— (1) Must include clear statements containing the following information— State choice: The hardship exception is elective; the notice requirement is conditional on that election. No Colorado or other state election is assumed. Potential error consequence, inferred: assuming the option exists or omitting an elected option could misdirect a response.Cross-reference links: https://www.ecfr.gov/current/title-42/section-435.555#p-435.555(c)HourKeep comparison row(s), review status not independently established: https://github.com/nickarrow/hourkeep/blob/main/docs/review/notices-and-fair-hearings.md#notice-gives-hardship-information-where-elected
Performance Indicators
2.7.1: Hardship Information
| Type | Start Date | End Date | ... | Status | Description |
|---|---|---|---|---|---|
| Target | Included if Elected | Include the short-term-hardship-event information described in § 435.555(c) when the state has elected to provide that exception. |
Other Information
The target condition derives from 42 CFR § 435.558(c)(1)(vii). Measurement dimension and completion descriptor are editorial representations. The ... unit is a qualitative display convention. No actual result or individual eligibility outcome is asserted. Applicability, source conditions, and incorporated safeguards must be checked before assessing performance.
Objective 2.8: Notice Accessibility 🔗
Provide the notice consistently with § 435.905(b), including its plain-language, timely accessibility, language-service, disability-access, and information-about-services requirements.
Other Information
Source: 42 CFR § 435.558(c)(2). https://www.ecfr.gov/current/title-42/section-435.558#p-435.558%28c%29%282%29Source text (verbatim with whitespace normalized): (2) Must be provided in a manner consistent with § 435.905(b).Governing context: (c) Content and form of noncompliance notice. A notice of noncompliance— Cross-reference context: § 435.905(b) includes no-cost language services and auxiliary aids and services, and informing individuals about their availability and access. This is not a complete separate conversion of § 435.905. Potential error consequence, inferred: inaccessible delivery could prevent an effective response.Cross-reference links: https://www.ecfr.gov/current/title-42/section-435.905#p-435.905(b)HourKeep comparison row(s), review status not independently established: https://github.com/nickarrow/hourkeep/blob/main/docs/review/notices-and-fair-hearings.md#notice-follows-section-435-905b
Performance Indicators
2.8.1: Notice Accessibility
| Type | Start Date | End Date | ... | Status | Description |
|---|---|---|---|---|---|
| Target | Provided Accessibly | Provide the notice consistently with § 435.905(b), including its plain-language, timely accessibility, language-service, disability-access, and information-about-services requirements. |
Other Information
The target condition derives from 42 CFR § 435.558(c)(2). Measurement dimension and completion descriptor are editorial representations. The ... unit is a qualitative display convention. No actual result or individual eligibility outcome is asserted. Applicability, source conditions, and incorporated safeguards must be checked before assessing performance.
Objective 2.9: Electronic Notices 🔗
Provide any electronic-format noncompliance notice in compliance with § 435.918(b).
Other Information
Source: 42 CFR § 435.558(c)(3). https://www.ecfr.gov/current/title-42/section-435.558#p-435.558%28c%29%283%29Source text (verbatim with whitespace normalized): (3) Must, if provided in electronic format, comply with § 435.918(b).Governing context: (c) Content and form of noncompliance notice. A notice of noncompliance— Conditional on use of electronic format. Section 435.918(b) must be checked for the actual requirements; this rendition does not assume a person elected electronic delivery or invent technical specifications. Potential error consequence, inferred: an invalid electronic process could prevent proper notice.Cross-reference links: https://www.ecfr.gov/current/title-42/section-435.918#p-435.918(b)HourKeep comparison row(s), review status not independently established: https://github.com/nickarrow/hourkeep/blob/main/docs/review/notices-and-fair-hearings.md#electronic-notice-follows-section-435-918b
Performance Indicators
2.9.1: Electronic Notices
| Type | Start Date | End Date | ... | Status | Description |
|---|---|---|---|---|---|
| Target | Provided Compliantly if Electronic | Provide any electronic-format noncompliance notice in compliance with § 435.918(b). |
Other Information
The target condition derives from 42 CFR § 435.558(c)(3). Measurement dimension and completion descriptor are editorial representations. The ... unit is a qualitative display convention. No actual result or individual eligibility outcome is asserted. Applicability, source conditions, and incorporated safeguards must be checked before assessing performance.
