US HR1 Medicaid Work Requirements IG (proposed, not supported by CMS)
0.1.0 - ci-build
US HR1 Medicaid Work Requirements IG (proposed, not supported by CMS)
0.1.0 - ci-build
US HR1 Medicaid Work Requirements IG (proposed, not supported by CMS) - Local Development build (v0.1.0) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the Directory of published versions
SEC. 71119. <<NOTE: Time periods.>> REQUIREMENT FOR STATES TO ESTABLISH MEDICAID COMMUNITY ENGAGEMENT REQUIREMENTS FOR CERTAIN INDIVIDUALS.
(a) In General.--Section 1902 of the Social Security Act (42 U.S.C. 1396a), as amended by sections 71103 and 71104, is further amended by adding at the end the following new subsection:
``(xx) Community Engagement Requirement for Applicable Individuals.--
``(1) <<NOTE: Deadline.>> In general.--Except as provided
in paragraph (11), beginning not later than the first day of the
first quarter that begins after December 31, 2026, or, at the
option of the State under a waiver or demonstration project
under section 1115 or the State plan, such earlier date as the
State may specify, subject to the succeeding provisions of this
subsection,
[[Page 139 STAT. 307]]
a State shall provide, as a condition of eligibility for medical
assistance for an applicable individual, that such individual is
required to demonstrate community engagement under paragraph
(2)--
``(A) in the case of an applicable individual who
has filed an application for medical assistance under a
State plan (or a waiver of such plan) under this title,
for 1 or more but not more than 3 (as specified by the
State) consecutive months immediately preceding the
month during which such individual applies for such
medical assistance; and
``(B) in the case of an applicable individual
enrolled and receiving medical assistance under a State
plan (or under a waiver of such plan) under this title,
for 1 or more (as specified by the State) months,
whether or not consecutive--
``(i) during the period between such
individual's most recent determination (or
redetermination, as applicable) of eligibility and
such individual's next regularly scheduled
redetermination of eligibility (as verified by the
State as part of such regularly scheduled
redetermination of eligibility); or
``(ii) in the case of a State that has elected
under paragraphyes (4) to conduct more frequent
verifications of compliance with the requirement
to demonstrate community engagement, during the
period between the most recent and next such
verification with respect to such individual.
``(2) Community engagement compliance described.--Subject to
paragraph <<NOTE: Determination. Criteria. Regulations.>> (3),
an applicable individual demonstrates community engagement under
this paragraph for a month if such individual meets 1 or more of
the following conditions with respect to such month, as
determined in accordance with criteria established by the
Secretary through regulation:
``(A) The individual works not less than 80 hours.
``(B) The individual completes not less than 80
hours of community service.
``(C) The individual participates in a work program
for not less than 80 hours.
``(D) The individual is enrolled in an educational
program at least half-time.
``(E) The individual engages in any combination of
the activities described in subparagraphs (A) through
(D), for a total of not less than 80 hours.
``(F) The individual has a monthly income that is
not less than the applicable minimum wage requirement
under section 6 of the Fair Labor Standards Act of 1938,
multiplied by 80 hours.
``(G) The individual had an average monthly income
over the preceding 6 months that is not less than the
applicable minimum wage requirement under section 6 of
the Fair Labor Standards Act of 1938 multiplied by 80
hours, and is a seasonal worker, as described in section
45R(d)(5)(B) of the Internal Revenue Code of 1986 .
``(3) Exceptions.--
``(A) Mandatory exception for certain individuals.--
The State shall deem an applicable individual to
[[Page 139 STAT. 308]]
have demonstrated community engagement under paragraph
(2) for a month, and may elect to not require an
individual to verify information resulting in such
deeming, if--
``(i) for part or all of such month, the
individual--
``(I) was a specified excluded
individual (as defined in paragraph
(9)(A)(ii)); or
``(II) was--
``(aa) under the age of 19;
``(bb) entitled to, or
enrolled for, benefits under
part A of title XVIII, or
enrolled for benefits under part
B of title XVIII; or
``(cc) described in any of
subclauses (I) through (VII) of
subsection (a)(10)(A)(i); or
``(ii) at any point during the 3-month period
ending on the first day of such month, the
individual was an inmate of a public institution.
