The purpose of the December 8, 2025, Center for Medicaid and CHIP Services (CMCS) Informational Bulletin is to provide an overview of the Medicaid-related “community engagement” requirement. Implementation of community engagement requirements will necessitate system, policy, and operational changes to state programs in the coming years. Rulemaking must be done by June 2026, but planning must begin now, as states enter budget and legislative sessions and begin procurement of new systems and services to support implementation of the Medicaid provisions.
Implementation of community engagement requirements will necessitate system, policy, and operational changes to state programs in the coming years.
Community engagement is not new to the Medicaid program. Multiple states submitted new section 1115 demonstration requests, prior to the passage of the legislation, to implement a community engagement program.
In short, CMS is “committed to supporting states” and “recognizes that planning must begin now” to establish Medicaid community engagement requirements for certain individuals
Applicable individuals in the Medicaid expansion
- Group VIII, otherwise known as the Medicaid expansion population
- Individuals that fit the description of Group VIII but live in states that provide minimum essential coverage through an 1115 waiver rather than the state plan
There are no community engagement requirements in states that have not adopted Expansion. (Community engagement requirements do not apply in states that have not adopted Medicaid expansion and have not adopted an 1115 waiver that provides coverage to the population that would otherwise be covered through Expansion if that state had adopted it.)
Implementation timeframe
States are required to implement work/community engagement requirements by Jan. 1, 2027, or sooner through an 1115 waiver or the state plan, approved by CMS. The work/community engagement provisions implemented in any 1115 waiver must align with those outlined in HR 1.
The Secretary of HHS is required to promulgate an interim final rule no later than June 1, 2026.
Medicaid work and community engagement requirements
- Work at least 80 hours per month
- Complete at least 80 hours of community service per month
- Participate in a work program defined by the Food and Nutrition Act of 2008 for at least 80 hours per month
- Be enrolled at least half-time in an education program at an institution of higher education or a career and technical education setting
- Engage in a combination of the above for a total of at least 80 hours a month
- Have a monthly income that is not less than the applicable federal minimum wage multiplied by 80 hours
- Be a seasonal worker and have had an average monthly income over the last 6 months that is not less than the applicable federal minimum wage multiplied by 80 hours
Exclusions and exceptions criteria
- Former foster care youth
- An American Indian or Alaska Native
- A parent, guardian, caretaker relative, or family caregiver of a child who is age 13 or under or of a disabled individual
- A veteran with a total disability
- Someone who is medically frail or has special medical needs (to be defined by the HHS Secretary) including an individual: who is blind or disabled, with a substance use disorder, who has a disabling mental disorder, with a physical, intellectual or developmental disability that impairs their ability to complete one or more activities of daily living (ADLs); or with a serious or complex medical condition
- An individual who meets the TANF work requirements or who’s a member of a SNAP household that is not exempt from work requirements
- Someone who’s participating in a drug addiction or alcoholic treatment and rehabilitation program (defined by the Food and Nutrition Act of 2008)
- An inmate of a public institution
- A woman who is pregnant or eligible for postpartum medical assistance
Demonstrating and verifying community engagement
For new applicants: states must require individuals to meet these requirements for at least one month prior to the month the person applies, but can require that the individual meet them for up to 3 months prior to applying.
- For example, if a state is implementing the one-month requirement, an individual would be required to meet the requirements in December 2026 for coverage to begin in January 2027. If a state requires 3 months, then the individual would need to meet the requirements for October through December of 2026.
For renewals: states must require Medicaid expansion enrollees to comply with the requirements for one or more months (specified by the state) between renewals, but the months need not be consecutive. The bulletin states that CMS considers an enrollee to have successfully met the requirements if they meet the requirements for the state specified number of months during any portion of the eligibility period.
Frequency: Included in HR 1 is a requirement to conduct eligibility checks every 6 months instead of every 12, as is currently done, for what is largely the same population of individuals newly subject to the work/community engagement requirements. States must comply with the 6 month checks, but are permitted to verify compliance with the work/community engagement requirements more frequently than every 6 months if they choose to.
Verifiable information is required at both application and renewal
States must first check information that comes from, but is not limited to “payroll data, Medicaid provider payments, or encounter data, and data sources about higher education enrollment, job training participation, or community service” to establish whether an enrollee is meeting their requirements.
The state cannot request more information from the individual unless it is unable to determine if someone is meeting the requirements with this “reliable information available to the state.” The use of this “reliable information available to the state” is required at both application and renewal.
“Non-compliance” procedures and ineligibility
If the state cannot verify that someone has met the requirements, it must provide notice to the individual. Both new applicants and current enrollees have 30 calendar days from receiving a notice to prove that they have either met the requirements or should be exempted from them. This notice has to include information on how to demonstrate compliance or an exemption. Coverage must be provided to enrollees during this 30 day period.
If applicant/enrollee cannot demonstrate compliance or exemption, the state must check that the individual isn’t eligible for Medicaid under another category or another insurance option.
An individual who is determined to be eligible for Medicaid expansion, but is not meeting the work/community engagement requirements, is ineligible for advance premium tax credits and premium tax credits in the Affordable Care Act health insurance marketplace.
Outreach responsibilities
States must notify current enrollees who it determines will be subject to these new requirements.
States must notify the enrollee by mail and at least one other communication method that can include text message, phone call, website, or other commonly available means of communication.
The outreach time frame is based on the state’s implementation date of work/community engagement requirements and the look back period it determines for meeting the requirement (one, two or three months). For example, if a state is requiring the minimum one month of work/community engagement and is implementing the requirements on 1/1/2027, then the outreach to the individual must begin no later than September 2026. If the state is requiring three months of community engagement, then outreach must begin no later than July 2026.
Managed care plans cannot determine compliance
Managed care plans and any entities with financial relationships with managed care plans are not permitted to determine beneficiary compliance with community engagement requirements.
Certain state Medicaid agency costs necessary to support implementation of these new requirements may be eligible for enhanced matching dollars from the federal government.
CMS support to states for implementation
$200 million will be allocated to states to support implementation of these changes
- $100 million will be distributed evenly to all 50 states and D.C.
- $100 million will be distributed to all 50 state and D.C. based on the share of Medicaid expansion enrollees relative to the total
The bulletin states that “these new requirements should function seamlessly with new and existing system functionality.”
Certain state Medicaid agency costs necessary to support implementation of these new requirements may be eligible for enhanced matching dollars from the federal government. A state can submit an advanced planning document (APD) for a 90/10 enhanced match for “design, development, and installation of their Medicaid Enterprise Systems (MES)” and may also submit an APD for a 75/25 enhanced match for ongoing operations.