Objective 2.10: Notice Receipt 🔗
Apply receipt five days after the date on the notice unless the applicant or beneficiary shows that the notice was not received within that five-day period.
Other Information
Source: 42 CFR § 435.558(c)(4). https://www.ecfr.gov/current/title-42/section-435.558#p-435.558%28c%29%284%29Source text (verbatim with whitespace normalized): (4) Is considered to be received 5 days after the date on the notice, unless the applicant or beneficiary shows that he or she did not receive the notice within the 5-day period.Governing context: (c) Content and form of noncompliance notice. A notice of noncompliance— This is a rebuttable legal presumption, not a requirement to deliver every notice in exactly five days. Do not replace notice date with an assumed mailing date, or disregard evidence of nonreceipt. Potential error consequence, inferred: an incorrect receipt date could shorten the response period.HourKeep comparison row(s), review status not independently established: https://github.com/nickarrow/hourkeep/blob/main/docs/review/notices-and-fair-hearings.md#notice-presumed-received-after-5-days
Performance Indicators
2.10.1: Notice Receipt
| Type | Start Date | End Date | ... | Status | Description |
|---|---|---|---|---|---|
| Target | Applied with Rebuttal | Apply receipt five days after the date on the notice unless the applicant or beneficiary shows that the notice was not received within that five-day period. |
Other Information
The target condition derives from 42 CFR § 435.558(c)(4). Measurement dimension and completion descriptor are editorial representations. The ... unit is a qualitative display convention. No actual result or individual eligibility outcome is asserted. Applicability, source conditions, and incorporated safeguards must be checked before assessing performance.
Goal 3: Response and Coverage 🔗
Provide the full response opportunity and continue enrolled beneficiaries’ Medicaid under the applicable conditions.
Other Information
Source: § 435.558(a)(2)–(3). Successful response may establish compliance, deemed compliance, or that the requirement does not apply. Receipt and the rebuttable presumption are addressed in Objective 2.10.
Objective 3.1: Response Opportunity 🔗
Provide 30 calendar days beginning on receipt of the noncompliance notice under paragraph (c)(4) for the individual to show compliance, deemed compliance for the required months, or that the requirement does not apply, including a specified exclusion.
Other Information
Source: 42 CFR § 435.558(a)(2). https://www.ecfr.gov/current/title-42/section-435.558#p-435.558%28a%29%282%29Source text (verbatim with whitespace normalized): (2) Provide such individual with a period of 30 calendar days beginning on the date on which such notice of noncompliance is received by the individual consistent with paragraph (c)(4) of this section, to make a satisfactory showing to the agency— (i) Of compliance with such requirement (including, as applicable, by showing that such individual demonstrated or should be deemed to have demonstrated community engagement under § 435.553 or, if applicable, § 435.555, for each month required under the State plan); or (ii) That such requirement does not apply to such individual on the basis that such individual does not meet the definition of applicable individual under § 435.551, including by meeting the criteria for one or more of the categories of a specified excluded individual as defined at § 435.554.The two alternative showings are preserved; the rule does not require both an activity showing and proof of nonapplicability. Potential error consequence, inferred: starting the clock too early or omitting a valid showing could expose an eligible person to adverse action.HourKeep comparison row(s), review status not independently established: https://github.com/nickarrow/hourkeep/blob/main/docs/review/notices-and-fair-hearings.md#notice-response-period ; https://github.com/nickarrow/hourkeep/blob/main/docs/review/notices-and-fair-hearings.md#showing-of-compliance-or-exception ; https://github.com/nickarrow/hourkeep/blob/main/docs/review/notices-and-fair-hearings.md#showing-requirement-does-not-apply
Performance Indicators
3.1.1: Response Opportunity
| Type | Start Date | End Date | Calendar days beginning on receipt of notice | Status | Description |
|---|---|---|---|---|---|
| Target | 30 | Provided | Provide 30 calendar days beginning on receipt of the noncompliance notice under paragraph (c)(4) for the individual to show compliance, deemed compliance for the required months, or that the requirement does not apply, including a specified exclusion. |
Other Information
The target condition derives from 42 CFR § 435.558(a)(2). Measurement dimension and completion descriptor are editorial representations. The regulation specifies a full 30-calendar-day period beginning on receipt under paragraph (c)(4); this is not a 30-day delay target for the agency or a period beginning automatically on mailing. No actual result or individual eligibility outcome is asserted. Applicability, source conditions, and incorporated safeguards must be checked before assessing performance.