``(B) Optional exception for short-term hardship
events.--
``(i) <<NOTE: Procedures.>> In general.--The
State plan (or waiver of such plan) may provide,
in the case of an applicable individual who
experiences a short-term hardship event during a
month, that the State shall, under procedures
established by the State (in accordance with
standards specified by the Secretary), in the case
of a short-term hardship event described in clause
(ii)(II) and, upon the request of such individual,
a short-term hardship event described in subclause
(I) or (III) of clause (ii), deem such individual
to have demonstrated community engagement under
paragraph (2) for such month.
``(ii) Short-term hardship event defined.--For
purposes of this subparagraph, an applicable
individual experiences a short-term hardship event
during a month if, for part or all of such month--
``(I) such individual receives
inpatient hospital services, nursing
facility services, services in an
intermediate care facility for
individuals with intellectual
disabilities, inpatient psychiatric
hospital services, or such other
services of similar acuity (including
outpatient care relating to other
services specified in this subclause) as
the Secretary determines appropriate;
``(II) such individual resides in a
county (or equivalent unit of local
government)--
``(aa) in which there exists
an emergency or disaster
declared by the President
pursuant to the National
Emergencies Act or the Robert T.
Stafford Disaster Relief and
Emergency Assistance Act; or
``(bb) that, subject to a
request from the State to the
Secretary, made in such form, at
such time, and containing such
information as the Secretary may
require, has an unemployment
rate that is at or above the
lesser of--
``(AA) 8 percent; or
[[Page 139 STAT. 309]]
``(BB) 1.5 times the
national unemployment rate;
or
``(III) such individual or their
dependent must travel outside of their
community for an extended period of time
to receive medical services necessary to
treat a serious or complex medical
condition (as described in paragraph
(9)(A)(ii)(V)(ee)) that are not
available within their community of
residence.
``(4) Option to conduct more frequent compliance
verifications.--With respect to an applicable individual
enrolled and receiving medical assistance under a State plan (or
a waiver of such plan) under this title, the State shall verify
(in accordance with procedures specified by the Secretary) that
each such individual has met the requirement to demonstrate
community engagement under paragraph (1) during each such
individual's regularly scheduled redetermination of eligibility,
except that a State may provide for such verifications more
frequently.
``(5) <<NOTE: Standards. Processes.>> Ex parte
verifications.--For purposes of verifying that an applicable
individual has met the requirement to demonstrate community
engagement under paragraph (1), or determining such individual
to be deemed to have demonstrated community engagement under
paragraph (3), or that an individual is a specified excluded
individual under paragraph (9)(A)(ii), the State shall, in
accordance with standards established by the Secretary,
establish processes and use reliable information available to
the State (such as payroll data or payments or encounter data
under this title for individuals and data on payments to such
individuals for the provision of services covered under this
title) without requiring, where possible, the applicable
individual to submit additional information.
``(6) Procedure in the case of noncompliance.--
``(A) <<NOTE: Notices.>> In general.--If a State is
unable to verify that an applicable individual has met
the requirement to demonstrate community engagement
under paragraph (1) (including, if applicable, by
verifying that such individual was deemed to have
demonstrated community engagement under paragraph (3))
the State shall (in accordance with standards specified
by the Secretary)--
``(i) provide such individual with the notice
of noncompliance described in subparagraph (B);
``(ii)(I) provide such individual with a
period of 30 calendar days, beginning on the date
on which such notice of noncompliance is received
by the individual, to--
``(aa) make a satisfactory showing
to the State of compliance with such
requirement (including, if applicable,
by showing that such individual was or
should be deemed to have demonstrated
community engagement under paragraph
(3)); or
``(bb) make a satisfactory showing
to the State that such requirement does
not apply to such individual on the
basis that such individual does not meet
the definition of applicable individual
under paragraph (9)(A); and
[[Page 139 STAT. 310]]
``(II) if such individual is enrolled under
the State plan (or a waiver of such plan) under
this title, continue to provide such individual
with medical assistance during such 30-calendar-
day period; and
``(iii) <<NOTE: Deadline. Determination.>> if
no such satisfactory showing is made and the
individual is not a specified excluded individual
described in paragraph (9)(A)(ii), deny such
individual's application for medical assistance
under the State plan (or waiver of such plan) or,
as applicable, disenroll such individual from the
plan (or waiver of such plan) not later than the
end of the month following the month in which such
30-calendar-day period ends, provided that--
``(I) the State first determines
whether, with respect to the individual,
there is any other basis for eligibility
for medical assistance under the State
plan (or waiver of such plan) or for
another insurance affordability program;
and
``(II) the individual is provided
written notice and granted an
opportunity for a fair hearing in
accordance with subsection (a)(3).
