Medicaid Program; Community Engagement Requirement for Certain Individuals

The following changes will be submitted to OMB for approval under control number 0938-1188 (CMS-10434 #15).

Section 1902(a) of the Act requires that States have a State plan for medical assistance that meets certain Federal requirements that set forth a framework for the State program. States will be required to submit a SPA (and any associated attachments) using a new, CMS-provided template to implement the community engagement requirement consistent with section 1902(xx) and CMS implementing regulations at Sec. 430.10.

SPA submissions will describe State policies and operational approaches, including notices, exceptions, exclusions, and compliance procedures, and will be updated as needed when State approaches change. As noted in section H.2. of this IFC, States must specify the number of consecutive months an applicable individual must demonstrate community engagement prior to the month of application in the State plan.

To develop the SPA, States will need to describe the process they are using to implement community engagement standards, including the processes to confirm and document an applicant's or beneficiary's compliance with the community engagement requirement.

We estimate that it will take approximately 44 hours per jurisdiction for this one-time activity. States will have to document their processes, identify and compile all necessary information, and amend their State Plans. Of the 44 hours, we estimate that it will take 40 hours at $87.52/hr for a Business Operations Specialist to prepare and submit the SPA and 4 hours at $128.00/hr for a General and Operations Manager to review the data and submit the SPA. In aggregate, we estimate a one-time burden of 1,936 hours (44 hr x 44 jurisdictions) at a cost of $176,563 ((44 jurisdictions x (40 hr x $87.52/hr) + (4 hr x $128.00/hr)). Accounting for the Federal administrative match of 50 percent, we estimate a State cost of $88,282 ($176,563 x 0.50). We have summarized the total burden in Table 9. [GRAPHIC] [TIFF OMITTED] TR03JN26.027

The following changes will be submitted to OMB for approval under control number 0938-1148 (CMS-10398 #11).

In section II.I. of this IFC, States are required to verify compliance, deemed compliance or status as a specified excluded individual for certain adults who are eligible for, or are enrolled in, Medicaid. Specifically, States must verify whether an applicant or beneficiary demonstrated community engagement, is deemed to have demonstrated community engagement for all or part of a month that the individual was in a mandatory or optional excepted status, or is a “specified excluded individual” to whom the community engagement requirement does not apply. Additionally, States are required to conduct ex parte verifications by maximizing reliance on electronic data sources in verifying compliance with the community engagement requirement, including deemed compliance, or that an individual is a “specified excluded individual” and in

what circumstances States may require individuals to provide additional information.

The regulation in Sec. 435.945(j) requires States to “develop, and update as modified, and submit to the Secretary, upon request, a verification plan describing the verification policies and procedures adopted by the State agency to implement the provisions set forth in Sec. Sec. 435.940 through 435.956,” which relate to the verification of income, assets and citizenship status, amongst other eligibility criteria. In this IFC, we incorporate this requirement for the purpose of verifying that an individual has met or is excluded from the community engagement requirement. As such, CMS has updated the MAGI verification plan to include a supplement specific to community engagement. States will be required to document and submit to CMS their verification plans describing how, consistent with Federal standards, the State will determine and verify:

Demonstration of compliance with the community engagement requirement.

Mandatory exceptions for deemed compliance.

Status as a specified excluded individual.

Optional exceptions for short-term hardship events for deemed compliance.

Use of ex parte processes and use of reliable data sources at both application and renewal, and more frequently at State option, including when the State will request information from individuals.

Controls to ensure consistency, timeliness, and proper documentation of determinations.

Section 1902(xx)(5) of the Act requires States to conduct ex parte verification of the community engagement requirement, directing States to verify compliance with, or exception (for deemed compliance) or exclusion from, the community engagement requirement using reliable information available to the State, including information in the individual's record and more recent information obtained from electronic data sources without requiring additional information from an applicant or a beneficiary. States must use reliable information available to the State to verify compliance with the community engagement requirement, which includes, but is not limited to, their existing data sources, the Federal Data Services Hub, or other data sources to determine income and other eligibility criteria. A State's own case records, claims systems or payments, or encounter data are also reliable information available to the State for purposes of verification requirements under Section 1902(xx)(5) of the Act.

To comply with the requirements for the verification plan, we estimate that each of the 43 States and the District of Columbia have a one-time burden of 124 hours to develop the verification plan. Of the 124 hours, we estimate that it will take 60 hours at $87.52/hr for a Business Operations Specialists to prepare the verification plan, 60 hours at $95.32/hr for an Operations Research Analyst to prepare and review the data, and 4 hours at $128.00/hr for a General and Operations Manager to review the data and submit the verification plan. In aggregate, we estimate a one-time burden of 5,456 hours (124 hr x 44 jurisdictions) at a cost of $505,226 (44 x [(60 hr x $87.52/hr) + (60 hr x $95.32/hr) + (4 hr x $128.00/hr)]). Accounting for the Federal administrative match of 50 percent, the requirement will cost States $252,613 ($505,226 x 0.50). We have summarized the total burden in Table 10. [GRAPHIC] [TIFF OMITTED] TR03JN26.028

Additionally, we assume recurring burden associated with updating and maintaining the initial verification plan supplement submission. We estimate 5 States per year will make verification plan updates. For each of these States, we estimate it will take 5 hours at $87.52/hr for a Business Operations Specialist and 5 hours at $95.32/hr for an Operations Research Analyst to update their verification plan. We also estimate that it will take 1 hour at $128.00/hr for General and Operations Managers to review the data and submit the verification plan. In aggregate, we estimate an annual burden of 55 hours (11 hr/ response x 5 jurisdictions) at a cost of $5,211 (5 x [(5 hr x $87.52/ hr) + (5 hr x $95.32/hr) + (1 hr x $128.00/hr)]). Accounting for the Federal administrative match of 50 percent, the requirement will cost States $2,606 ($5,211 x 0.50). We have summarized the total burden in Table 11. [GRAPHIC] [TIFF OMITTED] TR03JN26.029

We have summarized the total burden for the verification plan submission and annual updates in Table 12. [GRAPHIC] [TIFF OMITTED] TR03JN26.030

5. ICRs Regarding Beneficiary Application Updates (Single Streamlined and Presumptive Eligibility Applications) (Sec. Sec. 435.912, 435.556, and 435.557)

The following changes will be submitted to OMB for approval under control number 0938-1147 (CMS-10410).

Section 1902(xx) of the Act requires that “applicable individuals” demonstrate as a condition of their Medicaid eligibility, “community engagement” for a minimum period of time preceding their application month and during their enrollment. Section 1902(xx)(9)(A)(i) of the Act defines the term “applicable individual” to mean “an individual . . . who is eligible to enroll (or is enrolled) under the State plan under subsection (a)(10)(A)(i)(VIII), or who is otherwise eligible to enroll (or is enrolled) under a waiver of such plan . . .” and is not a “specified excluded individual.” These requirements will necessitate updates by States to their single, streamlined application; alternative single, streamlined application; associated instructions; and/or renewal-related materials, as applicable, to reflect community engagement-related information that must be communicated and collected consistent with section 1902(xx) of the Act and implementing regulations.

For these updates, we estimate that each of the 43 States and the District of Columbia will need to implement changes to their websites, required at Sec. 435.1200(f), including updates to the online and electronic versions of their applications, instructions, forms, notices, templates, and postings. We estimate a one-time burden of 116 hours per State to accomplish these tasks. States will need to incorporate the requirements of the terms “applicable individuals” and “specified excluded individuals” into their eligibility processes and documents. Of the 116 hours, we estimate it will take 80 hours at $90.08/hr for a Business and Financial Operations Occupation to perform this task, 32 hours at $99.66/hr for a Computer Programmer to implement the technical changes to the associated website, and 4 hours at $128.00/hr for a General and Operations Manager to review and provide oversight prior to submission and implementation. In aggregate, we estimate a one-time burden of 5,104 hours (116 hr x 44 jurisdictions) at a cost of $479,931 (44 x [(80 hr x $90.08/hr) + (32 hr x $99.66/hr) + (4 hr x $128.00/hr)]). Accounting for the Federal administrative match of 75 percent, the requirement will cost States $119,983 ($479,931 x 0.25). We have summarized the total burden in Table 13. [GRAPHIC] [TIFF OMITTED] TR03JN26.031

In addition to the single, streamlined applications and associated instructions and renewal-related material updates, States will need to make updates to their hospital presumptive eligibility and/or presumptive eligibility applications and provider training materials, including eligibility determination notices. The updates to hospital presumptive eligibility materials are applicable to those States that cover the adult group in their State plan, and for optional presumptive eligibility, to those States that have elected to provide presumptive eligibility to the adult group. For the updates to presumptive eligibility and hospital presumptive eligibility, we estimate that 38 States and the District of Columbia (39 jurisdictions) will need to incorporate the regulatory requirements into their provider training materials, eligibility notices, and application materials.

For these updates, we estimate that each of the 39 jurisdictions will need to incorporate the regulatory requirements into their application process and make updates to their hospital presumptive eligibility and/or presumptive eligibility

applications and provider training materials. States will also need to update any electronic hospital presumptive eligibility and/or presumptive eligibility forms, templates, and notice-generation artifacts, as applicable. We estimate a one-time burden of 64 hours per State consisting of 36 hours at $90.08/hr for a Business and Financial Operations Occupation to perform this task, 24 hours at $99.66/hr for a Computer Programmer to conduct the technical tasks, and 4 hours at $128.00/hr for a General and Operations Manager to review and provide oversight prior to submission. In aggregate, we estimate a one-time burden of 2,496 hours (64 hr x 39 jurisdictions) at a cost of $239,722 (39 x [(36 hr x $90.08/hr) + (24 hr x $99.66/hr) + (4 hr x $128.00/ hr)]. Accounting for the Federal administrative match of 75 percent, the requirement will cost States $59,931 ($239,722 x 0.25). We have summarized the total burden in Table 14. [GRAPHIC] [TIFF OMITTED] TR03JN26.032

In addition, Medicaid applicants and beneficiaries may be required to provide additional information or documentation to verify their status as excepted or excluded from the community engagement requirement, including their status as an individual that is medically frail or has other special medical needs as defined at Sec. 435.554(c)(5), or to provide information to the State to demonstrate how they satisfied the community engagement requirement. Beneficiaries will have to submit documentation or other information if the State cannot verify compliance based on available information, including data sources.

Based on State-reported renewal data from calendar year 2025, we estimate that approximately 56 percent of the approximately 20 million total applicable individuals that will be due for renewal will have their compliance with, or exception or exclusion from, the community engagement requirement verified ex parte, and that the remaining 44 percent, or 8.8 million beneficiaries, will need to provide information to the State.\121\ We also estimate, on average, it will take 2 hours at $12.92/hr for a beneficiary to document and submit their information or documentation regarding community engagement to the State every 6 months. We acknowledge the options at Sec. 435.557(d) for States to conduct more frequent verifications for applicable individuals. We also note that some applicable individuals enrolled in Medicaid under an 1115 demonstration will continue to have their eligibility renewed once every 12 months instead of every 6 months. Further, as described at Sec. 435.557(f)(1)(iii), States may elect to reverify continued medical frailty status once every 12 months for individuals whose specified excluded status on the basis of being medically frail or otherwise have special medical needs was initially verified based on available information or documentation. However, on balance, we believe that for the purpose of estimating burden, the vast majority of States will verify compliance with, or exception or exclusion from, the community engagement requirement, and that certain adults may be required to submit information to verify their compliance, every 6 months.

\121\ State Medicaid and CHIP Eligibility Processing Data, updated April 24, 2026. State Medicaid and CHIP Eligibility Processing Data.

In aggregate, we estimate an annual burden of 35.2 million hours (8.8 million beneficiaries providing information to the State x 2 hr/ response x 2 responses/year) at a cost of $454,784,000 (35.2 million hr x $12.92/hr). We have summarized the total burden in Table 15. [GRAPHIC] [TIFF OMITTED] TR03JN26.033

Additionally, we estimate that 3.75 million new applicants will have to submit their information to the State to demonstrate compliance with the requirements. This estimate of new applicants is an approximation. State-reported data published by CMS shows that 30.6 million applications for Medicaid and CHIP were received in 2025.\122\ If we assume 10 percent are CHIP applications, that would leave approximately 27.5 million Medicaid applications. However, this same dataset notes that many of the data reported by States include renewals and/or redeterminations, the burden for which is captured in Table 15. Therefore, we assume that only 15 million of these will be new Medicaid applications, of which 25 percent, or 3.75 million, will be subject to the community engagement requirement and required to submit information to demonstrate their compliance. We

estimate, on average, it will take 2 hours at $12.92/hr for a new applicant to document and submit their information or documentation regarding community engagement to the State at the time of application. In aggregate, we estimate an annual burden of 7,500,000 hours (3,750,000 beneficiaries providing information to the State x 2 hr/ response) at a cost of $96,900,000 (7,500,000 hr x $12.92/hr).

