Footnotes

1. CMS, Fiscal Year 2027; Justification of Estimates for Appropriations Committees. https://www.cms.gov/files/document/fy-2027-justification-estimates-appropriations-committees.pdf .

2.

Medicaid Budget and Expenditure System (MBES) data source updated with FY2025 data as of the June 2026 IFC publication date. Available at https://data.medicaid.gov/dataset/5b19d1d4-ae43-5fcd-ba14-3cecd99f473f and https://data.medicaid.gov/dataset/00505e90-f8ac-5921-b12f-5e23ba7ffcf3 .

3.

While the ACA established the adult group as a mandatory eligibility group, the U.S. Supreme Court decision, National Federation of Independent Business v. Sebelius, 567 U.S. 519 (2012), effectively made coverage of this eligibility group voluntary for States.

4.

See: CMS, Adult Coverage Expansion (December 1, 2023), available at https://www.medicaid.gov/medicaid/program-information/downloads/medicaid-expansion-state-map.pdf .

5.

NOTE: This document contains links to non-United States Government websites. We are providing these links because they contain additional information relevant to the topic(s) discussed in this document or that otherwise may be useful to the reader. We cannot attest to the accuracy of information provided on the cited third-party websites or any other linked third-party site. We are providing these links for reference only; linking to a non-United States Government website does not constitute an endorsement by CMS, HHS, or any of their employees of the sponsors or the information and/or any products presented on the website. Also, please be aware that the privacy protections generally provided by United States Government websites do not apply to third-party sites.

6.

Cigna Corporation. The Loneliness Epidemic Persists: A Post-Pandemic Look at the State of Loneliness among U.S. Adults. 2021. https://newsroom.thecignagroup.com/all-stories?item=446 .

7.

Bruce LD, Wu JS, Lustig SL, Russell DW, Nemecek DA. Loneliness in the United States: A 2018 National Panel Survey of Demographic, Structural, Cognitive, and Behavioral Characteristics. Am J Health Promot. 2019;33(8):1123-1133. doi: 10.1177/0890117119856551. Epub 2019 Jun 16. PMID: 31203639; PMCID: PMC7323762.

8.

Shovestul B, Han J, Germine L, Dodell-Feder D. Risk factors for loneliness: The high relative importance of age versus other factors. PLOS ONE. 2020;15. doi: 10.1371/journal.pone.0229087. PMID: 32045467; PMCID: PMC7012443.

9.

Buecker S, Mund M, Chwastek S, Sostmann M, Luhmann M. Is loneliness in emerging adults increasing over time? A preregistered cross-temporal meta-analysis and systematic review. Psychological Bulletin. 2021;147(8):787. doi: 10.1037/bul0000332. PMID: 34898234.

10.

Holt-Lunstad J, Robles TF, Sbarra DA. Advancing social connection as a public health priority in the United States. Am Psychol. 2017;72(6):517-530. doi: 10.1037/amp0000103. PMID: 28880099; PMCID: PMC5598785.

11.

Zafar, Q., M.A. Khan, A.Z. Warsi, and L. Iqbal. (2024). “Economic Strain and Recovery Trajectories in Mental Health: The Role of Financial Stability in Mental Health Outcomes.” Review of Applied Management and Social Sciences, 7(4): 345-358. https://doi.org/10.47067/ramss.v7i4.385 .

12.

R. Gerdes, T.D. Jackson, R. Roberts, et al. (2026). “Associations Between Employment and Health Outcomes: A Systematic Review of Reviews.” Journal of Occupational Rehabilitation. https://doi.org/10.1007/s10926-025-10357-5 .

13.

R. Chetty, M. Stepner, S. Abraham, et al. (2016) “The association between income and life expectancy in the United States, 2001-2014.” JAMA. 315(16):1750-1766. https://doi:10.1001/jama.2016.4226 .

14.

Schoufour, J., E. A.L. de Jonge, J. C. Kiefte-de Jong, et al. (2018). “Socio-economic indicators and diet quality in an older population” Maturitas, Volume 107: 71-77, ISSN 0378-5122, https://doi.org/10.1016/j.maturitas.2017.10.010 .

15.

Kim, S., B. Lee, M. Park, et al. (2016) “Prevalence of chronic disease and its controlled status according to income level.” Medicine 95(44):p e5286, https://doi.org/10.1097/MD.0000000000005286 .

16.

Brownell, N., Z. Boback, J. Nicholas, et al. (2024). “Trends in Income Inequities in Cardiovascular Health Among US Adults, 1988-2018” American Heart Association Journals. 17(5). https://doi.org/10.1161/CIRCOUTCOMES.123.010111 .

17.

Han,W.-J. (2024). “How longitudinal employment patterns shape health as individuals approach middle adulthood—US NLSY79 cohort.” PLOS ONE, 19(4), e0300245. https://doi.org/10.1371/journal.pone.0300245 .

