L. Outreach

Section 1902(xx)(8) of the Act, which we implement at new § 435.561 of the regulation, requires States, to notify enrolled applicable individuals of the requirement to demonstrate community engagement in accordance with standards specified by the Secretary. States must begin this outreach “not later than the date that precedes December 31, 2026, or, if the State elects to specify an earlier date, such earlier date, by the number of months specified by the State at section 1902(xx)(1)(A) of the Act plus 3 months, and periodically thereafter.” Such notices must include information on: (1) how to comply with the community engagement requirement, including an explanation of the exceptions under section 1902(xx)(3) of the Act and the definition of the term “applicable individual” under section 1902(xx)(9)(A)(i) of the Act; (2) the consequences of noncompliance; and (3) how to report to the State any changes to the individual's status that could result in the applicability or end the applicability of an exception under section 1902(xx)(3) of the Act or the individual qualifying as a specified excluded individual defined at section 1902(xx)(9)(A)(ii) of the Act. The outreach notice must be provided through at least two modalities: regular mail (or, if elected by the individual, in an electronic format) and in one or more additional modalities, which may include telephone, text message, an internet website, other commonly available electronic means, and other forms as the Secretary determines appropriate.

The regulations at § 435.905(a) require States to furnish information to all applicants and other individuals who request it about the eligibility requirements, available Medicaid services, and the rights and responsibilities of applicants and beneficiaries. States must furnish this program information in electronic and paper formats, and orally as appropriate. The regulations at § 435.1200(f) also require States to make available to current and prospective Medicaid applicants and beneficiaries a website that supports applicant and beneficiary activities, including accessing information on insurance programs available in the State.

In this section, we establish new § 435.561 to implement section 1902(xx)(8) of the Act. We discuss which individuals the State must notify of the community engagement requirement, how frequently States must conduct outreach, the modalities States must use to provide outreach notices, and how States may coordinate the outreach notice with other notices.

We require States at § 435.561 to notify individuals who are eligible to enroll or are enrolled under § 435.119 of the requirements to demonstrate or be deemed to demonstrate community engagement as required under section 1902(xx) of the Act. In addition to such individuals, States must also notify individuals who otherwise are eligible to enroll or are enrolled in coverage under an applicable section 1115 demonstration. While section 1902(xx)(8)(A) of the Act requires States to notify enrolled applicable individuals of the community engagement requirement, we believe it is necessary and appropriate to require that the initial and periodic outreach notification be provided to all individuals enrolled in the adult group described at § 435.119 or in an applicable section 1115 demonstration, rather than only to applicable individuals defined at § 435.551, since the status of an individual can change and render one subject to the community engagement requirement. We believe that the required outreach notification and the content of the outreach notification required by section 1902(xx)(8) of the Act contains information relevant to applicable individuals described at § 435.551 and specified excluded individuals described at § 435.554. In addition, we believe States would not be able to determine which enrolled beneficiaries meet the definition of an “applicable individual” at section 1902(xx)(9)(A)(i) of the Act to target the initial outreach notices to such individuals prior to the effective date of the community engagement requirement in the State. We, therefore, did not limit the outreach requirements at § 435.561 to applicable individuals described at § 435.551. However, as we explain below in our discussion of the content of the outreach notice, not every individual who receives an outreach notice will be required to comply with the community engagement requirement. States will need to include clear, consumer-friendly information in the outreach notice to help individuals understand who qualifies for an exception or is a specified excluded individual and that additional actions would not be needed by such individuals to demonstrate compliance.

Under § 435.905(a), States must provide applicants and all other individuals who request it, information on eligibility requirements and the rights and responsibilities of applicants and beneficiaries, which will now include information on complying with the community engagement requirement as a component of the eligibility information. To satisfy this requirement, we also interpret the community engagement outreach requirement at § 435.561(a) to require outreach notices be provided to the affected individual. Section 1902(xx)(8)(A) of the Act states that “the State shall notify applicable individuals enrolled under a State plan (or waiver) under this title of the requirement to demonstrate community engagement.” We interpret such requirements to mean that States must ( printed page 33420) direct the content in the outreach notice specifically to the individuals who must receive the notice rather than to the general public. A general, public notice, such as a web page about the community engagement requirement, would not satisfy the outreach requirement at § 435.561. This targeted approach ensures that affected individuals are aware of the applicability of the community engagement requirement. States must also provide information on eligibility requirements, including community engagement, to all other individuals who request it per § 435.905(a).