\122\ January 2026: Medicaid and CHIP Eligibility Operations and Enrollment Snapshot, slide 13. https://www.medicaid.gov/resources-for-states/downloads/eligib-oper-and-enrol-snap-jan2026.pdf.

We have summarized the annual burden for applicants in Table 16, and the total burden associated with beneficiary applications (single streamlined applications, presumptive eligibility applications, and hospital presumptive eligibility applications) in Table 17. [GRAPHIC] [TIFF OMITTED] TR03JN26.034

[GRAPHIC] [TIFF OMITTED] TR03JN26.035

The following changes will be submitted to OMB for approval under control number 0938-1148 (CMS-10398 #101).

Section II.G. of this IFC discusses the State option to deem an individual to have demonstrated community engagement for a month when the individual experiences one of the short-term hardship circumstances described in section 1902(xx)(3)(B)(ii) of the Act and codified at Sec. 435.555(d) during such month. As exceptions at Sec. 435.555 are optional, we acknowledge that not all States may elect to grant them. However, given uncertainty at this time and so as not to underestimate, our burden estimations described below assume that all 44 jurisdictions subject to the community engagement requirement will elect to make short-term hardship exceptions available under circumstances described at section 1902(xx)(3)(B)(ii) of the Act and Sec. 435.555(d). Generally, these circumstances are as follows: an individual receives for all or part of a month certain hospital or institutional services (or other services of “similar acuity” as the Secretary determines appropriate); subject to a request by the State, an individual resides in a county or equivalent unit of local government in which there has been declared by the President a Federal emergency or disaster, or, in which the unemployment rate is equal or greater than a particular threshold; or the individual or the individual's dependent must travel outside of their community for an extended period of time for treatment of a serious or complex medical condition.

Section 1902(xx)(3)(B)(i) of the Act and Sec. 435.555(c) direct that determinations of short-term hardship be made under procedures established by the State. States electing to allow short-term hardship exceptions will be required to establish and document processes and procedures and make any corresponding technical edits to relevant systems (for example, eligibility and enrollment systems) necessary to effectuate short-term hardship exceptions described at Sec. 435.555(d). Required processes and procedures include the method and timeframe by which an applicable individual or an individual acting on behalf of the

applicable individual may request a short-term hardship exception under Sec. 435.555(d)(1) and (4) and the timely process by which the State will determine whether such requests will be granted. We estimate a one-time burden of 116 hours per jurisdiction to accomplish these tasks. Of the 116 hours, we estimate it will take 80 hours at $90.08/hr for a Business and Financial Operations analyst to perform this task, 32 hours at $99.66/hr for a Computer Programmer to implement the technical changes to the associated system, and 4 hours at $128.00/hr for a General and Operations Manager to review and provide oversight. In aggregate we estimate a one-time burden of 5,104 hours (116 hours x 44 jurisdictions) at a cost of $479,931 (44 x [(80 hr x $90.08/hr) + (32 hr x $99.66/hr) + (4 hr x $128.00/hr)]). Accounting for the Federal administrative match of 75 percent, the requirement will cost States $119,983 ($479,931 x 0.25). We have summarized the burden associated with establishing and documenting short-term hardship exceptions in Table 18. [GRAPHIC] [TIFF OMITTED] TR03JN26.036

As directed at Sec. 435.555(c)(1), States electing the option for short-term hardship requests must provide notice informing applicable individuals that the State offers short-term hardship exceptions available under the circumstances described at Sec. 435.555(d)(2) and (3), and the anticipated end date of the exception. Separately, Sec. 435.555(c)(2) directs States to provide notice informing applicable individuals of short-term hardship exceptions available under the circumstances described at Sec. 435.555(d)(1) and (4) and the method by which such exceptions may be requested.

States electing to allow short-term hardship exception requests will need to develop notices, as described above, to inform beneficiaries of the various circumstances under which short-term hardship exceptions are available under Sec. 435.555(d), and to describe associated processes. These States will also need to establish or update the associated operational workflows to ensure individuals are notified about short-term hardships and to support required delivery modalities to individuals who receive paper notices, which is the default modality for agency communications to applicants and beneficiaries unless an individual elects to receive electronic notices as described in Sec. 435.918 and cross-referenced in Sec. Sec. 435.561(d) and 435.555(c) for communications related to community engagement. Because the mailing of paper notices is the default modality, we estimate that 75 percent of beneficiaries do not currently elect to receive electronic notices.

To comply with these requirements, we estimate that it will take a one-time burden of 80 hours at $87.52/hr for a Business Operations Specialist to develop or update the notice templates and update the associated workflows as necessary, 8 hours at $128.00/hr for a General and Operations Manager to review and approve the updated notice templates and workflows, and 24 hours at $99.66/hr for a Computer Programmer to conduct the technical changes to the associated State systems required to generate electronic notices. In aggregate, we estimate a one-time burden of 4,928 hours (112 hr x 44 jurisdictions) at a cost of $458,367 (44 x [(80 hr x $87.52/hr) + (24 hr x $99.66/hr) + (8 hr x $128.00/hr)]). Accounting for the Federal administrative match of 75 percent, the requirement will cost States $114,592 ($458,367 x 0.25). We have summarized the initial burden associated with developing short-term hardship exception notices in Table 19. [GRAPHIC] [TIFF OMITTED] TR03JN26.037

We also estimate it will take 1 minute (0.017 hr) at $38.66/hr for a Mail Clerk to mail each of the 2 short-term hardship exception notices to 75 percent of the applicable beneficiaries (20 million total applicable beneficiaries). This results in 30 million outreach notices (20,000,000 applicable beneficiaries x 0.75 that will not elect electronic delivery x 2 notices) in the initial year. In aggregate, we estimate a one-time burden of 510,000 hours (30,000,000 total mailings x 0.017 hr per mailing) for Mail Clerks to complete all mailings at a cost of $19,716,600 (510,000 x $38.66/hr). Accounting for the Federal administrative match of 50 percent, the labor burden of this requirement will cost States $9,858,300 ($19,716,600 x 0.50).

In addition, the mailing of the initial notices will add ancillary non-labor costs. We assume these costs include paper, toner, envelopes, and postage (envelope weight is normally considered negligible when citing these rates and is not included) for hard-copy mailings:

Paper: $3.50 for a ream of 500 sheets. The cost for one page is $0.007 ($3.50/500 sheets).

Toner: $70 for 10,000 pages. The toner cost per page is $0.007 ($70/10,000 pages).

Envelope: Bulk envelope costs are $440 for 10,000 envelopes or $0.044 per envelope.

Postage: The cost of first-class metered mail is $0.73 per letter up to 1 ounce. We estimate that a sheet of paper weighs 0.16 ounces (10.0 lb/1,000 sheets x 16 oz/lb), and do not anticipate additional postage for mailings in excess of 1 ounce.

We estimate the aggregate cost per mailed notice is $0.802 [($0.007 for paper * 2 pages) + ($0.007 for toner * 2 pages) + $0.73 for postage + $0.044 per envelope]. Assuming 30 million initial mailings in the initial year, we assume non-labor ancillary costs of $24,060,000 (30,000,000 x $0.802). Accounting for the Federal administrative match of 50 percent, the non-labor burden of this requirement will cost States $12,030,000 ($24,060,000 x 0.50). We have summarized the initial burden associated with mailing short-term hardship exception notices in Table 20. [GRAPHIC] [TIFF OMITTED] TR03JN26.038

States will also need to conduct ongoing annual maintenance of short-term hardship exception notice templates and the associated operational workflows to ensure continued compliance with required delivery modalities and timing. We estimate this ongoing annual activity will require approximately 28 hours per State (one-quarter of the 112-hour one-time effort) to review, update, and implement minor policy, operational, and technical changes to notices and delivery workflows. Of the 28 hours, this includes 20 hours at $87.52/hr for a Business Operations Specialist to update notices and workflows, 2 hours at $128.00/hr for a General and Operations Manager to review and approve updates, and 6 hours at $99.66/hr for a Computer Programmer to make necessary technical adjustments to the State's electronic data collection methods.

In aggregate, we estimate an annual burden of 1,232 hours (28 hr x 44 jurisdictions) at a cost of $114,592 (44 x [(20 hr x $87.52/hr) + (6 hr x $99.66/hr) + (2 hr x $128.00/hr)]). Accounting for the Federal administrative match of 75 percent, the requirement will cost States $28,648 ($114,592 x 0.25). We have summarized the ongoing burden associated with maintaining short-term hardship exception notices in Table 21. [GRAPHIC] [TIFF OMITTED] TR03JN26.039

In addition, we continue to estimate 1 minute (0.017 hr) at $38.66/ hr for a Mail Clerk to process and mail each beneficiary notice. We assume that the initial estimate of 15 million beneficiaries that receive paper notices will be moderately reduced in subsequent years as more beneficiaries opt to receive their notices electronically. On an ongoing basis we assume that 11.25 million beneficiaries (0.75 x 11,250,000) will need to be mailed 2 paper short-term hardship exception notices. For the combined 22.5 million beneficiary notices (11,250,000 x 2), this equals 382,500 hours annually (22,500,000 mailings x 0.017 mailings/hr) at an annual cost of $14,787,450 (382,500 hours x $38.66/hr). Accounting for the Federal administrative match of 50 percent, the annual labor cost to States is $7,393,725 ($14,787,450 x 0.50).

In addition, the ongoing mailing of the notices will add ancillary annual non-labor costs associated with paper, toner, envelopes, and postage. Assuming 22.5 million mailings annually at a cost of $0.802 [($0.007 for paper x 2 pages) + ($0.007 for toner x 2 pages) + $0.73 for postage + $0.044 per envelope], we estimate an additional

aggregate annual non-labor cost of $18,045,000 (22,500,000 x $0.802). Accounting for the Federal administrative match of 50 percent, the non- labor burden of this requirement will cost States $9,022,500 ($18,045,000 x 0.50). We have summarized the ongoing State burden associated with mailing short-term hardship exception notices in Table 22. [GRAPHIC] [TIFF OMITTED] TR03JN26.040

Beyond notices, States will also have additional burden associated with requesting short-term hardships as described at Sec. 435.555(d)(2) and (3).

Emergency or Disaster Exception: The emergency or disaster-related exception, codified at Sec. 435.555(d)(2) exists when an emergency or disaster is declared by the President under the National Emergencies Act or the Robert T. Stafford Disaster and Emergency Assistance Act. For emergencies declared under the National Emergencies Act (NEA), States must notify CMS timely of its plan to effectuate a short-term hardship exception at Sec. 435.555(d)(2)(ii) in which the State identifies its inclusion in the scope of an NEA-declared emergency, how the emergency affects the ability of applicable individuals to demonstrate community engagement, either in a particular county (or equivalent unit of local government), multiple counties, or statewide, and the anticipated duration of this effect on applicable individuals. Moreover, for Robert T. Stafford Disaster and Emergency Assistance Act (Stafford Act)-related declarations, in the event States would like extension of the exception beyond the duration described at Sec. 435.555(d)(2)(iv), States must submit a notification to provide information in support of such extension.

In 2025, the 44 jurisdictions with populations subject to community engagement experienced nine NEA declarations and 44 Stafford Act Major Disaster or Emergency declarations.123 124 Of the 44 Stafford Act declarations, we estimate that approximately 11, or 25 percent, may result in a State requesting an extension of the short- term hardship exception. In total, we estimate that there will be 20 emergency or disaster declarations (nine NEA declarations + 11 Stafford Act declarations) annually that would require a State to submit a request to CMS for either an exception or an extension.

\123\ FEMA, Disaster Declarations Summaries--v2: https://www.fema.gov/openfema-data-page/disaster-declarations-summaries-v2.

\124\ Brennan Center for Justice, Declared National Emergencies Under the National Emergencies Act: https://www.brennancenter.org/our-work/research-reports/declared-national-emergencies-under-national-emergencies-act.

We estimate it will require 22 hours annually to compile the necessary information and to request each emergency or disaster-related short-term hardship exception or exception extension to CMS. We estimate that it will take 20 hours at $87.52/hr for a Business Operations Specialist to perform the task and 2 hours at $128.00/hr for a General and Operations Manager to review the data and submit the short-term hardship requests. We estimate a total burden of 440 hours (22 hr/response x 20 responses) at a cost of $40,128 (20 responses x [(20 hr/response x $87.52/hr) + (2 hr/response x $128.00/hr)]). Accounting for the Federal administrative match of 50 percent, we estimate that this requirement will cost States $20,064 ($40,128 x 0.50). We have summarized the total burden in Table 23.

[GRAPHIC] [TIFF OMITTED] TR03JN26.041

Unemployment Hardship Exception: The unemployment-related short- term hardship exception, implemented at Sec. 435.555(d)(3), exists when the unemployment rate in a county or equivalent unit of local government is at or above the lesser of 8 percent or 1.5 times the national unemployment rate. As noted, this short-term hardship exception is contingent on a State first making a request of CMS relating to this circumstance.

