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Glossary

42 CFR 435.912

The federal Medicaid rule on how quickly a state must determine eligibility: 90 days for applicants on the basis of disability, 45 days for all others, with named exceptions. It times the financial determination by the state Medicaid agency, not the level-of-care decision a waiver or PACE applicant also needs.

Also § 435.912, timely determination of eligibility, Medicaid 45-day rule

How Vivlio handles this for case management

42 CFR 435.912, “Timely determination of eligibility”, is the rule behind the 45 days that everyone in Medicaid waiver work quotes and most people misattribute. Paragraph (c)(3) says that, except as provided in paragraph (e), “the determination of eligibility for any applicant may not exceed” 90 days “for applicants who apply for Medicaid on the basis of disability” and 45 days “for all other applicants”. Paragraph (e) lists the circumstances that excuse a longer determination, among them a delay caused by an examining physician.

Two things about it decide what the number means for an agency:

  • It is the financial clock. The determination it times is made by the state Medicaid agency on the application: income, resources, residency, citizenship. It is not the nursing facility level of care decision, which a waiver or PACE applicant also needs and which runs on the state’s own rules and the physician’s level-of-care form. An applicant can clear 435.912 on day 30 and still be waiting for the clinical half.
  • It binds the state, not the case manager. The agency that assembles the clinical packet is not the party the 45 days is counted against. What the agency controls is how quickly the records that substantiate level of care are in hand, and that is the delay families actually feel.

The section was amended in 2026 and its current text carries a sunset date of October 1, 2034 for these provisions, so the day counts above should be read against the current eCFR text rather than quoted from memory. The state-by-state level-of-care clocks that sit beside this one, Wisconsin’s 30 days, Ohio’s 14, Iowa’s 60, are collected in Which 45 days? The Medicaid waiver clocks. Vivlio’s part is the clinical packet: retrieving the hospital, physician and specialist records a Medicaid waiver case management agency needs under the applicant’s signed release, so the level-of-care review is not the clock that stalls.

Where it is defined

Vivlio for case managementThe physician's documentation behind the level-of-care form, retrieved before the state's clock runs out.

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  • Treatment, with the paperwork doneProduction access needs an NPI, a declared purpose of use and a signed BAA. Nobody swipes a card onto live PHI.

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