``(B) Notice.--The notice of noncompliance provided
to an applicable individual under subparagraph (A)(i)
shall include information (in accordance with standards
specified by the Secretary) on--
``(i) how such individual may make a
satisfactory showing of compliance with such
requirement (as described in subparagraph (A)(ii))
or make a satisfactory showing that such
requirement does not apply to such individual on
the basis that such individual does not meet the
definition of applicable individual under
paragraph (9)(A); and
``(ii) how such individual may reapply for
medical assistance under the State plan (or a
waiver of such plan) under this title in the case
that such individuals' application is denied or,
as applicable, in the case that such individual is
disenrolled from the plan (or waiver).
``(7) Treatment of noncompliant individuals in relation to
certain other provisions.--
``(A) Certain fmap increases.--A State shall not be
treated as not providing medical assistance to all
individuals described in section
1902(a)(10)(A)(i)(VIII), or as not expending amounts for
all such individuals under the State plan (or waiver of
such plan), solely because such an individual is
determined ineligible for medical assistance under the
State plan (or waiver) on the basis of a failure to meet
the requirement to demonstrate community engagement
under paragraph (1).
``(B) Other provisions.--For purposes of section
36B(c)(2)(B) of the Internal Revenue Code of 1986, an
individual shall be deemed to be eligible for minimum
essential coverage described in section
5000A(f)(1)(A)(ii) of such Code for a month if such
individual would have been eligible for medical
assistance under a State plan (or a waiver of such plan)
under this title but for a failure to meet
[[Page 139 STAT. 311]]
the requirement to demonstrate community engagement
under paragraph (1).
``(8) Outreach.--
``(A) <<NOTE: Effective date. Notification.>> In
general.--In accordance with standards specified by the
Secretary, beginning not later than the date that
precedes December 31, 2026 (or, if the State elects
under paragraph (1) to specify an earlier date, such
earlier date) by the number of months specified by the
State under paragraph (1)(A) plus 3 months, and
periodically thereafter, the State shall notify
applicable individuals enrolled under a State plan (or
waiver) under this title of the requirement to
demonstrate community engagement under this subsection.
Such notice shall include information on--
``(i) how to comply with such requirement,
including an explanation of the exceptions to such
requirement under paragraph (3) and the definition
of the term `applicable individual' under
paragraph (9)(A);
``(ii) the consequences of noncompliance with
such requirement; and
``(iii) how to report to the State any change
in the individual's status that could result in--
``(I) the applicability of an
exception under paragraph (3) (or the
end of the applicability of such an
exception); or
``(II) the individual qualifying as
a specified excluded individual under
paragraph (9)(A)(ii).
``(B) <<NOTE: Electronic formats.>> Form of
outreach notice.--A notice required under subparagraph
(A) shall be delivered--
``(i) <<NOTE: Mail.>> by regular mail (or, if
elected by the individual, in an electronic
format); and
``(ii) in 1 or more additional forms, which
may include telephone, text message, an internet
website, other commonly available electronic
means, and such other forms as the Secretary
determines appropriate.