To submit the necessary documentation to support the unemployment- related short-term hardship exception, we expect that a State will have to assess the circumstances within a county or equivalent unit of local government and then compile the necessary information to submit to CMS. Based on an analysis of 2024 county-level unemployment statistics, and by using BLS' 2024 average unemployment rate of 4.0 percent, we assume that around 23 of the applicable States will have at least one county that.125 126 Not all potentially eligible States will decide to request such an exception from CMS, whereas some States with multiple counties meeting an unemployment threshold may submit more. In total, we estimate that annually there would be 40 unemployment-related short-term hardship exception requests across 20 State respondents.

\125\ US Bureau of Labor Statistics LAUS 2024 Annual Averages. Released April 18, 2025. Accessed February 2026. https://www.bls.gov/lau/laucnty24.xlsx.

\126\ US Bureau of Labor Statistics Regional & State Unemployment 2024 Annual Averages (USDL-25-0294): Accessed February 2026. https://www.bls.gov/news.release/srgune.nr0.htm.

It will require between 84 and 104 hours annually to compile the necessary information and to report each unemployment-related short- term hardship exception to CMS. Of that range, we estimate that it will take between 80 and 100 hours at $87.52/hr for a Business Operations Specialist to perform the task and 4 hours at $128.00/hr for a General and Operations Manager to review the data and submit the short-term hardship requests. To avoid underestimating our burden analysis, we are using the high end of our estimates to score the PRA-related impact of the reporting requirements. In this regard we estimate a total burden of 4,160 hours (104 hr/response x 40 responses) at a cost of $370,560 (40 responses x [(100 hr/response x $87.52/hr) + (4 hr/response x $128.00/hr)]). Accounting for the Federal administrative match of 50 percent, we estimate that this requirement will cost States $185,280 ($370,560 x 0.50). We have summarized the total burden in Table 24. [GRAPHIC] [TIFF OMITTED] TR03JN26.042

Other Hardship Exceptions: For short-term hardship exceptions related to circumstances in which the individual alleges hardship due to the receipt of institutional/hospital services or other services, or in cases in which an individual alleges he or she (or a dependent) must travel outside of the individual's community for treatment of a medical condition, CMS directs under Sec. 435.555(c)(2) that States electing the short-term hardship exception must notify applicable individuals of the method by which a short-term hardship exception may be requested. These methods will be variable across States, but we estimate, on average, it would take 1 hour at $12.92/hr for an applicable individual, or an individual acting on behalf of an applicable individual, to document and submit their short-term hardship exception request to a State. Calculating the burden for the applicable individuals that will request short-term hardship exceptions available under Sec. 435.555(d)(1) and (4) is subject to significant approximation. In 2022 there were approximately 8.8 million non-COVID acute inpatient or ICU stays in Medicaid expansion States.\127\ We assume that approximately 25 percent or 2.2 million (8.8 million x .25) of those stays were for Medicaid expansion adults subject to community engagement. Further, using Healthcare Cost and Utilization Project data, we see that the mean Medicaid length of stay (LOS) in 2023 was 5 days.\128\ Hospital LOS data is typically right-skewed,\129\ meaning that fewer than half of stays have an LOS longer than the mean. Therefore, we assume that only 25 percent of stays for applicable individuals, or 550,000 (2.2 million x .25) will be of a duration that may lead an applicable individual to consider requesting a short-term hardship exception. Of those 550,000 stays, we estimate that 300,000 will result in a short-term hardship exception being requested. We further assume this number includes those individuals that may need to travel outside their community for treatment of a medical condition. In aggregate, we estimate an annual burden of 300,000 hours (300,000 short-term hardship exception requests x 1 hr per request) at a cost of $3,876,000 (300,000 hr x $12.92/hr) for an applicable individual, or an individual acting on behalf of an applicable individual, to request short-term hardship exception requests. We have summarized the total burden in Table 25.

\127\ Acute Care Services Provided to the Medicaid and CHIP Population, January 5, 2024. Acute Care Services Provided to the Medicaid and CHIP Population.

\128\ Agency for Healthcare Research and Quality (AHRQ), Healthcare Cost and Utilization Project (HCUP) Fast Stats, National Hospital Utilization & Costs, 2023. HCUP Fast Stats Data Tools-- Healthcare Cost and Utilization Project (HCUP) Fast Stats. [GRAPHIC] [TIFF OMITTED] TR03JN26.043

As required at Sec. Sec. 435.561(b)(3)(iv)(A)-(B), States will also need to send periodic outreach notices to beneficiaries when a hardship exception under Sec. 435.555(a) is deselected and to provide notice of the anticipated expiration of a short-term hardship event described at Sec. 435.555(d)(2) and (3). We previously estimated in this ICR that all 44 jurisdictions will elect to include in their SPAs the short-term hardship exception to the community engagement requirement. Because we have no reliable way of estimating how many jurisdictions will deselect the hardship exception in a given year and thus will need to send notices to beneficiaries informing them of the deselection of the hardship exception, we are not estimating burden for this requirement. To estimate the number of jurisdictions that will need to provide notice of the anticipated expiration of a short-term hardship event described at Sec. 435.555(d)(2) and (3), we rely on our previous estimate earlier in this ICR that 20 jurisdictions will request an emergency or disaster exception and 20 jurisdictions will request a high unemployment exception.

For the purpose of burden estimation, we estimate that there will be no overlap in the jurisdictions that request an emergency or disaster exception and a high unemployment exception, although it is possible that the same jurisdiction could request both exceptions. As such, we estimate 40 jurisdictions will need to send notices to beneficiaries to inform them of the anticipated expiration of a short- term hardship event described at Sec. 435.555(d)(2) and (3). We estimate that the 20 million beneficiaries that will receive notices of the potential availability of a short-term hardship exception cited earlier in this ICR are equally divided amongst the jurisdictions, and thus 18.2 million beneficiaries ((20 million beneficiaries/44 jurisdictions) x 40 jurisdictions) will reside in the 40 jurisdictions that will need to send notices of the anticipated expiration of a short-term hardship event described at Sec. 435.555(d)(2) and (3). We estimate it will take 1 minute (0.017 hr) at $38.66/hr for a Mail Clerk to mail the notice of anticipated expiration of a short-term hardship event described at Sec. 435.555(d)(2) and (3) to 18.2 million beneficiaries. In aggregate, we estimate an annual burden of 309,400 hours (18,200,000 notices x 0.017 hr per mailing) for Mail Clerks to complete all mailings at a cost of $11,961,404 (309,400 hr x $38.66/ hr). Accounting for the Federal administrative match of 50 percent, the labor burden of this requirement will cost States $5,980,702 ($11,961,404 x 0.50).

In addition, the mailing of notices about the anticipated expiration of a short-term hardship event described at Sec. 435.555(d)(2) and (3), will add ancillary annual non-labor costs associated with paper, toner, envelopes, and postage. Assuming 18.2 million mailings annually at a cost of $0.802 [($0.007 for paper x 2 pages) + ($0.007 for toner x 2 pages) + $0.73 for postage + $0.044 per envelope], we estimate an additional aggregate annual non-labor cost of $14,596,400 (18,200,000 mailings

x $0.802). Accounting for the Federal administrative match of 50 percent, the non-labor burden of this requirement will cost States $7,298,200 ($14,596,400 x 0.50). We have summarized the ongoing State burden associated with mailing notices about the anticipated expiration of a short-term hardship event described at Sec. 435.555(d)(2) and (3) in Table 26. [GRAPHIC] [TIFF OMITTED] TR03JN26.044

The following changes will be submitted to OMB for approval under control number 0938-1147 (CMS-10410).

As discussed in section II.L. of this IFC, State Medicaid agencies are required to develop (or update) and disseminate standardized, targeted communications notices to certain individuals about the requirement to demonstrate community engagement under section 1902(xx) of the Act. States must also implement the operational processes needed to deliver those communications in a timely manner. Among the communications, under new Sec. 435.561, States must provide outreach notices to individuals eligible for or enrolled under Sec. 435.119 and to certain individuals covered through specified section 1115 demonstrations. While CMS will not be providing States with templates for these notices, States must send outreach at the times specified at Sec. 435.561(b), include the content required by Sec. 435.561(c), and deliver outreach notices through at least two modalities as required by Sec. 435.561(d) (regular mail or, if elected by the individual, electronic delivery consistent with Sec. 435.918, plus at least one additional modality such as an electronic account, telephone, text message, or other commonly available electronic means), consistent with the plain language and accessibility standards at Sec. 435.905(b). States may also coordinate outreach with other beneficiary communications, such as eligibility determination notices under Sec. 435.917.

In addition, under new Sec. 435.558, when a State cannot verify compliance with, or an exception (for deemed compliance), or exclusion from the community engagement requirement, the State must issue a notice of noncompliance, in the form and manner outlined at Sec. 435.558(c), that provides at least 30 calendar days for the individual to demonstrate compliance or an exception/exclusion. This requirement will likely create additional information collection activities related to preparing and sending the notice, tracking the response period, and documenting outcomes prior to any denial or disenrollment, including advance notice and fair hearing rights. At renewal, States may choose when to send the noncompliance notice relative to the pre-populated renewal form but must still generate and issue the notice and track responses.

These requirements also leverage existing State communication infrastructure, including online accounts and portals. In particular, Sec. 435.561(d)(2)(i) (delivery through the individual's electronic account) extends State's Medicaid website obligations under Sec. 435.1200(f), including accessibility consistent with Sec. 435.905(b).

States will need to develop or update outreach and noncompliance notice templates and establish or update the associated operational workflows to support required delivery modalities and timing. For both outreach and noncompliance notices, these operational workflows will include mailing paper copies to the subset of individuals who receive paper notices. Since mailing paper notices is the default modality under Sec. 435.561(d), we estimate that 75 percent of beneficiaries do not elect to use electronic notices.

To comply with these requirements, we estimate that it will take a one-time burden of 80 hours at $87.52/hr for a Business Operations Specialist to develop or update the notice templates and update the associated workflows as necessary, 8 hours at $128.00/hr for a General and Operations Manager to review and approve the updated notice templates and workflows, and 24 hours at $99.66/hr for a Computer Programmer to conduct the technical changes to the State electronic data collection means. In aggregate, we estimate a one-time burden of 4,928 hours (112 hr x 44 jurisdictions) at a cost of $458,367 (44 x [(80 hr x $87.52/hr) + (24 hr x $99.66/hr) + (8 hr x $128.00/hr)]). Accounting for the Federal administrative match of 75 percent, the requirement will cost States $114,592 ($458,367 x 0.25). We have summarized the initial State outreach and noncompliance notice burden in Table 27.

[GRAPHIC] [TIFF OMITTED] TR03JN26.045

We also estimate it will take 1 minute (0.017 hr) at $38.66/hr for a Mail Clerk to mail paper materials to 75 percent of the applicable beneficiaries (20 million total applicable beneficiaries). This results in 15 million outreach notices (20,000,000 applicable beneficiaries x 0.75 that will not elect electronic delivery), as well as 6 million noncompliance notices (0.75 x the 8,000,000 applicable individuals whose eligibility could not be verified ex parte), or 21 million mailings in the initial year. In aggregate, we estimate a one-time burden of 357,000 hours (21,000,000 total mailings x 0.017 hr per mailing) for Mail Clerks to complete all mailings at a cost of $13,801,620 (357,000 hr x $38.66/hr). Accounting for the Federal administrative match of 50 percent, the labor burden of this requirement will cost States $6,900,810 ($13,801,620 x 0.50).

In addition, the mailing of the initial notices will add ancillary non-labor costs. We assume these costs include paper, toner, envelopes, and postage (envelope weight is normally considered negligible when citing these rates and is not included) for hard-copy mailings. Using the same assumptions as described for mailing short-term hardship request notices in ICR 6, we estimate the aggregate cost per mailed notice is $0.802 [($0.007 for paper x 2 pages) + ($0.007 for toner x 2 pages) + $0.73 for postage + $0.044 per envelope]. Assuming 21 million initial mailings in the initial year, we assume non-labor ancillary costs of $16,842,000 (21,000,000 x $0.802). Accounting for the Federal administrative match of 50 percent, the non-labor burden of this requirement will cost States $8,421,000 ($16,842,000 x 0.50). We have summarized the ongoing, total State outreach and noncompliance notice burden in Table 28. [GRAPHIC] [TIFF OMITTED] TR03JN26.046

States will also need to conduct ongoing annual maintenance of outreach and noncompliance notice templates and the associated operational workflows to ensure continued compliance with required outreach delivery modalities and timing. We estimate this ongoing annual activity will require approximately 28 hours per State (one- quarter of the 112-hour one-time effort) to review, update, and implement minor policy, operational, and technical changes to notices and delivery workflows. Of the 28 hours, this includes 20 hours at $87.52/hr for a Business Operations Specialist to update notices and workflows, 2 hours at $128.00/hr for a General and Operations Manager to review and approve updates, and 6 hours at $99.66/hr for a Computer Programmer to make necessary technical adjustments to the State's electronic data collection methods.