Objective 3.2: Coverage Continuation 🔗
Continue furnishing Medicaid to an enrolled beneficiary until the individual is determined ineligible consistently with § 435.930(b).
Other Information
Source: 42 CFR § 435.558(a)(3). https://www.ecfr.gov/current/title-42/section-435.558#p-435.558%28a%29%283%29Source text (verbatim with whitespace normalized): (3) Continue to furnish Medicaid for an enrolled beneficiary until the individual is determined ineligible consistent with § 435.930(b).Applies to enrolled beneficiaries; it does not establish that every applicant receives Medicaid while an application is pending. Coverage during a later hearing process is governed separately by incorporated hearing rules. Potential error consequence, inferred: treating nonverification as immediate ineligibility could interrupt coverage improperly.Cross-reference links: https://www.ecfr.gov/current/title-42/section-435.930#p-435.930(b)HourKeep comparison row(s), review status not independently established: https://github.com/nickarrow/hourkeep/blob/main/docs/review/notices-and-fair-hearings.md#coverage-continues-during-noncompliance
Performance Indicators
3.2.1: Coverage Continuation
| Type | Start Date | End Date | ... | Status | Description |
|---|---|---|---|---|---|
| Target | Continued | Continue furnishing Medicaid to an enrolled beneficiary until the individual is determined ineligible consistently with § 435.930(b). |
Other Information
The target condition derives from 42 CFR § 435.558(a)(3). Measurement dimension and completion descriptor are editorial representations. The ... unit is a qualitative display convention. No actual result or individual eligibility outcome is asserted. Applicability, source conditions, and incorporated safeguards must be checked before assessing performance.
Goal 4: Decisions and Review 🔗
Apply other-eligibility review, adverse-action safeguards, reapplication protections, and applicable reconsideration.
Other Information
Sources: § 435.558(d)–(f). Paragraph (d) is triggered only after the response period without a satisfactory showing; paragraph (d)(2) concerns those determined ineligible after considering all eligibility bases. Do not confuse noncompliance notices with final adverse-action notices.
Objective 4.1: Other Eligibility Bases 🔗
Consider all other bases of eligibility under the state plan or waiver consistently with §§ 435.911 and 435.916(f) before denying an application or determining ineligibility after the response period without a satisfactory showing.
Other Information
Source: 42 CFR § 435.558(d)(1). https://www.ecfr.gov/current/title-42/section-435.558#p-435.558%28d%29%281%29Source text (verbatim with whitespace normalized): (1) Consider all other bases of eligibility for medical assistance under the State plan (or waiver of such plan) in accordance with §§ 435.911 and 435.916(f) prior to denying coverage at application or determining that an individual is ineligible;Governing conditions: (d) State responsibilities in the event of no satisfactory showing. If no satisfactory showing is made after the 30-calendar day period consistent with paragraph (a)(2) of this section, the State must— This step precedes an adverse eligibility determination; lack of a community-engagement showing is not the only eligibility inquiry. Potential error consequence, inferred: skipping other bases could wrongly end or deny eligibility.Cross-reference links: https://www.ecfr.gov/current/title-42/section-435.911 ; https://www.ecfr.gov/current/title-42/section-435.916#p-435.916(f)HourKeep comparison row(s), review status not independently established: https://github.com/nickarrow/hourkeep/blob/main/docs/review/notices-and-fair-hearings.md#consider-all-other-bases-before-denial
Performance Indicators
4.1.1: Other Eligibility Bases
| Type | Start Date | End Date | ... | Status | Description |
|---|---|---|---|---|---|
| Target | Considered | Consider all other bases of eligibility under the state plan or waiver consistently with §§ 435.911 and 435.916(f) before denying an application or determining ineligibility after the response period without a satisfactory showing. |
Other Information
The target condition derives from 42 CFR § 435.558(d)(1). Measurement dimension and completion descriptor are editorial representations. The ... unit is a qualitative display convention. No actual result or individual eligibility outcome is asserted. Applicability, source conditions, and incorporated safeguards must be checked before assessing performance.