18.

Virtanen M, Kivimäki M, Joensuu M, Virtanen P, Elovainio M, Vahtera J. Temporary employment and health: a review. Int J Epidemiol. 2005 Jun;34(3):610-22. doi: 10.1093/ije/dyi024. Epub 2005 Feb 28. PMID: 15737968.

19.

Kim TJ, von dem Knesebeck O. Perceived job insecurity, unemployment and depressive symptoms: a systematic review and meta-analysis of prospective observational studies. Int Arch Occup Environ Health. 2016 May;89(4):561-73. doi: 10.1007/s00420-015-1107-1. Epub 2015 Dec 29. PMID: 26715495.

20.

Gerdes R, Jackson TD, Roberts R, Lytvyak E, Deibert D, Dennett L, Burton AK, Gross DP, Els C, Doroshenko A, Hagtvedt R, Straube S. Associations Between Employment and Health Outcomes: A Systematic Review of Reviews. J Occup Rehabil. 2026 Jan 6. doi: 10.1007/s10926-025-10357-5. Epub ahead of print. PMID: 41493509.

21.

Arizona, Arkansas, Georgia, Indiana, Kentucky, Maine, Michigan, Nebraska, New Hampshire, Ohio, South Carolina (two 1115 demonstrations), Utah, and Wisconsin.

22.

Centers for Medicare & Medicaid Services (CMS). (2025, December 8). Requirements for states to establish Medicaid community engagement requirements for certain individuals (CMCS Informational Bulletin: Section 71119 of the Working Families Tax Cut Legislation, P.L. 119-21 ). https://www.medicaid.gov/federal-policy-guidance/downloads/cib12082025.pdf .

23.

Medicaid and CHIP Payment and Access Commission (MACPAC). (2026, April 9). Implementing community engagement requirements in Medicaid. https://www.macpac.gov/wp-content/uploads/2026/04/01_April-Slides_Implementing-Community-Engagement-Requirements-in-Medicaid.pdf .

24.

Centers for Medicare & Medicaid Services (CMS). (2021, March 17). Letter to Arkansas regarding Arkansas Works demonstration. https://www.medicaid.gov/medicaid/section-1115-demonstrations/downloads/ar-works-ca2.pdf .

25.

Georgia Department of Community Health. (2025, April 28). Georgia section 1115 demonstration waiver extension request. https://www.medicaid.gov/medicaid/section-1115-demonstrations/downloads/ga-pathway-pa-04282025.pdf .

26.

NOTE: This document contains links to non-United States Government websites. We are providing these links because they contain additional information relevant to the topic(s) discussed in this document or that otherwise may be useful to the reader. We cannot attest to the accuracy of information provided on the cited third-party websites or any other linked third-party site. We are providing these links for reference only; linking to a non-United States Government website does not constitute an endorsement by CMS, HHS, or any of their employees of the sponsors or the information and/or any products presented on the website. Also, please be aware that the privacy protections generally provided by United States Government websites do not apply to third-party sites.”

27.

For more information on the section 71102 moratorium and how to interpret regulations that remain impacted, see the November 18, 2025, CMCS Informational Bulletin, “ “Working Families Tax Cut” Legislation, Public Law 119-21 : Summary of Medicaid and Children's Health Insurance Program (CHIP) Related Provisions,” available at https://www.medicaid.gov/federal-policy-guidance/downloads/cib11182025.pdf .

28.

MEC is defined in section 1902(xx)(9)(A)(i)(II)(aa) of the Act as follows: “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.” CMS does not read the provision in the statute to in any way change the current process for determining whether Medicaid coverage in section 1115 demonstrations is MEC.

29.

FNS's definition of unpaid work states that the unpaid work must be verified under standards established by the State agency. Our definition does not include this verification language because Medicaid has its own specific verification requirements that must be followed for community engagement. Section II.I.6.a. of this IFC includes information about verification requirements for unpaid work.

30.

While the Administration for Children and Families (ACF) definition of community service program uses the term “work”, ACF states in the preamble of the 2006 Reauthorization of the Temporary Assistance for Needy Families Program Interim final rule with request for comments, that community service programs are an unpaid work activity when discussing documentation requirements for unpaid work activities: “[o]ther unpaid work activities, including work experience, community service programs. . .”. See: Reauthorization of the Temporary Assistance for Needy Families Program, Medicaid Program; Premiums and Cost Sharing 71 FR 37468 (June 29, 2006). https://www.federalregister.gov/d/06-5743 .

31.

