5. ICRs Regarding Beneficiary Application Updates (Single Streamlined and Presumptive Eligibility Applications) (§§ 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 § 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 × 44 jurisdictions) at a cost of $479,931 (44 × [(80 hr × $90.08/hr) + (32 hr × $99.66/hr) + (4 hr × $128.00/hr)]). Accounting for the Federal administrative match of 75 percent, the requirement will cost States $119,983 ($479,931 × 0.25). We have summarized the total burden in Table 13.

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 ( printed page 33434) 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 × 39 jurisdictions) at a cost of $239,722 (39 × [(36 hr × $90.08/hr) + (24 hr × $99.66/hr) + (4 hr × $128.00/hr)]. Accounting for the Federal administrative match of 75 percent, the requirement will cost States $59,931 ($239,722 × 0.25). We have summarized the total burden in Table 14.

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 § 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 § 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 § 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.

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

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 ( printed page 33435) 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 × 2 hr/response) at a cost of $96,900,000 (7,500,000 hr × $12.92/hr).

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.