We recognize that the general public may not be aware of the forthcoming community engagement requirement in Medicaid, which may affect eligibility for future applicants. States must make program information available on their public website described at § 435.1200(f), which must include information related to community engagement. While we are not requiring States to engage in additional public outreach efforts, we encourage States to consider general public outreach as part of their efforts to implement the community engagement requirement. These additional public outreach efforts can complement the required outreach notices and raise broader community awareness of the new community engagement requirement. We also encourage States to use existing tools and to partner with interested parties and networks to disseminate resources and offer multiple channels to individuals to learn about and navigate the requirement. These may include but are not limited to aging and disability networks, hospitals, Federally qualified health centers, rural health clinics, provider networks, schools, churches and other religious institutions, managed care plans, and other community-based organizations.

We require States at § 435.561(b)(1) to conduct outreach prior to January 1, 2027, or an earlier implementation date specified by the State in accordance with § 435.559. States that later elect to implement the adult group under § 435.119 must also conduct outreach about the community engagement requirement prior to the effective date of the adult group in the State plan. Similarly, States that implement the community engagement requirement in a section 1115(a)(2) demonstration project under section 1902(xx)(9)(A)(i)(II) of the Act must conduct outreach prior to the implementation date of the demonstration project expenditure authority. We interpret the statute to require outreach notices to be provided 3 months prior to the date the community engagement requirement becomes effective in the State plus the number of months specified by the State for applicants to demonstrate compliance with the community engagement requirement under § 435.556(a)(1). This will result in States needing to send outreach notices to beneficiaries in the fourth, fifth, or sixth month prior to the date in which the community engagement requirement becomes effective. For example, in States with effective dates of January 1, 2027, States will need to send initial outreach notices in July 2026, August 2026, or September 2026, depending on whether the State elects for applicants to demonstrate they meet the community engagement requirement in the 3 months before, 2 months before, or 1 month before the month in which application is made. Table 2 depicts this and additional examples.

New § 435.561(b)(1) and (b)(2) require States to send notices to beneficiaries 4, 5, or 6 months prior to the community engagement requirement becoming effective in the State and to send the notices 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 § 435.119 or an applicable section 1115 demonstration will be made aware of the requirement. We also require States to notify all individuals described at § 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 § 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 at § 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 § 435.916, and based on a change in circumstances; (2) when the State elects the short-term hardship exception in the State plan under § 435.555(a); (3) each time a short-term hardship exception relating to an event described at § 435.555(d)(2) becomes available to applicable individuals or the State effectuates the short-term hardship event described at § 435.555(d)(3); (4) when the State reduces a beneficiary's eligibility and sends advance notice for: the deselection of the short-term hardship exception under § 435.555(a); the anticipated expiration of a short-term hardship event described at § 435.555(d)(2) and (3); and the loss of a beneficiary's specified excluded individual status under § 435.554; and (6) upon request by CMS, if State-reported monitoring data described at § 435.562 or other information indicates a need for increased outreach or a potential compliance issue with §§ 435.550 through 435.562, consistent with § 435.562(e). We believe this will allow States to align outreach notices with eligibility determination notices under § 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 ( printed page 33421) 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 us, 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 the monitoring data States must submit and about our approach to identifying 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 § 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 § 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 two 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. We seek public comment on whether CMS should establish a different frequency for periodic outreach. We also seek public comment on whether we should allow States to define what it means to conduct outreach on a “periodic basis” in the future.

At § 435.561(c), we require that outreach notices must be provided in a manner consistent with § 435.905(b), to align with requirements for all other program information and notices. To align with section 1902(xx)(8)(A) of the Act and ensure that individuals are notified of their rights and responsibilities in accordance with § 435.905(a), we also specify that the notice content must inform individuals of the following three types of information:

1. How to comply with the requirement to demonstrate community engagement as described at § 435.561(c)(1). This includes: (1) an explanation of the exceptions, including short-term hardship exceptions, if elected by the State; (2) who is an applicable individual, including an explanation of exclusions from such definition under § 435.554; (3) the number of months an applicable individual is required to demonstrate community engagement during the review period at renewal; and (4) if elected by the State, how frequently the State will periodically verify community engagement in between renewals.

2. The consequences of noncompliance with the community engagement requirement on eligibility for Medicaid and for APTC and PTC used to pay for coverage on a Health Insurance Exchange.

3. How to report to the State any change in the individual's status that could result in someone qualifying or no longer qualifying for an exception, short-term hardship, or being considered a specified excluded individual described at § 435.554.