Wroblewska K, Steigelman C, J, et al. (2022). “The Use of Supervised Job Search, Job Search Training, and Integrated Job Search in SNAP E&T: Three Cases Studies.” U.S. Department of Agriculture, Food and Nutrition Service. Prepared by Insight Policy Research, Inc. https://fns-prod.azureedge.us/sites/default/files/resource-files/SNAPETJobSearch.pdf .

32.

A secondary school is further defined at 20 U.S.C. 7801(45) as a nonprofit institutional day or residential school, including a public secondary charter school, that provides secondary education, as determined under State law, except that the term does not include any education beyond grade 12.

33.

On average, there are 4.33 weeks in a month. This is calculated by dividing the total number of weeks in a year (52), by the total number of months (12).

34.

Adler KM (2020). “Determining Carnegie Units: Student Engagement in Online Courses without a Residential Equivalent.” Online Journal of Distance Learning Administration, 23(1). https://ojdla.com/articles/determining-carnegie-units-student-engagement-in-online-courses-without-a-residential-equivalent .

35.

United States Department of Education, Office of Postsecondary Education, “Guidance to Institutions and Accrediting Agencies Regarding a Credit Hour as Defined in the Final Regulations Published on October 29, 2010,” (March 18, 2011). https://fsapartners.ed.gov/sites/default/files/attachments/dpcletters/GEN1106.pdf .

36.

The regulation further provides that this is for “approximately fifteen weeks for one semester or trimester hour of credit, or 10 to 12 weeks for one quarter hour of credit, or the equivalent amount of work over a different period of time.”

37.

Under SNAP or TANF, individuals receiving benefits may be enrolled in educational programs that use credit hours but still have their time counted based on hours in class or participation. As explained above, we developed the credit hour standard for educational programs that use credit hours to account more fully for the educational process typical in such programs.

38.

This example is from California's FNS SNAP E&T State Plan submission for FY26.

39.

Office of Management and Budget (OMB) #0970-0338, “Work Verification Plan Guide,” expires 10/31/2026. Available at: https://acf.gov/sites/default/files/documents/ofa/Work-verification-plan-guidance-valid-thru-2026-10.pdf .

40.

Ibid.

41. 29 U.S.C. 206(a)(1)(C) .

42. 29 U.S.C. 203(m) .

43.

For purposes of this discussion, “incarcerated” has the same meaning as “inmate of a public institution” as defined at § 435.1010.

44.

Section 1902(a)(84)(A), as amended by Division G, Title I, Section 205 of the CAA, 2024 requires States to suspend rather than terminate Medicaid eligibility during periods of incarceration for all Medicaid-eligible individuals; Section 1002 of the SUPPORT Act directed the Secretary of HHS to develop guidance on how section 1115 demonstrations can be used to support incarcerated individuals transitioning to the community.

45.

CMCS State Health Official (SHO) letter #22-003, “Coverage of Youth Formerly in Foster Care in Medicaid.” (December 16, 2022). Available at: https://www.medicaid.gov/federal-policy-guidance/downloads/sho22003.pdf .

46.

Medicaid Program; Premiums and Cost Sharing 75 FR 30243 (May 28, 2010). https://www.federalregister.gov/d/2010-12954 .

47.

Medicaid Program; Eligibility Changes Under the Affordable Care Act of 2010 77 FR 17144 (March 23, 2012). https://www.federalregister.gov/d/2012-6560 .

48.

Black's Law Dictionary (12th ed. 2024) s.v. “Parent,” accessed May 1, 2026.

49.

Merriam-Webster Dictionary Online, s.v. “Guardian,” accessed March 21, 2026, https://www.merriam-webster.com/dictionary/guardian .

50.

“Guardianship” U.S. Department of Justice, accessed on March 3, 2026. https://www.justice.gov/elderjustice/guardianship .

51.

“Guardianship: Key Concepts and Resources.” U.S. Department of Justice, last modified on February 18, 2026. https://www.justice.gov/elderjustice/guardianship-key-concepts-and-resources .

52.

Medicaid Program; Eligibility Changes Under the Affordable Care Act of 2010. 77 FR 17144 (March 23, 2012). https://www.federalregister.gov/d/2012-6560 .

53.

Medicaid Program; Eligibility Changes Under the Affordable Care Act of 2010. 76 FR 51148 (August 17, 2011). https://www.federalregister.gov/d/2011-20756 .

54.

SNAP Work Requirements. U.S. Department of Agriculture Food and Nutrition Services, last updated August 29, 2025, https://www.fns.usda.gov/snap/work-requirements .

55. 7 CFR 273.1 .

56.

Parker, K. “Family Caregiving in an Aging America.” Pew Research Center, February 2026. https://www.pewresearch.org/wp-content/uploads/sites/20/2026/02/ST_2026.2.26_family-caregivers_report.pdf .

57.

