CPP-080_eligibility-enrolment-retroactive-termination_v6.1.md

# CPP-080 — Eligibility, enrolment and retroactive termination **Version 6.1 · Effective 1 January 2026 · Supersedes v6.0** Owner: Enrolment Integrity Applies to: All lines of business — all states, with variations External basis: 45 CFR 156.270 (QHP grace period) · 42 CFR 435.916 (Medicaid redetermination) · CMS Medicare Managed Care Manual ch. 2 ## 1. Purpose Whether the member was covered on the date of service, and what happens to a claim already paid when enrolment changes afterwards. ## 2. What changed in version 6.1 Version 6.0 verified eligibility once, at adjudication. That is not a record an audit can defend months later. From 1 January 2026, eligibility must be re-verified at audit as well, and both results recorded against the claim with their source and timestamp. A retroactive termination discovered at audit is itself a recovery reason, and does not require a coding finding to accompany it.

## 3. Criteria ### 3.1 The date that governs Coverage is evaluated as at the date of service. Not the date of payment, and not the date of the audit. A member covered on the date of service whose coverage later ends prospectively creates no exposure on a claim already paid. ### 3.2 Recording the checks Both the enrolment status at adjudication and the status at re-verification are recorded against the claim, each with the source system consulted, the timestamp of the check, and the result returned. A status without a source and a timestamp is an assertion, not a verification. ### 3.3 Retroactive termination A retroactive termination whose effective date covers the date of service makes the full paid amount recoverable. The recovery is pursued against the provider where the provider was on notice, and otherwise handled under the plan's overpayment procedure. ### 3.4 Coordination of benefits Primacy is determined as at the date of service and re-checked at audit. Where this plan

was on notice, and otherwise handled under the plan's overpayment procedure. ### 3.4 Coordination of benefits Primacy is determined as at the date of service and re-checked at audit. Where this plan paid as primary and was in fact secondary, the difference is recoverable. See CPP-092.

## 4. Variations by state and line of business ### 4.1 Marketplace qualified health plans A member receiving an advance premium tax credit has a three-month grace period for non-payment of premium. Claims for services in the first month are paid. Claims in months two and three may be pended and, if the premium is not paid by the end of the grace period, recovered in full. A claim already paid for a service in month two or three of a grace period is recorded as an eligibility exposure while the grace period runs. It is not a coding finding, and it is not counted in the audit hit rate. ### 4.2 Texas Medicaid Coverage lost at redetermination terminates prospectively. A retroactive termination is raised only on a determination of ineligibility, not on a procedural closure. A prospective termination after the date of service creates no exposure. ### 4.3 Medicare Advantage A retroactive disenrolment processed by CMS makes the plan not liable for the period concerned. Reconciliation

e termination after the date of service creates no exposure. ### 4.3 Medicare Advantage A retroactive disenrolment processed by CMS makes the plan not liable for the period concerned. Reconciliation follows the monthly membership report.