In aggregate, we estimate an annual burden of 1,232 hours (28 hr x 44 jurisdictions) at a cost of $114,592 (44 x [(20 hr x $87.52/hr) + (6 hr x $99.66/hr) + (2 hr x $128.00/hr)]). Accounting for the Federal administrative match of 75 percent, the requirement will cost States $28,648 ($114,592 x 0.25). We have summarized the ongoing burden for State maintenance of outreach and noncompliance notices in Table 29. [GRAPHIC] [TIFF OMITTED] TR03JN26.047

In addition, we continue to estimate 1 minute (0.017 hr) at $38.66/ hr for a Mail Clerk to process and mail each beneficiary notice. We assume that the initial estimate of 15 million beneficiaries that receive paper notices will be moderately reduced in subsequent years as more beneficiaries opt to receive their notices electronically. On an ongoing basis we assume that 11.25 million beneficiaries (0.75 x 15,000,000) will need to be mailed paper outreach notices, and that 4.50 million beneficiaries (0.75 x 6,000,000) will need to be mailed noncompliance notices on an ongoing basis. For the combined 15.750 million beneficiary notices (11,250,000 + 4,500,000), this equals 267,750hours annually (15,750,000 mailings x 0.017 mailings/hr) at an annual cost of $10,351,215 (267,750 hours x $38.66/hr). Accounting for the Federal administrative match of 50 percent, the annual labor cost to States is $5,175,608.

In addition, the ongoing mailing of the notices will add ancillary annual non-labor costs associated with paper, toner, envelopes, and postage. Assuming 15.75 million mailings annually at a cost of $0.802 [($0.007 for paper x 2 pages) + ($0.007 for toner x 2 pages) + $0.73 for postage + $0.044 per envelope], we estimate an additional aggregate annual non-labor cost of $12,631,500. Accounting for the Federal administrative match of 50 percent, the non-labor burden of this requirement will cost States $6,315,750 ($12,631,500 x 0.50). We have summarized the ongoing, annual State outreach burden in Table 30. [GRAPHIC] [TIFF OMITTED] TR03JN26.048

States will also need to send notices to beneficiaries to inform them of the loss of a beneficiary's status as a specified excluded individual under Sec. 435.554. We estimate 44 jurisdictions will need to send notices to beneficiaries to inform them of the loss of a beneficiary's status as a specified excluded individual under Sec. 435.554. Per data from our “Medicaid and CHIP Leavers and Coverage Transitions” report, 3.02 million adult non-expansion beneficiaries left Medicaid between March 31, 2023, and December 31, 2023.\130\ We therefore use 3.02 million beneficiaries as a proxy for the number of beneficiaries that will need to be informed of the loss of a beneficiary's status as a specified excluded individual under Sec. 435.554 in a given year, but acknowledge that this number may be higher than the actual number of adult beneficiaries who may lose their status as a specified excluded individual in a given year, given the population differences between these two groups. We estimate it will take 1 minute (0.017 hr) at $38.66/hr for a Mail Clerk to mail the notice of the loss of a beneficiary's status as a specified excluded individual under Sec. 435.554 to 3.02 million beneficiaries. In aggregate, we estimate an annual burden of 51,340 hours (3,020,000 notices x 0.017 hr per mailing) for Mail Clerks to complete all mailings at a cost of $1,984,804 (51,340 hr x $38.66/hr). Accounting for the Federal administrative match of 50 percent, the labor burden of this requirement will cost States $992,402 ($1,984,804 x 0.50).

\130\ See “Leavers, excluding death and moving to Medicaid/CHIP in another state: Count” column in chart on page 7. “Medicaid & CHIP Leavers and Coverage Transitions: By Eligibility Category and Home & Community-Based Services (HCBS) 1915(c) Waiver Enrollment, March 31, 2023-December 31, 2023.” CMS. November 2024. https://www.medicaid.gov/resources-for-states/downloads/eligibility-group-leavers-transitions-novmbr-2024-release.pdf.

In addition, the mailing of notices to beneficiaries to inform them of the loss of a beneficiary's status as a specified excluded individual under Sec. 435.554 will add ancillary annual non-labor costs associated with paper, toner, envelopes, and postage. Assuming 3.02 million mailings annually at a cost of $0.802 [($0.007 for paper x 2 pages) + ($0.007 for toner x 2 pages) + $0.73 for postage + $0.044 per envelope], we estimate an additional aggregate annual non-labor cost of $2,422,040 (3,020,000 mailings x $0.802). Accounting for the Federal administrative match of 50 percent, the non-labor burden of this requirement will cost States $1,211,020 ($2,422,040 x 0.50). We have summarized the ongoing State burden associated with mailing notices to beneficiaries to inform them of the loss of a beneficiary's status as a specified excluded individual under Sec. 435.554 in Table 31.

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The changes in this IFC are necessary to align the Code of Federal Regulations (CFR) with statutory requirements set forth by section 1902(xx) of the Act as added by section 71119 (Requirement For States To Establish Medicaid Community Engagement Requirements For Certain Individuals) of the WFTC legislation, which adds a new community engagement requirement for certain adults in Medicaid.

The community engagement requirement has the potential to empower Medicaid beneficiaries through employment, education, or community service so they can escape isolation and dependency, build confidence, and achieve self-sufficiency and independence. States will be responsible for implementing and administering the new requirement in a manner that complies with this rule. CMS will provide oversight and monitor States' implementation of the new requirement, as well as outcomes related to community engagement.

This IFC specifies and explains:

Changes to the CFR to revert certain eligibility and enrollment regulatory provisions that were suspended due to the section 71102 moratorium and are needed to implement community engagement until October 1, 2034, with the provisions in effect prior to the 2024 Eligibility and Enrollment final rule as well as conforming amendments due to the restoration of the previous CFR;

Requirements for Medicaid applicants and beneficiaries who must demonstrate community engagement as a condition of their eligibility;

The types of qualifying activities that satisfy the community engagement requirement and the criteria to meet an exception (be deemed compliant) or specified exclusion from the requirement;

The steps States must take when they are unable to verify an applicable individual has met the community engagement requirement at application, renewal, or a more frequent periodic verification of compliance;

The notice of noncompliance States must use to inform the individual how they may make a satisfactory showing to demonstrate or be deemed as demonstrating compliance or that the individual should not be subject to the requirement, as well as how the individual can reapply for coverage if they are disenrolled;

When and how States must verify an applicable individual's compliance with the community engagement requirement and whether an individual meets an exception (for deemed compliance) or exclusion from the requirements, and the outreach and notice requirements for States;

Where States will have options in implementing the community engagement requirement; and,

Additional considerations for States and implications of the community engagement requirement for other existing ways that enable enrollment, such as presumptive eligibility, as well as demonstration projects authorized under section 1115 of the Act.

The IFC also describes implementation timing and establishes new State reporting requirements.

We have examined the impacts of this rule as required by Executive Order (E.O.) 12866, “Regulatory Planning and Review”; E.O. 13132, “Federalism”; E.O 13563, “Improving Regulation and Regulatory Review”; E.O. 14192, “Unleashing Prosperity Through Deregulation”; the Regulatory Flexibility Act (RFA) (Pub. L. 96354); section 1102(b) of the Act; section 202 of the Unfunded Mandates Reform Act of 1995 (Pub. L. 104-4); and the Congressional Review Act (5 U.S.C. 804(2)).

E.O. 12866 and E.O. 13563 direct agencies to assess all costs and benefits of available regulatory alternatives and, if regulation is necessary, to select those regulatory approaches that maximize net benefits (including potential economic, environmental, public health and safety, and other advantages; distributive impacts.). Section 3(f) of E.O. 12866 defines a “significant regulatory action” as any regulatory action that is likely to result in a rule that may: (1) have an annual effect on the economy of $100 million or more or adversely affect in a material way the economy, a sector of the economy, productivity, competition, jobs, the environment, public health or safety, or State, local, or tribal governments or communities; (2) create a serious inconsistency or otherwise interfere with an action taken or planned by another agency; (3) materially alter the budgetary impact of entitlements, grants, user fees, or loan programs or the rights and obligations of recipients thereof; or (4) raise novel legal or policy issues arising out of legal mandates, or the President's priorities.

A regulatory impact analysis (RIA) must be prepared for a regulatory action that is significant under section 3(f)(1) of E.O. 12866. Based on our estimates, this IFC does meet that criterion as the aggregate amount of benefits and costs may exceed the $100 million threshold in at least 1 year. OIRA has determined this rulemaking is significant per section 3(f)(1). Pursuant to Subtitle E of the Small Business Regulatory Enforcement Fairness Act of 1996 (also known as the Congressional Review Act), OIRA has also determined that this rule is major as it meets the criteria set forth in 5 U.S.C. 804(2).

We are specifying regulatory changes at 42 CFR parts 431, 435, 438, 457, and 600 to establish a community engagement requirement for certain adults applying for or enrolled in Medicaid, and corresponding requirements added by the WFTC legislation. This IFC provides a regulatory framework that specifies the requirements for States to implement the new community engagement requirement in an efficient, feasible, and cost-effective manner.

We believe the new community engagement requirement could have the potential to produce a range of benefits across multiple stakeholders. This section examines the anticipated benefits for three principal parties implicated by the new requirement: Medicaid applicants and beneficiaries subject to the community engagement requirement, States, and the Federal government.

The bulk of the benefits and costs are associated with the change in time allocation of program participants. The White House Council of Economic Advisers (2025) found that, among able-bodied adults aged 19- 64 participating in Medicaid in 2024, 49.6 percent did no work for pay at any time during the calendar year.\134\ CMS invites comment on the estimation of the number of adults moved to engagement as a result of the IFC. If those with zero work are more likely to participate in Medicaid for the full calendar year than the other able-bodied adults aged 19-64, then more than 49.6 percent of able-bodied adults aged 19- 64 on Medicaid in any given month did no work for pay at all during the calendar year, and even more did no work during that month. Under this IFC, such adults would either (a) not participate in Medicaid, (b) work to earn at least $580 per month (= $7.25 x 80 hours), (c) satisfy community engagement in another way, or (d) a combination of each. In the benefits and costs subsections of this economic analysis, we quantify benefits and costs per additional hour of work. The aggregate time allocation section multiplies dollar amounts per hour by our estimates of aggregate hours of time allocated to work as a result of the IFC.

\134\ The White House Council of Economic Advisers. (June 2025). “Medicaid Community Engagement Requirements and the Value of Work.” https://www.whitehouse.gov/wp-content/uploads/2025/03/Medicaid-Community-Engagement-Requirements-and-the-Value-of-Work.pdf. As noted later in the RIA, the 49.6 fits into the quantitative framework as support for estimates of the number adults moved to employment as a result of the IFC.

Employment is recognized as an important factor in long-term beneficiary health and welfare. Existing research indicates obtaining and maintaining stable employment provides individuals with reliable income and financial stability, which in turn supports access to safe housing, nutritious food, and other resources necessary for maintaining health.135 136Additionally, research suggests the relationship between health and employment is intrinsic--and bidirectional in nature, so negative benefits may be experienced by some coverage-losing individuals--as mentioned earlier in section I.B.137 138 139 140

\135\ Zafar, Q., M.A. Khan, A.Z. Warsi, and L. Iqbal. (2024). “Economic Strain and Recovery Trajectories in Mental Health: The Role of Financial Stability in Mental Health Outcomes.” Review of Applied Management and Social Sciences,7(4): 345-358. https://doi.org/10.47067/ramss.v7i4.385.

\136\ R. Gerdes, T.D. Jackson, R. Roberts, et al. (2026). “Associations Between Employment and Health Outcomes: A Systematic Review of Reviews.” Journal of Occupational Rehabilitation. https://doi.org/10.1007/s10926-025-10357-5.

\137\ Han, W.J. (2024). “How longitudinal employment patterns shape health as individuals approach middle adulthood--US NLSY79 cohort.” PLOS ONE, 19(4), e0300245. https://doi.org/10.1371/journal.pone.0300245.

\138\ Virtanen M, Kivim[auml]ki M, Joensuu M, Virtanen P, Elovainio M, Vahtera J. Temporary employment and health: a review. Int J Epidemiol. 2005 Jun;34(3):610-22. doi: 10.1093/ije/dyi024. Epub 2005 Feb 28. PMID: 15737968.

\139\ Kim TJ von dem Knesebeck O. Perceived job insecurity, unemployment and depressive symptoms: a systematic review and meta- analysis of prospective observational studies. Int Arch Occup Environ Health. 2016 May; 89(4):561-73. doi: 10.1007/s00420-015- 1107-1. Epub 2015 Dec 29. PMID: 26715495.

\140\ Gerdes R. Jackson T.D. Roberts R. Lytvyak E. Deibert D, Dennett L, Burton AK, Gross DP, Els C, Doroshenko A, Hagtvedt R, Straube S. Associations Between Employment and Health Outcomes: A Systematic Review of Reviews. J Occup Rehabil. 2026 Jan 6. doi: 10.1007/s10926-025-10357-5. Epub ahead of print. PMID: 41493509.