Sadick, B. “How to Provide Long-Distance Caregiving.” U.S. News, June 3, 2025. https://health.usnews.com/senior-care/articles/how-to-provide-long-distance-caregiving .

58.

AARP and National Alliance for Caregiving. (2025). “Caregiving in the U.S.” https://www.aarp.org/content/dam/aarp/ppi/topics/ltss/family-caregiving/caregiving-in-us-2025.doi.10.26419-2fppi.00373.001.pdf .

60.

The community engagement requirement does not apply to children under the age of 19 and therefore is not applicable to the individuals described in § 438.50(d)(3) or children with serious emotional disturbances. The regulation at § 438.50(d)(3) includes children under the age of 19 eligible for SSI under Title XVI of the Act; eligible under section 1902(e)(3) of the Act; in foster care or other out-of-home placement; receiving foster care or adoption assistance; or receiving services through a family-centered, community-based, coordinated care system that receives grant funds under section 501(a)(1)(D) of Title V of the Act, and is defined by the State in terms of either program participation or special health care needs.

61.

“Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR),” American Psychiatric Association, accessed February 27, 2026, https://www.psychiatry.org/psychiatrists/practice/dsm .

62.

“International Statistical Classification of Diseases and Related Health Problems 10th Revision,” World Health Organization, accessed February 27, 2026, https://icd.who.int/browse10/2019/en .

63.

“Treatment of Substance Use Disorders,” Centers for Disease Control and Prevention, last modified April 25, 2024, https://www.cdc.gov/overdose-prevention/treatment/ .

64.

“Treatment and Recovery,” National Institute on Drug Abuse, last modified July 2020, https://nida.nih.gov/publications/drugs-brains-behavior-science-addiction/treatment-recovery .

65.

Frone MR, Chosewood LC, Osborne JC, and Howard JJ. (2022). “Workplace Supported Recovery from Substance Use Disorders: Defining the Construct, Developing a Model, and Proposing an Agenda for Future Research.” Occupational Health Science 6 (4): 475-511. https://doi.org/10.1007/s41542-022-00123-x .

66.

Ibid.

67.

“What is Mental Illness?,” American Psychiatric Association, last modified July 2025, https://www.psychiatry.org/patients-families/what-is-mental-illness .

68.

Ibid.

69.

Ibid.

70.

“About Intellectual and Developmental Disabilities (IDDs),” Eunice Kennedy Shriver National Institute of Child Health and Human Development, last modified November 9, 2021, https://www.nichd.nih.gov/health/topics/idds/conditioninfo .

71.

“CMS Waiver Applications,” Centers for Medicare & Medicaid Services, last accessed February 27, 2026, https://wms-mmdl.cms.gov/WMS/faces/portal.jsp .

72.

The Institute of Medicine is now known as the National Academy of Medicine.

73.

CMS notes that the term used in this report is different from the “serious or complex” medical condition used in the community engagement statute but has determined the framework in the report to be sufficiently broad to implement this medical frailty exclusion.

74.

Chrvala CA, Sharfstein SS, Institute of Medicine (U.S.). Committee On Serious and Complex Medical Conditions, and Inc Netlibrary. 1999. Definition of Serious and Complex Medical Conditions. Washington, DC: National Academy Press. https://www.ncbi.nlm.nih.gov/books/NBK224968/ .

75.

Ibid, pg. 19.

76.

Section 407 of the Social Security Act.

77.

Sections 6(d)(1) and 6(o) of the Food and Nutrition Act of 2008.

78.

Falk G. (2026). “Temporary Assistance for Needy Families (TANF) Block Grant: A Primer.” U.S. Library of Congress. Congressional Research Service, R48413. https://www.congress.gov/crs-product/R48413 .

79.

Macartney S and Ghertner R. (2023). “How Many People that Receive One Safety Net Benefit Also Receive Others?.” Office of Human Services Policy, Assistant Secretary for Planning and Evaluation. https://aspe.hhs.gov/sites/default/files/documents/340f9d2586febc3cdc1510f793403d0c/program-overlap-datapoint.pdf .

80.

CMCS SHO letter #16-007, “To Facilitate Successful Re-entry for Individuals Transitioning from Incarceration to their Communities.” (April 28, 2016)., Available at: https://www.medicaid.gov/federal-policy-guidance/downloads/sho16007.pdf .

81.

Including, but not limited to, section 1001 of the SUPPORT Act ( Pub. L. 115-271 ), Section 5121 of the Consolidated Appropriations Act, 2023 ( Pub. L. 117-328 ), and Section 205 of the Consolidated Appropriations Act, 2024 ( Pub. L. 118-24 ). These legislative changes established, and then further amended section 1902(a)(84) of the Act.

82.