Objective 4.2: Application Decisions 🔗
Deny the application of an individual determined ineligible after the required consideration of all eligibility bases, and provide written notice and fair hearing rights consistently with §§ 435.917–435.918 and Part 431, Subpart E.
Other Information
Source: 42 CFR § 435.558(d)(2)(i). https://www.ecfr.gov/current/title-42/section-435.558#p-435.558%28d%29%282%29%28i%29Source text (verbatim with whitespace normalized): (i) Deny such individual's application and provide written notice and fair hearing rights consistent with §§ 435.917 and 435.918 and part 431, subpart E of this subchapter;Governing conditions: (d) State responsibilities in the event of no satisfactory showing. If no satisfactory showing is made after the 30-calendar day period consistent with paragraph (a)(2) of this section, the State must— (2) For individuals determined ineligible under the State plan (or waiver of such plan) after considering all bases of eligibility, as applicable: This conditional required action is represented alongside the prerequisite safeguards; denial itself is not an inferred program-success measure. Potential error consequence, inferred: treating the action as automatic before prerequisite review could wrongly deny coverage.Cross-reference links: https://www.ecfr.gov/current/title-42/section-435.917 ; https://www.ecfr.gov/current/title-42/section-435.918 ; https://www.ecfr.gov/current/title-42/part-431/subpart-EHourKeep comparison row(s), review status not independently established: https://github.com/nickarrow/hourkeep/blob/main/docs/review/notices-and-fair-hearings.md#deny-application-with-notice-and-hearing-rights
Performance Indicators
4.2.1: Application Decisions
| Type | Start Date | End Date | ... | Status | Description |
|---|---|---|---|---|---|
| Target | Decided with Notice and Hearing Rights | Deny the application of an individual determined ineligible after the required consideration of all eligibility bases, and provide written notice and fair hearing rights consistently with §§ 435.917–435.918 and Part 431, Subpart E. |
Other Information
The target condition derives from 42 CFR § 435.558(d)(2)(i). Measurement dimension and completion descriptor are editorial representations. The ... unit is a qualitative display convention. No actual result or individual eligibility outcome is asserted. Applicability, source conditions, and incorporated safeguards must be checked before assessing performance.
Objective 4.3: Disenrollment Safeguards 🔗
Disenroll an enrolled beneficiary determined ineligible after the required reviews no later than the end of the month following the month the 30-calendar-day period ends, and only after the advance written notice and fair hearing rights required by the incorporated provisions.
Other Information
Source: 42 CFR § 435.558(d)(2)(ii). https://www.ecfr.gov/current/title-42/section-435.558#p-435.558%28d%29%282%29%28ii%29Source text (verbatim with whitespace normalized): (ii) Disenroll such beneficiary not later than the end of the month following the month in which the 30-calendar day period under paragraph (a)(2) of this section ends and after the provision of advance written notice and fair hearing rights consistent with §§ 435.917 through 435.918 and part 431, subpart E of this subchapter prior to the disenrollment;Governing conditions: (d) State responsibilities in the event of no satisfactory showing. If no satisfactory showing is made after the 30-calendar day period consistent with paragraph (a)(2) of this section, the State must— (2) For individuals determined ineligible under the State plan (or waiver of such plan) after considering all bases of eligibility, as applicable: The calendar-month endpoint is not reduced to a fixed number of elapsed days. Apply §§ 435.917–435.918 and Part 431, Subpart E, including applicable maintenance or reinstatement of services and exceptions. This is not a target to maximize disenrollment. Potential error consequence, inferred: ignoring the notice, hearing, or continued-services conditions could interrupt coverage improperly.Cross-reference links: https://www.ecfr.gov/current/title-42/part-431/subpart-E ; https://www.ecfr.gov/current/title-42/section-431.230 ; https://www.ecfr.gov/current/title-42/section-431.231HourKeep comparison row(s), review status not independently established: https://github.com/nickarrow/hourkeep/blob/main/docs/review/notices-and-fair-hearings.md#disenroll-with-advance-notice-and-hearing-rights
Performance Indicators
4.3.1: Disenrollment Safeguards
| Type | Start Date | End Date | ... | Status | Description |
|---|---|---|---|---|---|
| Target | Disenrolled with Required Safeguards if Applicable | Disenroll an enrolled beneficiary determined ineligible after the required reviews no later than the end of the month following the month the 30-calendar-day period ends, and only after the advance written notice and fair hearing rights required by the incorporated provisions. |
Other Information
The target condition derives from 42 CFR § 435.558(d)(2)(ii). Measurement dimension and completion descriptor are editorial representations. The ... unit is a qualitative display convention. No actual result or individual eligibility outcome is asserted. Applicability, source conditions, and incorporated safeguards must be checked before assessing performance.