We believe a well-designed community engagement requirement may benefit individuals so that they are not dependent, demoralized, or stuck in situations that hinder their economic, physical, and mental state.

Work also creates value in the marketplace by adding to the aggregate production of goods and services, which is why employers pay for it. On an hourly basis, the value is described as the hourly marginal product of labor (MPL). MPL is often proxied by average hourly worker compensation before taxes and fringe benefits are subtracted, although MPL can exceed hourly compensation to the extent that labor or product markets are not competitive. That is, average hourly compensation has a tendency toward underestimating the expected benefit of an additional hour of work in the form of valuable goods and services produced.

Recognizing that most adults do not participate in Medicaid, and that Medicaid participants likely have earning potential below the population average and median, our estimate begins with measurement of the 25th percentile weekly earnings of full-time wage and salary workers of $838 in the first quarter of 2026.141 142 We divide this weekly rate by 40 hours to calculate an hourly pre-tax pre- benefit wage rate of $20.95. We then scale up by a factor of 1.186 to account for fringe benefits not already included in the $838, arriving at an hourly MPL of $24.84.\143\ This is intended to represent the productivity of the average Medicaid beneficiary induced to work, rather than the average or median worker working for a company, non- profit, or government agency that may spend time on clerical aspects of this rule.

\141\ Baxter JR, Robinson LA, and Hammitt JK. (June 2017). “Valuing Time in U.S. Department of Health and Human Services Regulatory Impact Analyses: Conceptual Framework and Best Practices.” Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation (ASPE). https://aspe.hhs.gov/sites/default/files/migrated_legacy_files//176806/VOT.pdf.

\142\ “Quartiles and selected deciles of usual weekly earnings of full-time wage and salary workers by selected characteristics,” US Bureau of Labor Statistics, last modified April 16, 2026. https://www.bls.gov/news.release/wkyeng.t05.htm..

\143\ ASPE estimates that fringe benefits are 45.6 percent of wages. We assume that the $838 from BLS reflects half of the fringe benefits, so that the scaling factor is 0.5 * 0.456/(1+0.5 * 0.456) + 1 = 1.186.

Some of the beneficiaries are expected to fulfill the community engagement requirement by community service, work program participation, or an educational program (often expected to enhance pay in the future) rather than paid work. The fact that such activities may not be paid does not negate their social benefit. Indeed, they could be more valuable than work for those who select them. This RIA values each hour of non-paid community engagement activities at the same $24.84 as paid work. 2. Costs

The following discussion builds on costs to States, the Federal government, and Medicaid applicants and beneficiaries that are summarized in Table 32. Costs associated with the collection of information are described in detail under section IV. of this IFC. As outlined in section IV. of this IFC, the provisions in this IFC are expected to impose additional costs given the significant eligibility changes to Medicaid. Demonstrating community engagement as a condition of Medicaid eligibility is not an entirely new policy for the Medicaid program; however, the scope and structure in this rule represents a significant expansion of such requirements. Given the expedited effective date of this rule following the passage of the WFTC legislation, we focus the cost analysis on three central parties to these changes: the Federal government, States, and Medicaid applicants and beneficiaries. We acknowledge that as these provisions are implemented and additional data become available, further cost implications may be identified that are not fully captured in this analysis. Moreover, the estimated costs of these provisions are not expected to be uniform. We expect these costs will vary based on differences among States' existing State Medicaid agency program operations and systems infrastructure, including payment delivery structures, State-specific policies, and the demographic composition of each State's Medicaid population. Additionally, these costs are expected to evolve over time as States gain implementation experience, applicant and beneficiary compliance patterns emerge, and the broader effects of the community engagement requirement become better understood. a. State and Federal Costs

States will need to make changes to their Medicaid eligibility systems to comply with the new community engagement requirement, and we expect that this will result in costs to the Federal government and States. Section 71119(e) of the WFTC legislation provides $200 million for States to establish systems necessary to carry section 71119 and other sections of the WFTC legislation, title VII, subtitle B, chapter 1 related to conducting eligibility determinations or redeterminations, which is expected to be spent in 2026. We expect States may have additional costs to upgrade their Medicaid eligibility systems to comply with this section; however, there is limited information on how much States will invest in these systems. To estimate State costs, we reviewed State-submitted Advanced Planning Documents (APDs) from 21 States that contain information on expected spending on eligibility system changes related to community engagement. For these 21 States, we estimate that the average cost reported in the APD is $12.2 million, ranging from $1 million to $47 million. Additionally, based on

discussions with the States on their estimated systems costs, we estimate the average cost is between $9 million and $21 million. Additionally, we estimate that a one-time cost for States to upgrade eligibility systems would be $15 million per State, which results in a total estimate of $660 million ($15 million multiplied by 44 States). We expect these costs to occur in 2026. We also project that there will be annual costs to maintain these systems, and we assume that those costs will be 10 percent of implementation costs ($66 million annually). In our estimates, we assume that FFP is available at a 90 percent match rate for design, development, and implementation costs States would be responsible for the remaining 10 percent, consistent with 42 CFR part 433, subpart C; for ongoing maintenance, the Federal government would pay 75 percent of costs, and the States would pay 25 percent.\144\

\144\ 42 CFR part 433 Subpart C, https://www.ecfr.gov/current/title-42/part-433/subpart-C.

We project that total spending on systems upgrades will be $1.52 billion from 2026 through 2036, with the Federal government paying $1.289 billion and the States paying $231 million. The estimated annual impacts are shown in Table 33. [GRAPHIC] [TIFF OMITTED] TR03JN26.055

We note that actual costs may differ from these estimates. Data are very limited and there is a wide range of expected costs across States. Additionally, roughly half of all States have not reported any community engagement system costs in their APDs. States may have additional costs beyond those already requested in the APDs. Moreover, we do not have data on how much States expect to spend beyond implementation. Thus, actual costs may be higher or lower than we estimated.

We also estimate the costs for State systems updates to comply with the new community engagement requirement. We estimate that States' costs will be $231 million from 2026 through 2036, as shown in Table 33. Additionally, this IFC outlines requirements for States (and, where applicable, their contractors, in compliance with statutory single State agency requirements and conflict-of-interest limitations) to collect, verify, maintain, and, in certain instances, report specified information to CMS on the community engagement requirement. Included in this list are requirements related to applicable individuals (Sec. Sec. 435.551, 435.552), exceptions and specified exclusions (Sec. Sec. 435.553, 435.554, 435.555), assessing and verifying compliance and noncompliance procedures (Sec. Sec. 435.556, 435.557, 435.558, 435.912), ex parte verification processes (Sec. 435.557), and outreach to beneficiaries (Sec. 435.561). The quantitative costs are reflected in section IV. of this IFC. For ease of reference, and for projection purposes, we include a summary of total costs for the Federal government and States in Table 34 and note that the FFP match rate varies by row. For additional details, see section IV. of this IFC. BILLING CODE 4120-01-P

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BILLING CODE 4120-01-C b. Costs to Medicaid Beneficiaries

The reallocation of the time of Medicaid participants toward work also has an opportunity cost according to the value of the activities foregone while working, such as leisure time or work done in the home. Labor market participants are expected to supply labor up to the point where their marginal opportunity cost equals the benefit of work net of taxes (including income, payroll, sales and excise taxes) and forgone government assistance. For consistency with the benefit section of this economic analysis, we take the hourly benefit before subtracting taxes to be the MPL of $24.84. For individuals potentially eligible for Medicaid, the foregone government assistance (including State and local assistance) can be substantial, and sometimes exceeds the MPL. Following the White House Council of Economic Advisers (2019), we estimate the gap between the MPL and the opportunity cost of time as 48 percent of the MPL.\145\ That is, we use an opportunity cost of time of $12.92 per hour (= $24.84 * (1-0.48)).

\145\ White House Council of Economic Advisers. (March 2019) Economic Report of the President, 2019, p. 423. https://www.govinfo.gov/content/pkg/ERP-2019/pdf/ERP-2019.pdf. See also https://www.nber.org/papers/w18088, as discussed in more detail near Table 46 in this regulatory preamble.

Some of the beneficiaries are expected to fulfill the community engagement requirement by community service, work program participation, or an educational program rather than paid work. This RIA estimates the hourly opportunity cost of these non-paid community engagement activities at the same $12.92 as paid work.

Notably, the MPL exceeds the opportunity cost of work for the economy as a whole, even when they are equal from the worker's perspective. This is known in labor economics, public economics, and macroeconomics as “the labor wedge” and is one of the most quantitatively significant features of labor markets.146 147

\146\ Hall RE. (1997) “Macroeconomic Fluctuations and the Allocation of Time,” Journal of Labor Economics 15, no. 1, Part 2: S223-S250. https://doi.org/10.1086/209862.

\147\ Hall RE. (2009). “Reconciling Cyclical Movements in the Marginal Value of Time and the Marginal Product of Labor,” Journal of Political Economy 117, no. 2: 281-323. https://doi.org/10.1086/599022.

The increase in the nation's labor supply due to this IFC may affect the wages and employment decisions of workers and employers that are not part of the Medicaid program. These market equilibrium effects are reasonably approximated as neither aggregate costs nor benefits and do not need to be assessed here.\148\

\148\ Induced changes in wages and employer profits are sometimes known as “pecuniary externalities,” which are transfers rather than an externality in the usual sense.

As specified at Sec. 435.552, an applicable individual demonstrates community engagement for a month if they work, complete community service, or participate in a work program for not less than 80 hours; enroll in an educational program at least half-time; or have monthly income, or average monthly income over the preceding 6 months as a seasonal worker, that is not less than the Federal minimum wage multiplied by 80 hours. Individuals can also demonstrate community engagement through a combination of qualifying activities. The combined time

for all activities must be a total of not less than 80 hours per month. At Sec. 435.553, we specify that States must deem any individual for a month as having demonstrated community engagement, if: (1) for all or part of a month, the individual was under the age of 19, entitled to or enrolled for Medicare benefits under Part A or enrolled for benefits under Part B, described in any of the mandatory eligibility groups in subclauses (I) through (VII) of section 1902(a)(10)(A)(i) of the Act, or a specified excluded individual; or (2) at any point during the 3 months prior to the month in question, the individual was an inmate of a public institution. Moreover, we specify that specified excluded individuals defined at Sec. 435.554 are excluded from the definition of applicable individual; therefore, community engagement is not a condition of their eligibility. Additionally, section 1902(xx)(3)(A) of the Act establishes mandatory exceptions from demonstrating community engagement via the pathways described in Sec. 435.552(a) (see section II.C. of this IFC for more information regarding demonstrating compliance) for certain applicable individuals. States must deem an applicable individual compliant for a month if the individual meets the mandatory exception criteria (which are further described in this section of this IFC). New Sec. 435.553 implements and interprets the mandatory exceptions in section 1902(xx)(3)(A) of the Act.

We anticipate some Medicaid beneficiaries and applicants will be required to provide additional information or documentation to verify that they demonstrated community engagement, should be deemed as having demonstrated community engagement through an exception, or be excluded from the community engagement requirement as a specified excluded individual. Applicants and beneficiaries may have to submit documentation if the State cannot verify compliance or deem compliance with the community engagement requirement or an individual's specified excluded status based on data sources or other available information to the State. Applicable beneficiaries may also need to document, track, and submit information to a State about their short-term hardship exception related to receipt of institutional or inpatient services or other services of similar acuity or when they or a dependent must travel outside of their community to receive certain medical services.

These quantified costs align with and are reflected in section IV. of this IFC. For ease of reference, and for projection purposes, we include a summary of total costs for new Medicaid applicants and Medicaid beneficiaries in Table 35. [GRAPHIC] [TIFF OMITTED] TR03JN26.058

3. Transfers a. Impacts on Medicaid Enrollment and Benefit Expenditures

This IFC implements the statutory definition of applicable individuals at Sec. Sec. 435.119 and 435.551 to describe Medicaid applicants and beneficiaries who must demonstrate community engagement as a condition of their Medicaid eligibility. With certain exclusions specified at Sec. 435.554, applicable individuals include those who are eligible for, or enrolled under, the State plan adult group described in section 1902(a)(10)(A)(i)(VIII) of the Act and Sec. 435.119, and individuals eligible for or enrolled in coverage under section 1115(a)(2) expenditure authority providing MEC who meet the other criteria in statute.

This IFC specifies the steps States must take to assess and verify compliance, established at Sec. Sec. 435.556 and 435.557, with the community engagement requirement at application and renewal; renewals for most beneficiaries who are subject to the community engagement requirement occur once every 6 months. At Sec. 435.556, the IFC describes the statutory requirement that, as a condition of eligibility at renewal, States must require applicable individuals to demonstrate or be deemed to demonstrate community engagement for at least 1 month since the individual's most recent eligibility determination or redetermination, though States may elect to conduct more frequent verifications and/or require more than 1 month of compliance or deemed compliance.