CMCS Informational Bulletin, “Prohibition on Termination of Enrollment Due to Incarceration (Division G, Title I, Section 205, of the Consolidated Appropriations Act, 2024).” (December 23, 2025). Available at https://www.medicaid.gov/federal-policy-guidance/downloads/cib122325.pdf .

83.

The Office of the Assistant Secretary for Planning and Evaluation found that, in 2018, 8.2% of enrollees with Medicaid/CHIP financed births were enrolled in the adult group. Gordon SH, Whitman A, Buchmueller T, et al., “Medicaid Eligibility Category Among Enrollees with Medicaid-Paid Births in 2018,” Health Services Research 61(1) (2026): e70053, https://doi.org/10.1111/1475-6773.70053 .

84.

For more information, see CMCS SHO Letter #21-007, “Improving Maternal Health and Extending Postpartum Coverage in Medicaid and the Children's Health Insurance Program (CHIP).” (December 7, 2021). Available at https://www.medicaid.gov/federal-policy-guidance/downloads/sho21007.pdf .

85.

Section 1917(b)(3)(A) of the Act reads: “The State shall establish procedures (in accordance with standards specified by the Secretary) under which the agency shall waive the application of this subsection . . . if such application would work an undue hardship as determined on the basis of criteria established by the Secretary.” Section 1917(c)(2) of the Act reads: “An individual shall not be ineligible for medical assistance by reason of [the asset transfer rules] to the extent that—(D) the State determines, under procedures established by the State (in accordance with standards specified by the Secretary) that the denial of eligibility would work an undue hardship as determined on the basis of criteria established by the Secretary.” Section 1917(d)(5) of the Act reads: “The State shall establish procedures (in accordance with standards specified by the Secretary) under which the agency waives the application of this subsection for an individual if the individual establishes that such application would work an undue hardship on the individual as determined on the basis of criteria established by the Secretary.”

86.

The CMS State Medicaid Manual is available at https://www.cms.gov/regulations-and-guidance/guidance/manuals/paper-based-manuals-items/cms021927 .

87.

We note the very slight difference in the prefatory language to the notice requirements described in Section 3258.10(C)(5) (relating to asset-transfers) and Section 3259.8, in that Section 3258.10(C)(5) instructs that a State's undue hardship procedure must “provide for and discuss the following administrative requirements.” (Emphasis added.) The notice requirement elements described above, however, are identical, and CMS does not consider the distinction in the prefatory language in these two provisions to be meaningful.

88.

After CMS established its policy for the undue hardship-related notice, request process, and appeal requirements for asset-transfers, the Deficit Reduction Act of 2005, Public Law 109-171 , at section 6011(d)(2), incorporated them into Federal law. See 42 U.S.C. 1396p note .

89.

See for example, Carpenter AC, Stepanczuk, C, Murray, et al. (2025). “Trends in Users and Expenditures for Home and Community-Based Services as a Share of Total Medicaid Long-Term Services and Supports Users and Expenditures, 2023.” https://www.medicaid.gov/medicaid/long-term-services-supports/downloads/ltss-rebalancing-brief-2023.pdf .

90.

“The Centers for Medicare & Medicaid Services (CMS) is committed to supporting States with strengthening and enhancing their LTSS systems and helping to ensure that Medicaid beneficiaries receive high quality, cost-effective, person-centered services in the setting of their choice.” CMS. (2020). “Long Term Services and Supports Rebalancing Toolkit,” pg. 3. https://www.medicaid.gov/medicaid/long-term-services-supports/downloads/ltss-rebalancing-toolkit.pdf .

91.

“Declaring a National Emergency at the Southern Border of the United States,” Proclamation 10886, January 20, 2025, 90 FR 8327 (January 29, 2025). https://www.whitehouse.gov/presidential-actions/2025/01/declaring-a-national-emergency-at-the-southern-border-of-the-united-states ; “Imposing Duties to Address the Flow of Illicit Drugs Across Our Northern Border,” Executive Order 14193 , February 1, 2025, 90 FR 9113 (February 7, 2025). https://www.whitehouse.gov/presidential-actions/2025/02/imposing-duties-to-address-the-flow-of-illicit-drugs-across-our-national-border .

92.

“Bolstering Efforts to Bring Hostages and Wrongfully Detained Unites States Nationals Home,” Executive Order 14078 , July 19, 2022, 87 FR 43389 (July 21, 2022). https://www.federalregister.gov/documents/2022/07/21/2022-15743/bolstering-efforts-to-bring-hostages-and-wrongfully-detained-united-states-nationals-home .

93.

Ibid.

94.

Horn DP, Lee E, Webster E. (2023). “Closing the Incident Period for the Stafford Act Declaration for the COVID-19 Pandemic,” Congressional Research Service, pg. 1. https://www.congress.gov/crs-product/IN12106 .

96.

