The Centers for Medicare & Medicaid Services has published an interim final rule implementing the Medicaid work/community engagement requirements mandated by H.R. 1, last year’s federal budget reconciliation bill.
The rule defines community engagement requirements for adults to gain or maintain Medicaid eligibility for applications on or after January 1, 2027. Under the rule, individuals will be eligible for Medicaid if they participate in 80 hours of employment, community service, work programs, or other qualifying activities.
Under this interim final rule, states must:
- identify who is subject to or exempt from the work requirements
- verify compliance at application and renewal
- conduct outreach to affected populations
- manage noncompliance workflows
- submit data to CMS for oversight
The rule also defines the specific circumstances that may exempt some adults from work requirements to enroll or maintain Medicaid coverage. Those circumstances include:
- parents and caretaker relatives of a dependent child (under the age of 14)
- disabled individuals and their caretaker relatives (for physical and mental disabilities, including behavioral health and substance use disorders. Homelessness on its own does not qualify an individual for exemption.)
- veterans with disability rated as total
- individuals who are medically frail (those who have conditions “that significantly impair their ability to consistently work or participate in other community engagement activities”)
States also may offer short-term exceptions, including for:
- hospitalization or medical treatment
- travel for specialized care
- high-unemployment areas
- federally declared disasters/emergencies
Learn more about the proposed new Medicaid eligibility criteria from this CMS news release; an accompanying CMS fact sheet; this preview version of the formal notice; and the Becker’s Hospital Review article “CMS finalizes framework for Medicaid work rules: 8 things to know.”