What to do, and when

At diagnosis or the first visit

• Confirm the patient has Medicaid, is 19 to 64, and does not have Medicare.
• Ask whether the patient has received any Medicaid letters about work or "community engagement."
• Confirm the address and phone number Medicaid has on file. Help update them if they are wrong.
• Run the screener and record which path fits: excluded, medically frail, meets the activity requirement, or needs a plan.
• Find the patient's next Medicaid renewal month and add it to the chart.
• Have the patient sign the state's authorized representative or release form, so staff can talk to Medicaid and get copies of notices.
• Give the patient the patient guide (or the Spanish guide).

At treatment start or a change in plan

• Clinician documents the diagnosis, stage, treatment plan, expected duration and functional limits in the chart.
• Clinician completes and signs a frailty letter, or the state's own form.
• Social worker or navigator sends it to the state the way the state accepts, keeps proof of sending, and gives the patient a copy.
• If clinician documentation cannot be obtained in time and the state accepts it, help the patient complete a truthful statement signed under penalty of perjury. From 2028 this can be used only once per enrollment period, so do not use it when a clinician letter is available.
• If the patient is admitted or must travel far for treatment, ask whether the state offers the short-term hardship exception, and request it.

60 days before each renewal

• Remind the patient that a renewal is coming, to watch the mail, phone and online account, and to return the renewal form by its due date, even if they are excluded.
• Check whether the frailty documentation on file is less than 12 months old and still matches the treatment plan. Update it if not.
• If the patient meets the requirement through work, school or service, collect the last months of proof.
• If treatment has ended, check whether lasting effects still limit work, or whether another path now fits better.

When a notice of noncompliance arrives

The patient has 30 days from receiving it, presumed to be 5 days after the date on the letter. Coverage continues while it is pending.

• Write down the date on the letter and the response deadline. Add it to the chart.
• Read what the state says is missing.
• Send proof of activity, of an exclusion, or of medical frailty, through any channel the state accepts. Keep a copy and the date sent.
• Call the state within a week to confirm it was received.
• If time is short or the case is complex, refer to legal aid now, not after a denial.

If coverage is denied or ended

• Request a fair hearing before the date coverage ends (usually about 10 days after the notice) so coverage can continue during the appeal.
• Refer to free legal aid (LawHelp.org) or a cancer legal navigation service.
• If coverage ended because papers were not sent, send them now: during the reconsideration period (at least 90 days) the state must reconsider without a new application. After that, reapply right away. There is no waiting period or lockout.
• Screen for hospital financial assistance, state cancer programs, and drug manufacturer or foundation assistance to bridge the gap.
• Do not rely on the Marketplace: people who lose Medicaid for this reason generally cannot get premium tax credits.
• Tell the treating team, so active treatment is not interrupted without a plan.