See generally, “About the U.S. Bureau of Labor Statistics,” U.S. Bureau of Labor Statistics, last modified February 28, 2025, https://www.bls.gov/bls/about-bls.htm .

97.

“Local Area Unemployment Statistics,” U.S. Bureau of Labor Statistics, https://www.bls.gov/lau/ .

98.

See, for example, https://www.merriam-webster.com/dictionary/dependent .

99.

Section 3258.11, 3259.8(A) of the State Medicaid Manual.

100.

CMCS State Medicaid Director letter #23-005, “Assurance of Transportation: A Medicaid Transportation Coverage Guide.” (September 28, 2023), pg. 30. Available at https://www.medicaid.gov/federal-policy-guidance/downloads/smd23006.pdf .

101.

AARP and National Alliance for Caregiving. (2025). “Caregiving in the U.S.” https://www.aarp.org/content/dam/aarp/ppi/topics/ltss/ family-caregiving/caregiving-in-us-2025.doi.10.26419-2fppi.00373.001.pdf.

102.

“Caregivers Communications and Marketing Toolkit,” Support Caregiving, https://supportcaregiving.org/caregivers-communications-and-marketing-toolkit/ .

103.

“2019 Caregiving Module,” Centers for Disease Control and Prevention. https://www.cdc.gov/healthy-aging-data/media/pdfs/2024/07/2019-caregiver-module-5081.pdf .

104.

For more information about the 42 CFR part 2 requirements regarding confidentiality of SUD patient records, see: “Understanding Confidentiality of Substance Use Disorder (SUD) Patient Records or “Part 2”,” OCR, last updated February 13, 2026, https://www.hhs.gov/hipaa/part-2/index.html .

105.

CMCS Informational Bulletin, “Medicaid and Children's Health Insurance Program (CHIP) Renewal Requirements,” (December 4, 2020), pg. 5, available at https://www.medicaid.gov/federal-policy-guidance/downloads/cib120420.pdf .

106.

CMCS Informational Bulletin, “Medicaid and Children's Health Insurance Program (CHIP) Renewal Requirements,” (December 4, 2020), pg. 7, available at https://www.medicaid.gov/federal-policy-guidance/downloads/cib120420.pdf .

107.

CMCS, State Medicaid Director Letter 26-001, Implementation of “Eligibility Redeterminations,” Section 71107 of the “Working Families Tax Cut” Legislation ( Pub. L. 119-21 ), March 6, 2026, available at https://www.medicaid.gov/federal-policy-guidance/downloads/smd26001.pdf .

108.

Under 45 CFR 95.605 , enhancements are defined as “modifications which change the functions of software and hardware beyond their original purposes, not just to correct errors or deficiencies which may have been present in the software or hardware, or to improve the operational performance of the software or hardware.”

109.

CMCS Informational Bulletin, “Medicaid Enterprise Systems Compliance and Reapproval Process for State Systems with Operational Costs Claimed at the 75 Percent Federal Match Rate,” (May 24, 2023), available at https://www.medicaid.gov/federal-policy-guidance/downloads/cib052423.pdf .

110.

Ibid.

111.

Ibid.

113.

Ibid.

114.

As used in this document, “managed care plan” means a managed care organization (MCO), prepaid inpatient health plan (PIHP), or prepaid ambulatory health plan (PAHP), as defined in § 438.2.

115.

“Medicaid Managed Care Enrollment and Program Characteristics, 2024.” CMS https://www.medicaid.gov/medicaid/managed-care/downloads/2024-medicaid-managed-care-enrollment-report.pdf .

116. 42 CFR 438.8(e)(2)(i)(A) .

117. 42 CFR 438.812 .

118.

Section 1903(m)(9)(D) of the Act.

119.

States may allow hospitals to determine presumptive eligibility for other groups, such as those whose eligibility is established by section 1115 demonstration authority. If the population in the section 1115 demonstration includes applicable individuals and the State elects to cover PE/HPE for this demonstration population in the State plan; the State must follow the same guidance as laid out in this section as it relates to the adult expansion population and PE/HPE.

120.

White House Council of Economic Advisers. (March 2019) Economic Report of the President, 2019, p. 423. https://www.govinfo.gov/content/pkg/ERP-2019/pdf/ERP-2019.pdf . See also https://www.nber.org/papers/w18088 , as discussed in more detail near Table 46 in this regulatory preamble.

121.

State Medicaid and CHIP Eligibility Processing Data, updated April 24, 2026. State Medicaid and CHIP Eligibility Processing Data.

122.

January 2026: Medicaid and CHIP Eligibility Operations and Enrollment Snapshot, slide 13. https://www.medicaid.gov/resources-for-states/downloads/eligib-oper-and-enrol-snap-jan2026.pdf .

123.