Objective 4.4: Adverse-Action Reasons 🔗
Include a clear statement of the specific reasons supporting the intended adverse action, addressing both failure to show compliance or applicable deemed compliance for the assessed months and failure to show that the requirement does not apply.
Other Information
Source: 42 CFR § 435.558(d)(2)(iii). https://www.ecfr.gov/current/title-42/section-435.558#p-435.558%28d%29%282%29%28iii%29Source text (verbatim with whitespace normalized): (iii) Include in the clear statement of the specific reasons supporting the intended action under § 431.210(b) of this subchapter that the individual failed to: (A) Make a satisfactory showing of compliance with the community engagement requirement under § 435.552, including by meeting the criteria for an exception to be deemed as having demonstrated community engagement under § 435.553 or, if applicable, § 435.555, for the month(s) specified in accordance with § 435.556(a); and (B) Make a satisfactory showing that the community engagement requirement does not apply to the individual on the basis that the individual does not meet the definition of applicable individual at § 435.551, including failure to demonstrate the individual meets the criteria for one or more of the categories of a specified excluded individual under § 435.554; andGoverning conditions: (d) State responsibilities in the event of no satisfactory showing. If no satisfactory showing is made after the 30-calendar day period consistent with paragraph (a)(2) of this section, the State must— (2) For individuals determined ineligible under the State plan (or waiver of such plan) after considering all bases of eligibility, as applicable: The source uses both (A) and (B); neither category should be silently omitted from the required explanation. This is the later adverse-action notice content, distinct from paragraph (c). Potential error consequence, inferred: inadequate reasons could impede an informed hearing request or response.Cross-reference links: https://www.ecfr.gov/current/title-42/section-431.210#p-431.210(b)HourKeep comparison row(s), review status not independently established: https://github.com/nickarrow/hourkeep/blob/main/docs/review/notices-and-fair-hearings.md#adverse-notice-names-both-failures
Performance Indicators
4.4.1: Adverse-Action Reasons
| Type | Start Date | End Date | ... | Status | Description |
|---|---|---|---|---|---|
| Target | Included | Include a clear statement of the specific reasons supporting the intended adverse action, addressing both failure to show compliance or applicable deemed compliance for the assessed months and failure to show that the requirement does not apply. |
Other Information
The target condition derives from 42 CFR § 435.558(d)(2)(iii). Measurement dimension and completion descriptor are editorial representations. The ... unit is a qualitative display convention. No actual result or individual eligibility outcome is asserted. Applicability, source conditions, and incorporated safeguards must be checked before assessing performance.
Objective 4.5: Other Coverage Assessment 🔗
Determine the individual’s or beneficiary’s potential eligibility for other insurance affordability programs in accordance with § 435.1200(e).
Other Information
Source: 42 CFR § 435.558(d)(2)(iv). https://www.ecfr.gov/current/title-42/section-435.558#p-435.558%28d%29%282%29%28iv%29Source text (verbatim with whitespace normalized): (iv) Determine the individual's or beneficiary's potential eligibility for other insurance affordability programs in accordance with § 435.1200(e).Governing conditions: (d) State responsibilities in the event of no satisfactory showing. If no satisfactory showing is made after the 30-calendar day period consistent with paragraph (a)(2) of this section, the State must— (2) For individuals determined ineligible under the State plan (or waiver of such plan) after considering all bases of eligibility, as applicable: Potential eligibility assessment is not a guarantee of enrollment or tax-credit entitlement. Potential error consequence, inferred: omitting the assessment could impede access to available alternative coverage.Cross-reference links: https://www.ecfr.gov/current/title-42/section-435.1200#p-435.1200(e)HourKeep comparison row(s), review status not independently established: https://github.com/nickarrow/hourkeep/blob/main/docs/review/notices-and-fair-hearings.md#check-other-insurance-affordability-programs
Performance Indicators
4.5.1: Other Coverage Assessment
| Type | Start Date | End Date | ... | Status | Description |
|---|---|---|---|---|---|
| Target | Determined | Determine the individual’s or beneficiary’s potential eligibility for other insurance affordability programs in accordance with § 435.1200(e). |
Other Information
The target condition derives from 42 CFR § 435.558(d)(2)(iv). Measurement dimension and completion descriptor are editorial representations. The ... unit is a qualitative display convention. No actual result or individual eligibility outcome is asserted. Applicability, source conditions, and incorporated safeguards must be checked before assessing performance.