To assess the impact of the new community engagement requirement on Medicaid enrollment and benefit expenditures, we estimate these impacts based on the President's Fiscal Year 2027 Budget (PB 2027) Medicaid enrollment and expenditure projections, with FY 2023 as the base year for actual observed data and exclude the impact of any Medicaid provisions of the WFTC legislation. Several provisions of the

WFTC legislation are expected to have effects on Medicaid enrollment and expenditures. We have excluded those other effects from this analysis to present clearly the anticipated impacts of the community engagement requirement on Medicaid. Projected national total Medicaid enrollment and expenditures for the adult group, which includes both newly eligible and not-newly eligible subgroups, are as follows in Table 36. We project enrollment will increase at an average rate of 0.7 percent per year and expenditures will increase at an average rate of 6.6 percent per year. [GRAPHIC] [TIFF OMITTED] TR03JN26.059

The community engagement requirement established by section 71119 of the WFTC legislation has not previously been implemented as a condition of receiving coverage under the Medicaid State plan. Prior to this IFC, States could only impose such requirements through section 1115 demonstrations. The limited section 1115 demonstration experience that exists involved different implementation patterns, including reinstatements following terminations of eligibility and self-selected enrollment populations, that are not directly applicable to estimating the impact of mandatory requirements applied to an existing State plan enrollment. We have not relied on these previous demonstrations for data or assumptions used in this analysis. Accordingly, there is no direct historical experience from which to derive empirical estimates of how many enrollees will not meet the requirement, the community engagement implementation policies States will adopt, or how verification systems will perform in practice.

The primary data challenge in developing these estimates is that the characteristics most relevant to this analysis--work status, educational enrollment, disability status, caretaker responsibilities, and incarceration history--are not currently captured in Medicaid administrative data. As a result, we relied on a combination of external survey data, Medicaid administrative data, and published research to develop the key assumptions underlying these estimates. Each of these sources has limitations that are discussed further in the limitations and caveats section below.

A second source of uncertainty is that the estimates depend heavily on State implementation choices that are not yet known. For example, the statute establishes minimum requirements for compliance checks at application and renewal, with at least 1 month of demonstrated compliance between redeterminations, but it gives States discretion to require more frequent verifications and more months for beneficiaries to demonstrate compliance. These choices will affect both the noncompliance and procedural disenrollment rates. Similarly, States have discretion over whether to adopt the option to consider short-term hardship events, described at Sec. 435.555, and the extent of adoption will affect the share of enrollees subject to the requirement at a given time. We model a range of scenarios to reflect this uncertainty, but the actual distribution of State choices is unknown.

Finally, the estimates in this section do not capture potential behavioral responses, such as increased workforce participation or educational enrollment in response to the requirements, or the extent to which individuals who lose Medicaid coverage may obtain alternative coverage. Both factors could partially offset the projected coverage losses, but neither is quantifiable with available data.

Enrollment and per-enrollee expenditure projections are drawn from PB 2027, as described previously. Total computable and Federal per- enrollee expenditures are trended separately. Federal per-enrollee figures reflect current law FMAP rates throughout the

projection period. For purposes of the underlying cost model, the adult group is separated into newly eligible and non-newly eligible subgroups. The FMAP differs for these subgroups; projecting expenditures separately allows the projections to apply the appropriate average FMAP to each subgroup. The distinction between newly eligible and non-newly eligible adult group drives the Federal and State cost split. All other assumptions in the analysis are identical for newly eligible and non-newly eligible adult group.

We do not assume any change to the average per-enrollee costs for the remaining enrolled population relative to current projections. There are some reasons per-enrollee costs for the remaining population may be lower than for those that lose coverage. Individuals meeting the community engagement requirement may be healthier on average than those that lose coverage, as individuals not working or active in community engagement may have poorer health, making it harder to participate. In addition, younger individuals are more likely to meet the requirement based on already established activities, such as being enrolled in a full-time education program. If a higher proportion of younger individuals meet the community engagement requirement and, as a result, remain enrolled than the proportion of older individuals that maintain coverage, that may contribute to lower average costs per enrollee. However, there are also some reasons that the costs of those remaining could be higher. Most notably, individuals experiencing a short-term medical hardship (including inpatient hospital or nursing facility care) and those determined medically frail likely have substantially higher health care costs than others in this eligibility group, and they would remain covered in Medicaid under this new requirement. Given the factors that could lead to lower or higher per-enrollee costs, and the uncertainty of their relative magnitude, we made no adjustment to the average per enrollee cost for those losing coverage or retaining coverage under section 71119 of the WFTC legislation.

To develop this analysis, we started by determining how many enrollees may be subject to the community engagement requirement under this rule. We started with the projection of the number of enrollees who would be: (1) a newly eligible adult made eligible under 1902(a)(10)(A)(i)(VIII); (2) a non-newly eligible adult otherwise not eligible under 1902(a)(10)(A)(i)(I) through (VII); and (3) an adult eligible under a section 1115 demonstration who would otherwise be eligible under 1902(a)(10)(A)(VIII). Those projections are shown in Table 34.

Several groups of enrollees would have mandatory exceptions from the community engagement requirement, which include individuals under age 19, individuals also entitled to or enrolled in Medicare Part A and/or Part B, and those described in another mandatory categorically needy eligibility group in sections 1902(a)(10)(A)(i)(I) through (VII). Those individuals are not included in our analysis.

For the purposes of these estimates, we estimated how many people would be excluded from or meet the community engagement requirement in two steps. In the first step, we developed assumptions for the percentage of individuals that would not be subject to the community engagement requirement because they qualify for certain specified exclusions. In the second step, we made assumptions for the percentage of remaining individuals who would meet the community engagement requirement. This group would also include individuals who would be eligible for other specific exclusions, including those currently enrolled in TANF and/or SNAP and meeting the work requirements for those programs. Generally, we assumed that if an individual would meet the Medicaid community engagement requirement (for example, by meeting the employment or education requirements described in this IFC), then they were also likely to meet those requirements for TANF and/or SNAP (if they were enrolled in those programs). Therefore, we did not separately estimate how many individuals would qualify as specified excluded individuals on the basis of meeting or not being exempt from the work requirements of other programs.

There are also several categories under which an individual may qualify as a specified excluded individual and as such would not be subject to the community engagement requirement. As described in the preceding paragraph, in the first step we developed assumptions about how many people would qualify as a specified excluded individual under a subset of the exclusions in the statute. This subset includes: American Indians and Alaska Natives; pregnant women or individuals entitled to postpartum medical assistance; a parent, guardian, caretaker relative, or family caregiver of a dependent child 13 years of age and under or a disabled individual; inmates of a public institution; and individuals who are medically frail or otherwise have special medical needs. Individuals who have been an inmate at any point in the previous 3 months are mandatorily excepted from the community engagement requirement and are deemed to have demonstrated community engagement in each of the 3 months following their release. We have combined the impact of the mandatory exception and the specific exclusion for current inmates together in this analysis. We estimate that about 24 percent of applicable individuals would be specifically excluded under one or more of these categories and therefore not subject to the community engagement requirement. This estimate is derived by applying these exclusions and reflects the combined effect of removing American Indian and Alaska Native specified excluded individuals (2.5 percent) and applying the other 4 listed exclusion categories additively (21.7 percent combined). (There may be some overlap between these categories--for example, someone could be both pregnant and a parent of a child under age 13. Calculating the impact of these exclusions multiplicatively instead of additively to account for potential overlap could lead to a lower percentage of those estimated to receive specific exclusions; however, we believe the differences would be small (less than 1 percent) and that the 21.7 percent assumption is a reasonable estimate of the percentage of individuals who would be specifically excluded under one of these criteria.)

The combined impact of these 5 specific exclusions is 24 percent; that is, we estimate 24 percent of applicable individuals would meet one or more of these 5 specific exclusions. The assumptions for each specific exclusion and sources for those assumptions are shown in the following Table 37. BILLING CODE 4120-01-P

[GRAPHIC] [TIFF OMITTED] TR03JN26.060

We also estimated the effect of short-term hardship exceptions, which we estimate would be equal to 3.45 percent of applicable individuals. States electing the optional exception must adopt all qualifying circumstances listed as short-term hardship events. We assume that 75 percent of States will adopt the optional exception for short-term hardship events. The assumptions for the short-term hardship exceptions are described in Table 38.

[GRAPHIC] [TIFF OMITTED] TR03JN26.061

Combining the impacts of the subgroup of specified exclusions and the short-term exceptions, we estimate that 26 percent of applicable individuals would either have a specific exclusion (as listed in Table 37) or a short-term hardship exception (as listed in Table 38), and the other 74 percent of applicable individuals would either need to demonstrate compliance or be deemed to demonstrate compliance (via a mandatory exception) with the community engagement requirement or receive one of the other specified exclusions.

States are required to implement the community engagement requirement on or before January 1, 2027. States may elect to implement early, and the statute provides for delayed implementation for States demonstrating good-faith compliance efforts. We assume that the majority of States will implement the requirements effective January 1, 2027. Nebraska began implementing the community engagement requirement on May 1, 2026, and other States may also start later in 2026.

Because enrollment impacts depend heavily on State implementation choices that are not yet known, we modeled four scenarios representing a range of possible State policies. The scenarios vary by verification frequency (semi-annual or quarterly) and the number of months within each review period during which an applicable individual must demonstrate compliance.

We assigned scenario weights based on our actuarial judgment about the distribution of likely State implementation approaches, with 50 percent of enrollees assumed to be in States adopting the minimum statutory requirement of semi-annual verification with 1 month of compliance required between verifications, and the remaining 50 percent in States adopting more frequent verifications and/or longer compliance periods. [GRAPHIC] [TIFF OMITTED] TR03JN26.062

From these scenarios, we derive two distinct disenrollment rates. First, we estimate that 12 percent of applicable individuals subject to the requirement will not meet them and lose coverage. This estimate reflects a scenario-weighted average. Scenario-specific noncompliance rates are derived from KFF work status data for Medicaid adults,\149\ reflecting the share of enrollees who are not working, not in school, and do not otherwise meet the community engagement threshold under each scenario's compliance rules. We assume that all individuals who report working full time would meet the community engagement requirement in each of the four scenarios. The portion of individuals that report working or attending school part-time who are assumed to meet the community engagement requirement varies from 100 percent to 75 percent depending on the scenario. This is because part-time work or school attendance may be subject to seasonal variation or other variations in either the number of work (or school) hours that are offered or that the individual is able to work (or attend school), and these variations may mean that the individual is not able to meet the community engagement requirement in every month of the year. Individuals who report not working for reasons other than caretaking, illness, or disability are assumed not to meet the community engagement requirement in any scenario. Taken together, these assumptions result in 81 percent of enrollees meeting the community engagement requirement in the lowest impact scenario and 75 percent of enrollees meeting the community engagement requirement in the highest impact scenario.

\149\ Tolbert J., Cervantes S., Rudowitz R., Burns A. (2025). “Understanding the Intersection of Medicaid and Work: An Update,” KFF. https://www.kff.org/medicaid/issue-brief/understanding-the-intersection-of-medicaid-and-work-an-update/.

In addition, we estimate that 7 percent of applicable individuals who may be working, enrolled in school, or otherwise performing activities in line with community engagement requirement, or qualify for a mandatory exception or short-term hardship exception that deems them as demonstrating community engagement, would lose coverage due to administrative or procedural reasons (or in the case of a new applicant, may have their application denied and thus not enroll). These potential reasons for loss of coverage include, for example, not responding to verification requests or submitting insufficient documentation. The reasons individuals may not respond or submit insufficient documentation are manifold. This could include scenarios in which the required documentation was not received by the individual in a timely manner due to mail delivery delays or the individual had difficulty understanding or completing the required paperwork. Those fraudulently or improperly enrolled in the program or attempting to enroll in the program are unlikely to furnish documentation or respond to verification requests. Additionally, individuals with access to employer coverage or other forms of coverage may not complete documentation or respond to verification requests. Coverage losses may also be attributable, in part, to procedural processing errors at the State level. The gross procedural disenrollment rate is a scenario- weighted average anchored to post-unwinding (of the continuous enrollment condition related to the COVID-19 Public Health Emergency) Medicaid renewal data, which shows an average procedural disenrollment rate of about 12 percent for annual redeterminations over the most recent 12 months.\150\ The procedural disenrollment rate may include non-responses by individuals who no longer meet requirements to qualify for Medicaid, documentation errors or non-responses by individuals who do meet requirements to qualify for Medicaid, or other factors. We assume that about half of those with procedural disenrollments (about 5.5 percent) are due to documentation errors or non-responses by individuals who do meet program requirements, a population which is more closely related to applicable individuals who either demonstrate community engagement or are deemed to demonstrate community engagement via an exception. Where redeterminations take place more than once a year, we assume that this procedural disenrollment rate applies at each redetermination, resulting in a 12 percent procedural disenrollment rate for scenarios with semi-annual renewals and a 20 percent rate for scenarios with quarterly verifications. The gross rate is then reduced by 50 percent to exclude baseline renewal attrition that would occur regardless of the community engagement requirement. The reduction accounts for the share of procedural disenrollments that would occur at routine renewal regardless of the community engagement requirement, which should not be attributed to this policy.

