What Is Medicaid Redetermination? How Renewals Can End a Rider's NEMT Trips

Your rider’s Medicaid card can look the same the day after their coverage ends. Redetermination is the reason. Every member’s eligibility is rechecked on a schedule, and a missed letter can end coverage, and the ride benefit, weeks before anyone at your office hears about it.

What Medicaid redetermination means

Redetermination is the state Medicaid agency’s recheck of whether a member still qualifies. The federal rule is titled “Periodic renewal of Medicaid eligibility” (42 CFR 435.916). Its section on members whose eligibility rests on modified adjusted gross income (MAGI), the standard income test, speaks of renewal. Its section on members covered for other reasons, such as age, blindness, or disability, speaks of redetermination. In its guidance, CMS uses renewal for the scheduled recheck and redetermination for any recheck, including one after a reported change (SMD 26-001).

How often it happens depends on the member’s coverage group:

Rider’s coverage	How often eligibility is rechecked	Rule
Other income-based (MAGI) groups, such as parents, caretaker relatives, and pregnant members	Once every 12 months, and no more often	42 CFR 435.916(a), SMD 26-001
Expansion adults, 19 to 64, not pregnant, without Medicare	Every 6 months, starting with renewals scheduled on or after January 1, 2027	Public Law 119-21 section 71107, SMD 26-001
Certain American Indians and Alaska Natives in the expansion group	Stay at 12 months	SMD 26-001
Covered because of age 65 or older, blindness, or disability	At least every 12 months	42 CFR 435.916(b)
Children under 19	12 months of continuous coverage, ending early only at age 19, a move out of state, a voluntary request, agency error or fraud, or death	42 CFR 435.926
Any member who reports a change	Promptly, between regular renewals, if the change may affect eligibility	42 CFR 435.916(d)

The six-month rule reaches expansion adults covered under the state plan or under a Section 1115 waiver that covers the whole group. In a state that covers these adults only through a partial Section 1115 expansion, they stay on the 12-month schedule (SMD 26-001).

How a renewal works

The steps are the same whether a rider is renewed every 6 or every 12 months (SMD 26-001, March 6, 2026).

Step	What the state must do	What your rider sees
1. Data check	Try to renew from information it already has, called an ex parte renewal	A notice that coverage continues. No reply needed if it is correct
2. Renewal form	If that fails, send a form filled in with what it knows	At least 30 days to return it by internet, phone, mail, in person, or other electronic means, with no in-person interview
3. Full review	Consider every other way the member might qualify before finding them ineligible	Sometimes a move to a different Medicaid group
4. Notice	Send notice at least 10 days before the date coverage ends, with fair hearing rights	A letter with an end date
5. Second chance	For income-based members cut off for missing paperwork, reconsider without a new application if the form comes back within 90 days, or longer if the state allows	Coverage can be restored

Steps 2 and 5 are required for income-based members. For members covered because of age, blindness, or disability, states may use them but do not have to.

In an example in its March 6, 2026 letter, CMS shows a state starting a renewal about 90 days before the eligibility period ends. On a six-month cycle, that means renewal mail can arrive about three months after coverage begins. CMS also reminds states that they generally must finish each renewal by the end of the eligibility period.

What changes in 2027

Public Law 119-21, signed July 4, 2025, brings three changes that land at renewal time:

• Six-month renewals. Expansion adults move to six-month coverage periods. New applicants whose coverage starts on or after January 1, 2027 get six months from the start, and states choose how to move current members over. See six-month Medicaid renewals.
• Work requirement checks. At each scheduled renewal on or after January 1, 2027, states generally must also decide whether members who are subject to the community engagement requirement meet it. A state that shows good faith efforts to comply can get a federal exemption, but none lasts past December 31, 2028. See the Medicaid work requirement rule.
• Less back coverage. For applications made on or after January 1, 2027, coverage before the month of application is limited to one month for expansion adults and two months for everyone else. Today the rule reaches back as far as three months (42 CFR 435.915). See the retroactive coverage cut.

What redetermination means for your trips

The state checks eligibility on every claim. Its review before payment must confirm the member was in the eligibility file on the date of service (42 CFR 447.45(f)). A ride given after coverage ends goes unpaid unless coverage is later restored for that date.

A dispatch example

A rider goes to treatment three times a week on a standing order. Her renewal form sits unopened, and the state sends a notice ending coverage in 10 days. The broker assigned you her trips for the whole month when she was still covered. If you check eligibility only at booking, you drive the rest of the month’s trips, and none of them is covered. If you check on each ride date, the end date shows up on the first trip after it, and you can call the broker before you send the van. Follow your broker agreement on what to do with an assigned trip when the member is no longer eligible.

A billing example

Now say the same rider misses the 90-day window and reapplies instead. Today the state must cover up to three months before the month she applies, if she would have qualified then and received covered care (42 CFR 435.915). CMS says states must pay claims for covered services in a retroactive eligibility period, including rides, and a provider who collected money from the rider may first have to refund it (SMD 23-006). A trip you drove after her old coverage ended can become payable that way. For applications made on or after January 1, 2027, an expansion adult gets at most one month of back coverage, so the same gap may stay uncovered. Federal rules require claims within 12 months of the date of service, and your state or broker may set a shorter limit. See timely filing limit.

Appeals keep coverage running

If a rider asks for a fair hearing before the date of action on the notice, the state may not end coverage until the hearing decision, unless the only question is one of law or policy (42 CFR 431.230). If the rider asks within 10 days after that date, the state may reinstate coverage (42 CFR 431.231). Either way, check the state’s system on the day of each ride.

How to keep rides running through renewals

1. Check eligibility on the date of every ride. A check at booking is not enough for trips weeks out. See Medicaid eligibility verification.
2. Recheck standing orders often. Run every recurring rider through the state system at least at the start of each month, and again before each ride.
3. Ask about renewal mail at intake. Add a question to your trip intake script, and remind riders to answer renewal mail right away. Income-based members get at least 30 days to answer by phone, mail, online, or in person.
4. Tell cut-off riders about the second chance. An income-based member who lost coverage for missing paperwork can send the form within 90 days after coverage ends and be reconsidered without a new application.
5. Point riders who got a notice to the hearing option. Asking before the date on the notice generally keeps coverage in place until a decision.
6. Offer another way to pay. A rider between coverage periods can still ride as private pay, with a written agreement on what happens if Medicaid later covers the date.
7. Save proof of each check. Keep the portal screen or phone verification number with the trip record in case a claim is disputed.