``(9) Definitions.--In this subsection:
``(A) Applicable individual.--
``(i) In general.--The term `applicable
individual' means an individual (other than a
specified excluded individual (as defined in
clause (ii)))--
``(I) who is eligible to enroll (or
is enrolled) under the State plan under
subsection (a)(10)(A)(i)(VIII); or
``(II) who--
``(aa) is otherwise eligible
to enroll (or is enrolled) under
a waiver of such plan that
provides coverage that is
equivalent to minimum essential
coverage (as described in
section 5000A(f)(1)(A) of the
Internal Revenue Code of 1986
and as determined in accordance
with standards prescribed by the
Secretary in regulations); and
``(bb) has attained the age
of 19 and is under 65 years of
age, is not pregnant, is not
entitled to, or enrolled for,
benefits under part A of title
XVIII, or enrolled for benefits
[[Page 139 STAT. 312]]
under part B of title XVIII, and
is not otherwise eligible to
enroll under such plan.
``(ii) Specified excluded individual.--For
purposes of clause (i), the term `specified
excluded individual' means an individual, as
determined by the State (in accordance with
standards specified by the Secretary)--
``(I) who is described in subsection
(a)(10)(A)(i)(IX);
``(II) who--
``(aa) is an Indian or an
Urban Indian (as such terms are
defined in paragraphs (13) and
(28) of section 4 of the Indian
Health Care Improvement Act);
``(bb) is a California
Indian described in section
809(a) of such Act; or
``(cc) has otherwise been
determined eligible as an Indian
for the Indian Health Service
under regulations promulgated by
the Secretary;
``(III) who is the parent, guardian,
caretaker relative, or family caregiver
(as defined in section 2 of the RAISE
Family Caregivers Act) of a dependent
child 13 years of age and under or a
disabled individual;
``(IV) who is a veteran with a
disability rated as total under section
1155 of title 38, United States Code;
``(V) who is medically frail or
otherwise has special medical needs (as
defined by the Secretary), including an
individual--
``(aa) who is blind or
disabled (as defined in section
1614);
``(bb) with a substance use
disorder;
``(cc) with a disabling
mental disorder;
``(dd) with a physical,
intellectual or developmental
disability that significantly
impairs their ability to perform
1 or more activities of daily
living; or
``(ee) with a serious or
complex medical condition;
``(VI) who--
``(aa) is in compliance with
any requirements imposed by the
State pursuant to section 407;
or
``(bb) is a member of a
household that receives
supplemental nutrition
assistance program benefits
under the Food and Nutrition Act
of 2008 and is not exempt from a
work requirement under such Act;
``(VII) who is participating in a
drug addiction or alcoholic treatment
and rehabilitation program (as defined
in section 3(h) of the Food and
Nutrition Act of 2008);
``(VIII) who is an inmate of a
public institution; or
[[Page 139 STAT. 313]]
``(IX) who is pregnant or entitled
to postpartum medical assistance under
paragraph (5) or (16) of subsection (e).
``(B) Educational program.--The term `educational
program' includes--
``(i) an institution of higher education (as
defined in section 101 of the Higher Education Act
of 1965); and
``(ii) a program of career and technical
education (as defined in section 3 of the Carl D.
Perkins Career and Technical Education Act of
2006).
``(C) State.--The term `State' means 1 of the 50
States or the District of Columbia.
``(D) Work program.--The term `work program' has the
meaning given such term in section 6(o)(1) of the Food
and Nutrition Act of 2008.
``(10) Prohibiting waiver of community engagement
requirements.--Notwithstanding section 1115(a), the provisions
of this subsection may not be waived.
``(11) <<NOTE: Determinations.>> Special implementation
rule.--
``(A) In general.--Subject to subparagraph (C), the
Secretary may exempt a State from compliance with the
requirements of this subsection if--
``(i) the State submits to the Secretary a
request for such exemption, made in such form and
at such time as the Secretary may require, and
including the information specified in
subparagraph (B); and
``(ii) the Secretary determines that based on
such request, the State is demonstrating a good
faith effort to comply with the requirements of
this subsection.
``(B) Good faith effort determination.--In
determining whether a State is demonstrating a good
faith effort for purposes of subparagraph (A)(ii), the
Secretary shall consider--
``(i) any actions taken by the State toward
compliance with the requirements of this
subsection;
``(ii) any significant barriers to or
challenges in meeting such requirements, including
related to funding, design, development,
procurement, or installation of necessary systems
or resources;
``(iii) the State's detailed plan and timeline
for achieving full compliance with such
requirements, including any milestones of such
plan (as defined by the Secretary); and
``(iv) any other criteria determined
appropriate by the Secretary.