\150\ “January 2026: Medicaid and CHIP Eligibility Operations and Enrollment Snapshot.” (April 24, 2025). https://www.medicaid.gov/resources-for-states/downloads/eligib-oper-and-enrol-snap-jan2026.pdf.

The 12 percent noncompliance rate is applied to the 74 percent of adult group enrollees estimated to be applicable individuals who are not receiving a specific exclusion nor excepted under a short-term hardship. The 7 percent net procedural disenrollment rate is applied to both the applicable individuals deemed compliant due to a mandatory exception or short-term hardship exception and to the applicable individuals subject to and meeting the requirements. Together, they yield a combined estimated disenrollment rate of approximately 15 percent of total adult group enrollment. [GRAPHIC] [TIFF OMITTED] TR03JN26.063

These rates are applied as full annual rates beginning in FY 2027, the first year of implementation. Because we assume implementation is effective January 1, 2027, the impacts in FY 2027 reflect 75 percent of the full-year impact.

The estimated enrollment impact is the estimated number of enrollees (1) who would be subject to the community engagement requirement and not meet the requirement, or (2) would meet the requirement or qualify for an exception, and would not successfully demonstrate their compliance or exception, developed based on the assumptions described above. The estimated impact on expenditures is the enrollment impact multiplied by the average per-enrollee expenditures.

We project that enrollment would be reduced by 2.3 million individuals in FY 2027 (accounting for implementation occurring in the second quarter of the fiscal year) and by between 3.1 to 3.3 million individuals in subsequent years. We project Federal Medicaid spending would be reduced by $350.3 billion over the next 10 years and State Medicaid spending would be reduced by $41.6 billion over the same time period. The impacts are shown in Table 41. [GRAPHIC] [TIFF OMITTED] TR03JN26.064

These estimates are subject to uncertainty. The disenrollment estimates reflect a weighted average of four implementation scenarios, and the actual distribution of State choices regarding verification frequency, compliance period length, adoption of short-term hardship exceptions, and implementation timing is unknown and could produce outcomes materially different from the central estimate. Additionally, assumptions are based on annual or average annual data; the timing of an enrollee's work or school hours relative to the timing of their redetermination may cause individual-level variation not captured in the aggregate estimates. The estimate for the incarceration mandatory exception is based on November 2025 Eligibility Operations and Enrollment Snapshot data \151\ and does not capture individuals recently released from incarceration who remain covered by the 3-month review provision.

\151\ “November 2025: Medicaid and CHIP Eligibility Operations and Enrollment Snapshot.” (February 27, 2026). https://www.medicaid.gov/resources-for-states/downloads/eligib-oper-and-enrol-snap-nov2025.pdf.

This analysis does none of the following: (1) estimate the extent to which individuals who lose Medicaid coverage may obtain alternative coverage, and (2) model interactions with other provisions of Public Law 119-21. We assume both of these factors could partially offset or modify the projected coverage losses. Per-enrollee cost projections extend 10 years into the future and are subject to uncertainty inherent in long-range medical cost forecasting. 4. Aggregate Time Allocation and Additional Effects on the Federal Deficit

The estimates in this section do not introduce an independent forecast of induced work; they monetize the time-allocation implications of the scenario assumptions in Table 39. As noted, at least 50 percent of able-bodied adults enrolled in Medicaid did not work. If, say, 80 percent are to work when the IFC is in effect (see Table 39), then at least 30 percent of those who would participate absent the IFC must have their time allocation affected by the IFC. An applicable individual demonstrates community engagement through employment by either working not less than 80 hours or the income alternative

of having a monthly income not less than $580 (applicable Federal minimum wage multiplied by 80). Table 42 shows this bound separately for the four scenarios introduced in Table 39. [GRAPHIC] [TIFF OMITTED] TR03JN26.065

Table 43 shows the annual hours added to the labor market for each scenario, assuming baseline adult group enrollment of 20.4 million, 75 percent of which are subject to the community engagement requirement. The high-impact scenario (scenario 2 requires $580 dollars of earnings, which would be about 27 hours per month for a worker with hourly wage at the 25th percentile. CMS expects, in that scenario, 3.8 million to meet such a requirement who would not have worked. Another 0.6 million would be in unpaid community engagement, for a total of 4.4 million moving to engagement, as shown in the table. As shown in the low-impact scenario, a weaker requirement of just 1 of the past 6 months is expected to be met by an additional 1.0 million beneficiaries. The table's first aggregate hours row shows what the added hours would be if all 5.4 million met the requirement only at the minimum. The next “additional months” row assumes that the 4.4 million in scenario 2, who would meet the “maximum” requirement (all months at $580 income), instead would work at a level halfway between the minimum and maximum while they are enrolled in Medicaid. An accurate forecast requires an “additional months row” because working in 1 month involves the acquisition of knowledge, relationships, and other experiences that increase the net benefit to work in adjacent months. [GRAPHIC] [TIFF OMITTED] TR03JN26.066

Note that Table 43 otherwise has a tendency toward underestimation in that it (a) it ignores those who work due to exiting the Medicaid program, (b) it assumes that all those exempt or noncompliant are neither working under the IFC nor in the baseline, and (c) that workers meet the requirement by earning $580 for the month rather than working 80 hours.\152\ Additional underestimation of Table 43's cost entries (thus generating a tendency toward overestimation of net benefits) is possible if $12.92 were a lower bound on affected individuals' opportunity cost of time.

\152\ Regarding possible effects of Medicaid participation on work, see Garthwaite C., Gross T., and Notowidigdo M.J. “Public Health Insurance, Labor Supply, and Employment Lock,” Quarterly Journal of Economics 129, no. 2 (2014): 653-696. https://doi.org/10.1093/qje/qju005.

Tables 44 and 45 show the costs and benefits associated with the IFC's change in time allocation using annual discount rates of 7 percent and 3 percent, respectively. The dollar

amounts in the top part of the tables are annualized. For beneficiary engagement, aggregate dollar amounts are obtained by multiplying the aggregate annual hours of Medicaid beneficiaries from Table 43, including the bare-minimum hours as well as the additional hours, by the hourly MPL of $24.84 or the opportunity cost of $12.92. BILLING CODE 4120-01-P [GRAPHIC] [TIFF OMITTED] TR03JN26.067

[GRAPHIC] [TIFF OMITTED] TR03JN26.068

BILLING CODE 4120-01-C

A substantial fraction of adults on Medicaid during 1 calendar year would no longer be enrolled in Medicaid the following year. Individuals who move to work and satisfy the community engagement requirement while participating in Medicaid acquire knowledge, relationships, habits, and health increase the net benefit to work even after they leave Medicaid. In other words, working encourages human capital investment, which itself feeds back to encourage additional work hours. The human capital perspective suggests that some fraction of beneficiaries would continue to work in months after the requirement ended. Based on (a) Card and Hyslop's (2005) finding that the additional earnings resulting from participation in a welfare demonstration project persisted over time but decayed at 3 percent per month after exit from the program, (b) an able-bodied engagement-compliant adult Medicaid annual exit rate of 43 percent, and (c) a 29 percent annual reentry rate of former beneficiaries, we estimate the effect of the community engagement requirement on engagement after Medicaid exit.153 154 155 Because these are effects in the future, the corresponding “ex- beneficiary” benefit and cost rows in Tables 44 and 45 depend on the assumed discount rate for future benefits and costs. The ex-beneficiary rows are about 45 percent of, and in addition to, the current beneficiary rows.

\153\ Card D. and Hyslop D.R. (2005). “Estimating the Effects of a Time-Limited Earnings Subsidy for Welfare-Leavers.” Econometrica 73, no. 6: 1723-1770. https://doi.org/10.1111/j.1468- 0262.2005.00637.x.\.

\154\ Sommers B.D. (2009). “Loss of Health Insurance Among Non- Elderly Adults in Medicaid.” Journal of General Internal Medicine 24, no.1: 1-7. https://doi.org/10.1007/s11606-008-0792-9 estimates a 43 percent annual exit rate.

\155\ A 29 percent reentry rate is required for the steady-state number of ex-beneficiaries to outnumber current beneficiaries by a factor of 1.5-to-1. Other studies have demonstrated that interventions designed to increase employment and earnings among populations eligible for or receiving welfare benefits can persist over time. For example, a large-scale randomized control study of the Subsidized and Transitional Employment Demonstration, launched by HHS in 2010, found that earnings improved more than three years after enrollment, with earnings increases for three of the seven interventions maintained for six years after enrollment. HHS's Health Profession Opportunity Grants Program (HPOG)--the original 1.0 study launched in 2010, and the 2.0 study launched in 2015-- found persistent increases in employment in the health care profession, though the interventions did not identify earnings increases. In particular, HPOG 1.0 found employment gains in health care by 5 percentage points six years after enrollment. The Pathways for Advancing Careers and Education project studied a number of interventions and found that one resulted in large earnings (around $1,900) gains after six years.

The total annual expected net benefit (averaging across scenarios) from the time reallocation effects of the IFC is about $52 billion. The final entry in each table is the net present value (NPV) of time allocation benefits minus time allocation costs, calculated as an expectation by weighting each scenario value according to the scenario weight. The NPV is $459 billion at a 3 percent annual discount rate and $388 billion at a 7 percent rate.

An important reason for the labor wedge-adjacent societal welfare gain--the gap between the aggregate benefit of an hour of market work and the worker's opportunity cost at the margin--is that work (and the spending it enables) generates revenue for government treasuries in the form of taxes on income, payroll, sales, and excise.\156\ (Work also tends to move workers off safety net programs, or at least phase out some of their benefits. Either way, the work reduces deficits.)

\156\ Harberger, A.C. 1971. “Three Basic Postulates for Applied Welfare Economics: An Interpretive Essay.” Journal of Economic Literature, 9(3), 785-797.

Table 46 uses the most recent marginal tax rate calculations posted at the National Bureau of Economic Research website in The Redistribution Recession that focuses on measuring the labor wedge and its fiscal components.\157\ The components include Federal revenue items, such as payroll taxes, State tax items, as well as Federal and State safety-net spending items. The Federal savings as additional work results in Medicaid exits is excluded from Table 46 in order to avoid double-counting savings calculated in previous tables. The Table's marginal tax rate (MTR) column is the part of the 48.0 percent labor wedge that reflects the contributions to the indicated segment of society to which the benefits accrue.\158\

\157\ Mulligan C.B. (2012). “Do Welfare Policies Matter for Labor Market Aggregates? Quantifying Safety Net Work Incentives since 2007,” National Bureau of Economic Research. https://www.nber.org/papers/w18088. Data available at https://data.nber.org/data-appendix/w18088/StatutoryIndices.nber.xlsx.

\158\ The MTR column adds to less than 48.0 percent because the 48.0 includes private sector markups and Medicaid.

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After the MTR column, each entry in Table 46 is in billions of dollars. Each is calculated in two steps. First, we refer to the scenario-specific time allocation aggregate benefits from Table 44 (7 percent discount rate) or Table 45 (3 percent discount rate) but eliminate unpaid volunteer time because that does not generate tax revenue. We estimate the unpaid volunteer time from Table 33 as half of the non-work part of community engagement. The remaining aggregate benefits can be understood as the MPL applied to non-volunteer community engagement hours. These remaining aggregate benefits are multiplied by the corresponding MTR from Table 46. The final column of Table 46combines the four scenarios into a single weighted average using the weights from Table 39.

Overall, the time-reallocation effects of the IFC are expected to reduce annual government deficits by about $35 billion. This is economically substantial, although somewhat less than the fiscal effects of reducing enrollment in Medicaid. 5. Regulatory Review Cost Estimation

If regulations impose administrative costs on private entities, such as the time needed to read and interpret this IFC, we should estimate the cost associated with regulatory review. There is uncertainty involved with accurately quantifying the number of entities that will review the IFC. However, for the purposes of this IFC we assume that on average, each of the 44 affected jurisdictions will have two contractors per State to review this IFC. This average assumes that some State Medicaid agencies may use the same contractor, others may use multiple contractors to address the various provisions within this IFC, and some State Medicaid agencies may perform the review in-house. We also assume that each of the affected managed care plans (estimated to be 417 managed care plans) will review the IFC. Lastly, we assume that an average of two advocacy or interest group representatives from each State will review this IFC. In total, we estimate that 593 entities (88 State Contractors + 417 Managed Care Plans + 88 Advocacy and Interest Groups) will review this IFC. We acknowledge that this assumption may understate or overstate the costs of reviewing this IFC.

Using the wage information from BLS for medical and health service managers (Code 11-9111), we estimate that the cost of reviewing this IFC is $113.42 per hour, including overhead and fringe benefits (https://www.bls.gov/oes/current/oes_nat.htm). Assuming the average reading speed of 250 words per minute, we estimate that it would take approximately 3.1 hours for staff to review half of this IFC ([93,000 words x 0.5]/250 words per minute/60 minutes per hour). For each entity that reviews the rule, the estimated cost is $351.60 (3.1 hours x $113.42). Therefore, we estimate that the total cost of reviewing this regulation is $208,498.80 ($351.60 per individual review x 593 reviewers).