FEMA, Disaster Declarations Summaries—v2: https://www.fema.gov/openfema-data-page/disaster-declarations-summaries-v2 .

124.

Brennan Center for Justice, Declared National Emergencies Under the National Emergencies Act: https://www.brennancenter.org/our-work/research-reports/declared-national-emergencies-under-national-emergencies-act .

125.

US Bureau of Labor Statistics LAUS 2024 Annual Averages. Released April 18, 2025. Accessed February 2026. https://www.bls.gov/lau/laucnty24.xlsx .

126.

US Bureau of Labor Statistics Regional & State Unemployment 2024 Annual Averages (USDL-25-0294): Accessed February 2026. https://www.bls.gov/news.release/srgune.nr0.htm .

127.

Acute Care Services Provided to the Medicaid and CHIP Population, January 5, 2024. Acute Care Services Provided to the Medicaid and CHIP Population.

128.

Agency for Healthcare Research and Quality (AHRQ), Healthcare Cost and Utilization Project (HCUP) Fast Stats, National Hospital Utilization & Costs, 2023. HCUP Fast Stats Data Tools—Healthcare Cost and Utilization Project (HCUP) Fast Stats.

130.

See “Leavers, excluding death and moving to Medicaid/CHIP in another state: Count” column in chart on page 7. “Medicaid & CHIP Leavers and Coverage Transitions: By Eligibility Category and Home & Community-Based Services (HCBS) 1915(c) Waiver Enrollment, March 31, 2023-December 31, 2023.” CMS. November 2024. https://www.medicaid.gov/resources-for-states/downloads/eligibility-group-leavers-transitions-novmbr-2024-release.pdf .

134.

The White House Council of Economic Advisers. (June 2025). “Medicaid Community Engagement Requirements and the Value of Work.” https://www.whitehouse.gov/wp-content/uploads/2025/03/Medicaid-Community-Engagement-Requirements-and-the-Value-of-Work.pdf . As noted later in the RIA, the 49.6 fits into the quantitative framework as support for estimates of the number adults moved to employment as a result of the IFC.

135.

Zafar, Q., M.A. Khan, A.Z. Warsi, and L. Iqbal. (2024). “Economic Strain and Recovery Trajectories in Mental Health: The Role of Financial Stability in Mental Health Outcomes.” Review of Applied Management and Social Sciences, 7(4): 345-358. https://doi.org/10.47067/ramss.v7i4.385 .

136.

R. Gerdes, T.D. Jackson, R. Roberts, et al. (2026). “Associations Between Employment and Health Outcomes: A Systematic Review of Reviews.” Journal of Occupational Rehabilitation. https://doi.org/10.1007/s10926-025-10357-5 .

137.

Han, W.J. (2024). “How longitudinal employment patterns shape health as individuals approach middle adulthood—US NLSY79 cohort.” PLOS ONE, 19(4), e0300245. https://doi.org/10.1371/journal.pone.0300245 .

138.

Virtanen M, Kivimäki M, Joensuu M, Virtanen P, Elovainio M, Vahtera J. Temporary employment and health: a review. Int J Epidemiol. 2005 Jun;34(3):610-22. doi: 10.1093/ije/dyi024. Epub 2005 Feb 28. PMID: 15737968.

139.

Kim TJ von dem Knesebeck O. Perceived job insecurity, unemployment and depressive symptoms: a systematic review and meta-analysis of prospective observational studies. Int Arch Occup Environ Health. 2016 May; 89(4):561-73. doi: 10.1007/s00420-015-1107-1. Epub 2015 Dec 29. PMID: 26715495.

140.

Gerdes R. Jackson T.D. Roberts R. Lytvyak E. Deibert D, Dennett L, Burton AK, Gross DP, Els C, Doroshenko A, Hagtvedt R, Straube S. Associations Between Employment and Health Outcomes: A Systematic Review of Reviews. J Occup Rehabil. 2026 Jan 6. doi: 10.1007/s10926-025-10357-5. Epub ahead of print. PMID: 41493509.

141.

Baxter JR, Robinson LA, and Hammitt JK. (June 2017). “Valuing Time in U.S. Department of Health and Human Services Regulatory Impact Analyses: Conceptual Framework and Best Practices.” Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation (ASPE). https://aspe.hhs.gov/sites/default/files/migrated_legacy_files//176806/VOT.pdf .

142.

“Quartiles and selected deciles of usual weekly earnings of full-time wage and salary workers by selected characteristics,” US Bureau of Labor Statistics, last modified April 16, 2026. https://www.bls.gov/news.release/wkyeng.t05.htm ..

143.

ASPE estimates that fringe benefits are 45.6 percent of wages. We assume that the $838 from BLS reflects half of the fringe benefits, so that the scaling factor is 0.5 * 0.456/(1+0.5 * 0.456) + 1 = 1.186.