``(C) Duration of exemption.--
``(i) <<NOTE: Expiration date.>> In
general.--An exemption granted under subparagraph
(A) shall expire not later than December 31, 2028,
and may not be renewed beyond such date.
``(ii) Early termination.--The Secretary may
terminate an exemption granted under subparagraph
(A) prior to the expiration date of such exemption
if the Secretary determined that the State has--
``(I) failed to comply with the
reporting requirements described in
subparagraph (D); or
[[Page 139 STAT. 314]]
``(II) based on the information
provided pursuant to subparagraph (D),
failed to make continued good faith
efforts toward compliance with the
requirements of this subsection.
``(D) Reporting requirements.--A State granted an
exemption under subparagraph (A) shall submit to the
Secretary--
``(i) quarterly progress reports on the
State's status in achieving the milestones toward
full compliance described in subparagraph
(B)(iii); and
``(ii) information on specific risks or newly
identified barriers or challenges to full
compliance, including the State's plan to mitigate
such risks, barriers, or challenges.''.
(b) Conforming Amendment.--Section 1902(a)(10)(A)(i)(VIII) of the Social Security Act (42 U.S.C. 1396a(a)(10)(A)(i)(VIII)) is amended by striking ``subject to subsection (k)'' and inserting ``subject to subsections (k) and (xx)''.
(c) <<NOTE: 42 USC 1396b note.>> Prohibiting Conflicts of Interest.--A State shall not use a Medicaid managed care entity or other specified entity (as such terms are defined in section 1903(m)(9)(D)), or other contractor to determine beneficiary compliance under such section unless the contractor has no direct or indirect financial relationship with any Medicaid managed care entity or other specified entity that is responsible for providing or arranging for coverage of medical assistance for individuals enrolled with the entity pursuant to a contract with such State.
(d) <<NOTE: Deadline. 42 USC 1396a note.>> Interim Final Rulemaking.--Not later than June 1, 2026, the Secretary of Health and Human Services shall promulgate an interim final rule for purposes of implementing the provisions of, and the amendments made by, this section. Any action taken to implement the provisions of, and the amendments made by, this section shall not be subject to the provisions of section 553 of title 5, United States Code.
(e) <<NOTE: 42 USC 1396a note.>> Development of Government Efficiency Grants to States.--
(1) In general.--In order for States to establish systems
necessary to carry out the provisions of, and amendments made
by, this section or other sections of this chapter that pertain
to conducting eligibility determinations or redeterminations,
the Secretary of Health and Human Services shall--
(A) out of amounts appropriated under paragraph
(3)(A), award to each State a grant equal to the amount
specified in paragraph (2) for such State; and
(B) out of amounts appropriated under paragraph
(3)(B), distribute an equal amount among such States.
(2) <<NOTE: Effective date.>> Amount specified.--For
purposes of paragraph (1)(A), the amount specified in this
paragraph is an amount that bears the same ratio to the amount
appropriated under paragraph (3)(A) as the number of applicable
individuals (as defined in section 1902(xx) of the Social
Security Act, as added by subsection (a)) residing in such State
bears to the total number of such individuals residing in all
States, as of March 31, 2025.
(3) Funding.--There are appropriated, out of any monies in
the Treasury not otherwise appropriated--
[[Page 139 STAT. 315]]
(A) $100,000,000 for fiscal year 2026 for purposes
of awarding grants under paragraph (1)(A), to remain
available until expended; and
(B) $100,000,000 for fiscal year 2026 for purposes
of award grants under paragraph (1)(B), to remain
available until expended.
(4) Definition.--In this subsection, the term ``State''
means 1 of the 50 States and the District of Columbia.
(f) Implementation Funding.--For the purposes of carrying out the provisions of, and the amendments made by, this section, there are appropriated, out of any monies in the Treasury not otherwise appropriated, to the Administrator of the Centers for Medicare & Medicaid Services, $200,000,000 for fiscal year 2026, to remain available until expended.