Sec. 44141. Requirement for States to establish Medicaid community engagement requirements for certain individuals
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Section 1902 of the Social Security Act ( 42 U.S.C. 1396a ), as amended by sections 44103 and 44104, is further amended by adding at the end the following new subsection: Beginning January 1, 2029, subject to the succeeding provisions of this subsection, 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)— 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 (as specified by the State) consecutive months immediately preceding the month during which such individual applies for such medical assistance; and 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— 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 in the case of a State that has elected under paragraph
(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. Subject to paragraph
(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: The individual works not less than 80 hours. The individual completes not less than 80 hours of community service. The individual participates in a work program for not less than 80 hours. The individual is enrolled in an educational program at least half-time. The individual engages in any combination of the activities described in subparagraphs
(A)through (D), for a total of not less than 80 hours. 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. The State shall deem an applicable individual to have demonstrated community engagement under paragraph
(2)for a month if— for part or all of such month, the individual— was a specified excluded individual (as defined in paragraph (9)(A)(ii) ); or was— under the age of 19; pregnant or entitled to postpartum medical assistance under paragraph
(5)or
(16)of subsection (e); entitled to, or enrolled for, benefits under part A of title XVIII, or enrolled for benefits under part B of title XVIII; or described in any of subclauses
(I)through
(VII)of subsection (a)(10)(A)(i); or 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. 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, upon the request of such individual under procedures established by the State (in accordance with standards specified by the Secretary), deem such individual to have demonstrated community engagement under paragraph
(2)for such month. 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— 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 as the Secretary determines appropriate; such individual resides in a county (or equivalent unit of local government)— 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 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— 8 percent; or 1.5 times the national unemployment rate; or such individual experiences any other short-term hardship (as defined by the Secretary). 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. For purposes of verifying that an applicable individual has met the requirement to demonstrate community engagement under paragraph
(1), 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) without requiring, where possible, the applicable individual to submit additional information. 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)— provide such individual with the notice of noncompliance described in subparagraph
(B); 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— make a satisfactory showing to the State of compliance with such requirement (including, if applicable, by showing that such individual was deemed to have demonstrated community engagement under paragraph
(3)); or 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 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 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— 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 the individual is provided written notice and granted an opportunity for a fair hearing in accordance with subsection (a)(3). 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— 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 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). 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). 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 the requirement to demonstrate community engagement under paragraph
(1). In accordance with standards specified by the Secretary, beginning not later than October 1, 2028 (or, if earlier, the date that precedes January 1, 2029, 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— 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); the consequences of noncompliance with such requirement; and how to report to the State any change in the individual’s status that could result in— the applicability of an exception under paragraph
(3)(or the end of the applicability of such an exception); or the individual qualifying as a specified excluded individual under paragraph (9)(A)(ii) . A notice required under subparagraph
(A)shall be delivered— by regular mail (or, if elected by the individual, in an electronic format); and 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. In this subsection: The term applicable individual means an individual (other than a specified excluded individual (as defined in clause
(ii)))— 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 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 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 under part B of title XVIII, and is not otherwise eligible to enroll under such plan. 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)— who is described in subsection (a)(10)(A)(i)(IX); who— 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); is a California Indian described in section 809(a) of such Act; or has otherwise been determined eligible as an Indian for the Indian Health Service under regulations promulgated by the Secretary; who is the parent, guardian, or caretaker relative of a disabled individual or a dependent child; who is a veteran with a disability rated as total under section 1155 of title 38, United States Code; who is medically frail or otherwise has special medical needs (as defined by the Secretary), including an individual— who is blind or disabled (as defined in section 1614); with a substance use disorder; with a disabling mental disorder; with a physical, intellectual or developmental disability that significantly impairs their ability to perform 1 or more activities of daily living; with a serious and complex medical condition; or subject to the approval of the Secretary, with any other medical condition identified by the State that is not otherwise identified under this clause; who— is in compliance with any requirements imposed by the State pursuant to section 407; or 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; 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); who is an inmate of a public institution; or who meets such other criteria as the Secretary determines appropriate. The term educational program means— an institution of higher education (as defined in section 101 of the Higher Education Act of 1965); a program of career and technical education (as defined in section 3 of the Carl D. Perkins Career and Technical Education Act of 2006); or any other educational program that meets such criteria as the Secretary determines appropriate. The term State means 1 of the 50 States or the District of Columbia. The term work program has the meaning given such term in section 6(o)(1) of the Food and Nutrition Act of 2008. Notwithstanding section 1115(a), the provisions of this subsection may not be waived. . 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). Not later than July 1, 2027, the Secretary of Health and Human Services shall promulgate regulations for purposes of carrying out the amendments made by this section. The Secretary of Health and Human Services shall, out of amounts appropriated under paragraph (3), award to each State a grant equal to the amount specified in paragraph
(2)for such State for purposes of establishing systems necessary to carry out the provisions of, and amendments made by, this section. For purposes of paragraph (2), the amount specified in this paragraph is an amount that bears the same ratio to the amount appropriated under paragraph
(3)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. There are appropriated, out of any monies in the Treasury not otherwise appropriated, $100,000,000 for fiscal year 2026 for purposes of awarding grants under paragraph (1). In this subsection, the term State means 1 of the 50 States and the District of Columbia. 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 Secretary of Health and Human Services, $50,000,000 for fiscal year 2026, to remain available until expended.
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Sec. 44141
Requirement for States to establish Medicaid community engagement requirements for certain individuals
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