144. 42 CFR part 433 Subpart C , https://www.ecfr.gov/current/title-42/part-433/subpart-C .

145.

White House Council of Economic Advisers. (March 2019) Economic Report of the President, 2019, p. 423. https://www.govinfo.gov/content/pkg/ERP-2019/pdf/ERP-2019.pdf . See also https://www.nber.org/papers/w18088 , as discussed in more detail near Table 46 in this regulatory preamble.

146.

Hall RE. (1997) “Macroeconomic Fluctuations and the Allocation of Time,” Journal of Labor Economics 15, no. 1, Part 2: S223-S250. https://doi.org/10.1086/209862 .

147.

Hall RE. (2009). “Reconciling Cyclical Movements in the Marginal Value of Time and the Marginal Product of Labor,” Journal of Political Economy 117, no. 2: 281-323. https://doi.org/10.1086/599022 .

148.

Induced changes in wages and employer profits are sometimes known as “pecuniary externalities,” which are transfers rather than an externality in the usual sense.

149.

Tolbert J., Cervantes S., Rudowitz R., Burns A. (2025). “Understanding the Intersection of Medicaid and Work: An Update,” KFF. https://www.kff.org/medicaid/issue-brief/understanding-the-intersection-of-medicaid-and-work-an-update/ .

150.

“January 2026: Medicaid and CHIP Eligibility Operations and Enrollment Snapshot.” (April 24, 2025). https://www.medicaid.gov/resources-for-states/downloads/eligib-oper-and-enrol-snap-jan2026.pdf .

151.

“November 2025: Medicaid and CHIP Eligibility Operations and Enrollment Snapshot.” (February 27, 2026). https://www.medicaid.gov/resources-for-states/downloads/eligib-oper-and-enrol-snap-nov2025.pdf .

152.

Regarding possible effects of Medicaid participation on work, see Garthwaite C., Gross T., and Notowidigdo M.J. “Public Health Insurance, Labor Supply, and Employment Lock,” Quarterly Journal of Economics 129, no. 2 (2014): 653-696. https://doi.org/10.1093/qje/qju005 .

153.

Card D. and Hyslop D.R. (2005). “Estimating the Effects of a Time-Limited Earnings Subsidy for Welfare-Leavers.” Econometrica 73, no. 6: 1723-1770. https://doi.org/10.1111/j.1468-0262.2005.00637.x .\ .

154.

Sommers B.D. (2009). “Loss of Health Insurance Among Non-Elderly Adults in Medicaid.” Journal of General Internal Medicine 24, no.1: 1-7. https://doi.org/10.1007/s11606-008-0792-9 estimates a 43 percent annual exit rate.

155.

A 29 percent reentry rate is required for the steady-state number of ex-beneficiaries to outnumber current beneficiaries by a factor of 1.5-to-1. Other studies have demonstrated that interventions designed to increase employment and earnings among populations eligible for or receiving welfare benefits can persist over time. For example, a large-scale randomized control study of the Subsidized and Transitional Employment Demonstration, launched by HHS in 2010, found that earnings improved more than three years after enrollment, with earnings increases for three of the seven interventions maintained for six years after enrollment. HHS's Health Profession Opportunity Grants Program (HPOG)—the original 1.0 study launched in 2010, and the 2.0 study launched in 2015—found persistent increases in employment in the health care profession, though the interventions did not identify earnings increases. In particular, HPOG 1.0 found employment gains in health care by 5 percentage points six years after enrollment. The Pathways for Advancing Careers and Education project studied a number of interventions and found that one resulted in large earnings (around $1,900) gains after six years.

156.

Harberger, A.C. 1971. “Three Basic Postulates for Applied Welfare Economics: An Interpretive Essay.” Journal of Economic Literature, 9 (3), 785-797.

157.

Mulligan C.B. (2012). “Do Welfare Policies Matter for Labor Market Aggregates? Quantifying Safety Net Work Incentives since 2007,” National Bureau of Economic Research. https://www.nber.org/papers/w18088 . Data available at https://data.nber.org/data-appendix/w18088/StatutoryIndices.nber.xlsx .

158.

The MTR column adds to less than 48.0 percent because the 48.0 includes private sector markups and Medicaid.

159.

While § 435.912 is subject to the section 71102 moratorium, the requirements for states to make eligibility determinations promptly and without undue delay and to process applications within 45 or 90 days was not amended by the 2024 Eligibility and Enrollment final rule.

160.

See Accounting Methods under E.O. 14192 . https://www.reginfo.gov/public/pdf/eo14192/Accounting_Methods_under_EO_14192.pdf .

BILLING CODE 4120-01-P

BILLING CODE 4120-01-C

[ FR Doc. 2026-11094 Filed 6-1-26; 4:45 pm]