When considering alternatives, we reviewed existing statutory and regulatory definitions and frameworks from Medicaid and other Federal benefit programs, adopting them to the extent possible, where we determined additional information in this IFC was necessary. Recognizing that States vary considerably in their administrative capacity, eligibility system infrastructure, and prior experience with the community engagement requirement, we provide targeted flexibilities, where permitted by the WFTC legislation, to allow States to implement these requirements in a manner tailored to their specific needs. Given the detail and breadth of the provisions in this IFC, we present illustrative examples of alternatives considered, organized under three categories: Compliance and Verification Provisions, State Implementation, and Monitoring and Reporting. 1. Compliance and Verification Provisions

Section 1902(xx) of the Act prescribes specific requirements for how applicable individuals demonstrate compliance with the community engagement requirement (section 1902(xx)(2) of the Act). We aligned definitions of compliance activities as closely as possible with existing statutory and regulatory requirements across Medicaid and/or other Federal benefit programs to minimize disruption of States' existing eligibility systems and operational capacities. For instance, the

statute at section 1902(xx)(2)(F) and (G) of the Act refers to an individual's “monthly income” and “average monthly income,” but does not further define how States should calculate monthly income for these purposes. For the calculation of an applicable individual's monthly income under new Sec. 435.552(f) and average monthly income under new Sec. 435.552(g), we define “monthly income” to have the same meaning as the individual's household income used for financial eligibility for Medicaid. Most applicable individuals are eligible for or enrolled in the adult group under Sec. 435.119, which is a group that has an income standard based on MAGI using MAGI-based methodologies, as described in Sec. 435.603. Similarly, most section 1115 demonstrations that have applicable individuals (as discussed in section II.B. of this IFC) have an income standard based on MAGI and use MAGI-based methodologies for the relevant demonstration population.

In some instances, we considered alternative approaches for operationalizing a new requirement in light of existing Medicaid eligibility and enrollment rules. For example, timeliness standards for Medicaid eligibility determinations at Sec. 435.912 \159\ as implemented in this IFC require States to complete Medicaid eligibility determinations promptly and without undue delay. In general, the determination of eligibility for any individual may not exceed 90 days for applicants who apply on the basis of disability and 45 days for all other applicants, which includes individuals whose eligibility is being determined based on MAGI.

\159\ While Sec. 435.912 is subject to the section 71102 moratorium, the requirements for states to make eligibility determinations promptly and without undue delay and to process applications within 45 or 90 days was not amended by the 2024 Eligibility and Enrollment final rule.

While we believe the 45-day timeliness standard under Sec. 435.912 for MAGI beneficiaries is necessary to prevent delays in applicants' eligibility determinations and access to coverage, we recognized that the new provision may impose an additional requirement on States. Specifically, Sec. 435.558(a) would require States to provide notice of noncompliance to an applicable individual whom the State is unable to verify as being compliant with the community engagement requirement. Upon receiving such notice, the individual would have 30 calendar days from the date they receive the notice to demonstrate community engagement, establish that they should be deemed to have demonstrated community engagement, or show that they do not meet the definition of an applicable individual. States must account for this process when making eligibility determinations.

We considered taking no action in this IFC since depending on States' existing eligibility systems and operational capacities, the required 30-calendar day period for applicants to return information will not always result in a delay in completing a determination of eligibility for an applicable individual who receives notice of noncompliance at application. States that can make an eligibility determination for applicants who receive a notice of noncompliance must do so within the timeliness standard. However, we considered that not all applicants will respond to the notice early in the 30-calendar day period, and States are unable to notify the individual of an eligibility decision for failure to respond prior to the 30-calendar day period. We believe an exception is necessary to prevent States from being subject to compliance action for failure to meet the regulatory timeliness standard as a result of complying with section 1902(xx) of the Act. Therefore, we are adding Sec. 435.912(e)(3) to provide a new exception to the timeliness standard at Sec. 435.912(c)(3)(ii) for applicants who receive the notice of noncompliance under Sec. 435.558(a) and when the State is unable to meet the 45-day timeliness standard due to the required 30-calendar day period discussed in this section of this IFC. When a State uses this exception, it must do so on a case-by-case basis and document the reason for the delay in the applicant's case record as required by Sec. 435.912(f). 2. State Implementation

The WFTC legislation establishes specific requirements for State implementation of community engagement. These requirements include addressing the timing and standards for the implementation date, outreach processes, demonstration of good-faith effort, and conflict of interest safeguards with manage care plans. While this IFC aligns accordingly with these requirements, we believe that additional explanation is necessary for certain provisions to assist States in implementing them more efficiently.

Section 435.561(b)(1) and (2) newly requires States to send notices to beneficiaries 4, 5, or 6 months prior to the community engagement requirement becoming effective in the State and to beneficiaries who apply and enroll after the initial outreach notice is sent, but before the community engagement requirement becomes effective in the State. This will ensure beneficiaries who newly enroll in the adult group described at Sec. 435.119 or an applicable section 1115 demonstration will be made aware of the requirement.

We also require States to notify all individuals described in Sec. 435.561(a) on a periodic basis thereafter and outline when States must provide outreach notices through at least two modalities on an ongoing basis at Sec. 435.561(d). Under the authority given to the Secretary to specify standards for outreach notices, we define “periodic basis thereafter” to mean that for individuals described in Sec. 435.561(a) outreach notices must be provided: (1) following a determination or redetermination of eligibility at application, at renewal described at section 1902(e)(14)(L) of the Act and Sec. 435.916, and based on a change in circumstances; (2) when the State elects the short-term hardship exception in the State plan under Sec. 435.555(a) and each time the State effectuates a short-term hardship event described in Sec. 435.555(d)(2) and (3) (except for an occasion included as part of the State plan election) and (3) upon request by CMS, if State reported monitoring data described at Sec. 435.562 or other information indicate a potential compliance issue with Sec. Sec. 435.550 through 435.562. We believe this will allow States to align outreach notices with eligibility determination notices under Sec. 435.917, since States must already provide information to individuals about their eligibility and rights and responsibilities. For example, States may align such notices by combining the content of the outreach notice with the eligibility determination notice or send a separate outreach notice when an eligibility determination notice is issued. We also believe this approach will allow States to keep individuals updated about changes in the State's short-term hardship exception policy with less burden by utilizing the outreach process already required by section 1902(xx)(8) of the Act. Finally, we believe that this will allow States to provide additional outreach, if requested by CMS, when States' community engagement monitoring data indicate potential problems or concerning trends, such as if a State is experiencing large shifts in month-over-month determination and redetermination outcomes, or greater disenrollments for procedural denials compared to other States. For more information about monitoring data States must submit and our approach to identify potential compliance issues

that could result in additional outreach, see section II.O. of this IFC. While we are requiring States to conduct ongoing, periodic outreach each time an individual described at Sec. 435.561(a) is provided an eligibility determination notice, States may choose to conduct additional outreach to individuals on an ad hoc or routine basis.

We considered defining outreach on a “periodic basis thereafter” to mean that States must conduct outreach upon enrollment for applicants determined eligible and at least every 6 or every 12 months thereafter for beneficiaries described at Sec. 435.561(a) to provide a consistent time frame for all beneficiaries to receive outreach. While such a definition would provide consistency for all individuals and across all States, we recognize this could result in outreach that may not be meaningful as it was not necessarily aligned with the timing of the eligibility information that must already be provided when someone receives an eligibility determination notice. We also considered specifying when States should conduct periodic outreach in 2027 and 2028 or the first 2 years of implementation and then later permitting States to determine how frequently periodic outreach should occur after the first few years of implementation. While this would allow States to determine when it would be most effective to conduct outreach, we were concerned that this may increase the likelihood that CMS would need to request additional outreach based on monitoring data if States did not conduct outreach frequently enough. 3. Monitoring and Reporting

We considered not including State data reporting requirements since section 71119 of the WFTC legislation does not prescribe new State reporting requirements specific to community engagement. However, we decided to require at Sec. 435.562 that States submit data that is timely, complete, and of sufficient quality to support monitoring of State eligibility and enrollment operations concerning the implementation and impact of the community engagement requirement. While States already submit a considerable amount of data to CMS for monitoring and oversight of State eligibility operations and enrollment, these new data will assist CMS to maintain high levels of program integrity to ensure States implement the community engagement requirement under section 1902(xx) of the Act and maintain timely and accurate determinations and redeterminations of eligibility for all applicants and beneficiaries. As a result, at Sec. 435.562(d), we require that States submit data elements for applicants and beneficiaries applying for and receiving medical assistance, including individuals subject to the requirements of section 1902(xx) of the Act through five specified categories. We also outline at Sec. 435.562(e) that failure to submit data or data that indicate compliance issues may be subject to corrective action under section 1904 of the Act, additional data collection, or additional outreach noticing as described at Sec. 435.561(b). We believe these additional reporting requirements will support the agency's oversight obligations, public transparency, and accountability of the State Medicaid agencies.

42 CFR Part 431

Grant programs-health, Health facilities, Medicare, Privacy, Reporting and recordkeeping requirements.

42 CFR Part 435

Aid to families with dependent children, Grant programs-health, Medicaid, Reporting and recordkeeping requirements, Supplemental Security Income (SSI), Wages.

42 CFR Part 438

Citizenship and naturalization, Civil rights, Grant programs- health, Individuals with disabilities, Medicaid, Reporting and recordkeeping requirements, Sex discrimination.

42 CFR Part 457

Administrative practice and procedure, Grant programs-health, Health insurance, Reporting and recordkeeping requirements.

42 CFR Part 600

Administrative practice and procedure, Health care, Health insurance, Intergovernmental relations, Penalties, Reporting and recordkeeping requirements.

For the reasons set forth in the preamble, the Centers for Medicare & Medicaid Services amends 42 CFR chapter IV as set forth below:

PART 431--STATE ORGANIZATION AND GENERAL ADMINISTRATION

0 1. The authority citation for part 431 continues to read as follows:

Authority: 42 U.S.C. 1302.

0 2. Section 431.213 is amended by revising paragraph (d) to read as follows:

Sec. 431.213 Exceptions from advance notice.

* * * * *

(d) The beneficiary's whereabouts are unknown and the post office returns agency mail directed to him indicating no forwarding address (see Sec. 431.231(d) for procedure if the beneficiary's whereabouts become known). The provisions of this paragraph (d) sunset on October 1, 2034. CMS will follow applicable rulemaking procedures to ensure that policies governing whereabouts unknown are implemented and effective on October 1, 2034, replacing the policies scheduled to sunset on that date; * * * * *

0 3. Section 431.231 is amended by adding paragraph (d) to read as follows:

Sec. 431.231 Reinstating services.

* * * * *

(d) If a beneficiary's whereabouts are unknown, as indicated by the return of unforwardable agency mail directed to him, any discontinued services must be reinstated if his whereabouts become known during the time he is eligible for services. The provisions of this paragraph (d) sunset on October 1, 2034. CMS will follow applicable rulemaking procedures to ensure that policies governing when a beneficiary's whereabouts become known are implemented and effective on October 1, 2034, replacing the policies scheduled to sunset on that date.

PART 435--ELIGIBILITY IN THE STATES, DISTRICT OF COLUMBIA, THE NORTHERN MARIANA ISLANDS, AND AMERICAN SAMOA

0 4. The authority citation for part 435 continues to read as follows:

Authority: 42 U.S.C. 1302.

0 5. Section 435.3 is amended in paragraph (a) by adding an entry for “1902(xx)” in sequential order to read as follows:

Sec. 435.3 Basis.

(a) * * *

1902(xx) Requirement for States to Establish Medicaid Community Engagement Requirement for Certain Individuals. * * * * *

0 6. Section 435.119 is amended by adding paragraph (d) to read as follows:

Sec. 435.119 Coverage for individuals age 19 or older and under age 65 at or below 133 percent FPL.

* * * * *

(d) Community engagement. As of the implementation date in accordance with Sec. 435.559, the 50 States and the District of Columbia must provide that eligibility under this section is subject to the community engagement requirement described at Sec. Sec. 435.550 through 435.563.

0 7. Add Sec. Sec. 435.550 through 435.563 under the undesignated center heading “Community Engagement Requirement” to read as follows: * * * * * Community Engagement Requirement Sec. 435.550 Basis and scope. 435.551 Applicable individual. 435.552 Demonstrating community engagement. 435.553 Mandatory exceptions for certain applicable individuals. 435.554 Specified excluded individuals. 435.555 Optional exception for short-term hardship events. 435.556 Assessing compliance with the community engagement requirement. 435.557 Verifying compliance with or exception or exclusion from the community engagement requirement. 435.558 Noncompliance procedures. 435.559 Implementation timing for the community engagement requirement. 435.560 Good faith effort exemption. 435.561 State requirements for outreach. 435.562 Requirements for States to submit data for monitoring community engagement.

435.563 Prohibition of waivers of the community engagement requirement. * * * * *