Objective 4.6: Reapplication Access 🔗
Avoid restricting an applicable individual’s ability to reapply or receive coverage if determined eligible upon reapplication because of a prior denial or disenrollment for noncompliance under this section.
Other Information
Source: 42 CFR § 435.558(e). https://www.ecfr.gov/current/title-42/section-435.558#p-435.558%28e%29Source text (verbatim with whitespace normalized): (e) Prohibition on restrictions to re-applying for coverage. An agency must not impose any restriction on an applicable individual's ability to re-apply for coverage or their ability to receive coverage if determined eligible upon reapplication based on a prior denial of eligibility or disenrollment for noncompliance under this section.This prohibition does not eliminate other lawful eligibility conditions. No lockout is invented from the prior noncompliance decision. Potential error consequence, inferred: an unsupported lockout could prolong a coverage gap.HourKeep comparison row(s), review status not independently established: https://github.com/nickarrow/hourkeep/blob/main/docs/review/notices-and-fair-hearings.md#no-restriction-on-reapplying
Performance Indicators
4.6.1: Reapplication Access
| Type | Start Date | End Date | ... | Status | Description |
|---|---|---|---|---|---|
| Target | Avoided | Avoid restricting an applicable individual’s ability to reapply or receive coverage if determined eligible upon reapplication because of a prior denial or disenrollment for noncompliance under this section. |
Other Information
The target condition derives from 42 CFR § 435.558(e). Measurement dimension and completion descriptor are editorial representations. The ... unit is a qualitative display convention. No actual result or individual eligibility outcome is asserted. Applicability, source conditions, and incorporated safeguards must be checked before assessing performance.
Objective 4.7: Eligibility Reconsideration 🔗
Reconsider eligibility consistently with § 435.916(a)(3)(iii) when a former MAGI-based enrollee was disenrolled for failing to submit information requested in a noncompliance notice and submits that information during the incorporated reconsideration period.
Other Information
Source: 42 CFR § 435.558(f). https://www.ecfr.gov/current/title-42/section-435.558#p-435.558%28f%29Source text (verbatim with whitespace normalized): (f) Reconsideration period. A State must reconsider eligibility consistent with § 435.916(a)(3)(iii), if an individual, who was enrolled with eligibility based on MAGI, was disenrolled for failure to submit information requested in a notice of noncompliance and submits the information during the reconsideration period described in § 435.916(a)(3)(iii).All specified conditions must be met. The incorporated period and treatment of the submission must be verified against § 435.916(a)(3)(iii); no new application requirement, automatic approval, or numeric period is invented. Potential error consequence, inferred: failure to reconsider a qualifying submission could extend a coverage gap.Cross-reference links: https://www.ecfr.gov/current/title-42/section-435.916#p-435.916(a)(3)(iii)HourKeep comparison row(s), review status not independently established: https://github.com/nickarrow/hourkeep/blob/main/docs/review/notices-and-fair-hearings.md#reconsideration-after-disenrollment
Performance Indicators
4.7.1: Eligibility Reconsideration
| Type | Start Date | End Date | ... | Status | Description |
|---|---|---|---|---|---|
| Target | Reconsidered if Conditions Met | Reconsider eligibility consistently with § 435.916(a)(3)(iii) when a former MAGI-based enrollee was disenrolled for failing to submit information requested in a noncompliance notice and submits that information during the incorporated reconsideration period. |
Other Information
The target condition derives from 42 CFR § 435.558(f). Measurement dimension and completion descriptor are editorial representations. The ... unit is a qualitative display convention. No actual result or individual eligibility outcome is asserted. Applicability, source conditions, and incorporated safeguards must be checked before assessing performance.