As part of describing how to comply with the community engagement requirement, States must include information about how an applicable individual may demonstrate compliance with community engagement as required under Section 1902(xx)(2) of the Act and described further in section II.C. of this IFC. This includes providing information on the types of activities that demonstrate community engagement, such as types of community service activities that count towards the community engagement requirement. The outreach notices must provide clear, consumer-friendly information to help individuals understand if they qualify for an exception to the community engagement requirement (which means they will be deemed compliant) or if they are a specified excluded individual (in which case, they would not be required to demonstrate compliance). Some individuals, particularly family caregivers or those who are medically frail, may not identify themselves as meeting an exception or exclusion if the State does not provide clear communication about how the exceptions and exclusions are defined. For individuals who qualify as specified excluded individuals, States will also need to clearly communicate that for such individuals, additional actions to demonstrate compliance are not required at that time.

Additionally, we remind States that while the outreach notice must inform individuals how to report changes in their status, a change is not necessarily a change in circumstances that may affect the individual's eligibility, as discussed in section II.H.3.d. of this IFC. States must accept updated information from beneficiaries the same way they would accept other information reported by the beneficiary even if it does not impact eligibility, such as a change of an in-State address.

We require States at § 435.561(d)(1) to provide the outreach notice by regular mail or, if elected by the individual, in an electronic format consistent with § 435.918. If an individual has elected to receive notices and communications electronically, the State must post the outreach notice described at § 435.561(d)(1) via the individual's preferred electronic format. We specify at § 435.561(d)(2) that outreach notices must also be provided in at least one or more additional modalities, which means the individual must receive their outreach notification via at least two different modalities, including via the individual's electronic account, by telephone, by text message, or through other commonly available electronic means. For an individual who elected to receive electronic notices and communications consistent with § 435.918, the State cannot use that same electronic modality as the additional modality to satisfy the requirement at § 435.561(d)(2). For example, if a State posts the outreach notice to an individual's electronic account consistent with § 435.561(d)(1) and as elected by the individual, the additional modality for the additional notice at § 435.561(d)(2) cannot also be the individual's electronic account. At this time, we have not identified any specific commonly available electronic means through which States may send ( printed page 33422) an outreach notice, nor do we prescribe any additional modalities for States in this IFC.

We interpret the “internet website” modality at section 1902(xx)(8)(B)(ii) to mean the individual's electronic account available through an internet website, as opposed to the State agency's public facing website. As stated earlier in this section, we interpret that the outreach notices required by section 1902(xx)(8) of the Act must be targeted to the individual rather than the general public. For individuals who do not have an electronic account, the State must use a different modality to satisfy the requirement at § 435.561(d)(2), which may include telephone, text message, or other commonly available electronic means. States are reminded that general program information, including the community engagement requirement, must be separately posted to the State agency's websites in accordance with § 435.905(a).

Section 1902(xx)(8) of the Act does not preclude States from including the outreach notice described in this section or incorporating the content of the outreach notice in another notice or communication that the State provides to the individual. For example, States may include the outreach notice content with the eligibility determination notice provided when an individual is redetermined eligible at renewal. This would meet the State's requirement for periodically notifying an individual of the community engagement requirement when an individual redetermined eligible at renewal. As such, we specify at § 435.561(e)(1) that States may include the outreach notice required at § 435.561(a) with an eligibility determination notice described at § 435.917 or with other communication from the State to the individual.

Section 1902(xx)(8) of the Act does not limit State flexibility to use managed care plans [ 114 ] to assist in the administrative activity of providing an outreach notice “in one or more additional forms.” In 2024, over 80 percent of all Medicaid beneficiaries received some or all of their covered services through a managed care plan. [ 115 ] To ensure that the outreach notices are provided timely and consistently, we believe that States may find it beneficial to utilize their managed care plans to assist with providing the periodic outreach notices in one or more of the additional modalities specified at § 435.561(d)(2). We permit States at § 435.561(e)(2) to utilize managed care plans to provide the outreach notice periodically, consistent with § 435.561, through one or more of the modalities described in paragraph § 435.561(d)(2). States that elect to do this are expected to direct their managed care plans on which individuals must receive the outreach notice, how frequently such individuals must receive such notice, and the exact content of such notice as required under § 435.561. Section II.M. of this IFC provides additional information about the roles managed care plans can play in helping States accurately implement and ensure compliance with the community engagement requirement, as well as the activities that managed care plans are prohibited from participating in.