§435.552. Demonstrating community engagement. — Inbound Citations

(d) As of the implementation date in accordance with § 435.559, the 50 States and the District of Columbia must provide that eligibility under this section is subject to the community engagement requirement described at §§ 435.550 through 435.563.

Sections 435.550 through 435.563 implement section 1902(xx) of the Act and apply to the 50 States and the District of Columbia. These sections do not apply to the territories.

A State must deem an applicable individual to have demonstrated community engagement under § 435.552 for a month if—

(a) At State option, the agency may provide that an applicable individual, as defined at § 435.551, is deemed to have demonstrated community engagement, as defined at § 435.552, for a month in which, for all or part of such month, the individual experiences any one of the short-term hardship events described in paragraph (d) of this section.

(a) A State must require applicable individuals, as defined at § 435.551, to demonstrate community engagement under § 435.552, or be deemed to demonstrate community engagement under § 435.553 or, if applicable, § 435.555, as a condition of eligibility for medical assistance. The State must require—

(1) For an applicable individual who files an application for medical assistance under a State plan, or a waiver of such plan, demonstration of community engagement for at least one, but not more than 3 consecutive months, as specified in the State plan, immediately preceding the month of application.

(2) For an applicable individual who is enrolled and receiving medical assistance under a State plan, or waiver of such plan, demonstration of community engagement for 1 or more months, as specified in the State plan and subject to paragraph (b) of this section, whether or not consecutive—

(i) During the period between the effective date of such individual's most recent determination or redetermination at renewal, as applicable, and the date the individual's renewal is due, consistent with section 1902(e)(14)(L) of the Act and § 435.916, as applicable, if the State has not opted to conduct more frequent verifications of community engagement compliance under § 435.557(d);

(ii) During the period between the most recent demonstration of community engagement and the date the individual's next demonstration of community engagement is due, consistent with § 435.557(d), if the State has opted to conduct more frequent verifications of community engagement compliance as provided in § 435.557(d); or

(iii) During the period between the effective date of such individual's most recent determination or redetermination at renewal, as applicable, and the end of the month prior to the month in which the individual becomes an applicable individual as a result of a redetermination based on a change in circumstances in accordance with § 435.916(d).

(a) For purposes of this section—

Period of enrollment means a continuous period of enrollment in coverage under the State plan or waiver without the individual being disenrolled, regardless of the number of consecutive eligibility periods, of redeterminations or renewals, or of transitions between eligibility groups.

Reliable information available to the State means, for purposes of verifying compliance, deemed compliance or exclusion from the community engagement requirement in accordance with §§ 435.550 through 435.563, information necessary for determining eligibility to which the agency has access or should have access including, but not limited to:

(i) Information from electronic data sources that the agency has determined to be effective consistent with paragraph (b)(1)(ii) of this section, as documented in the agency's verification plan in accordance with paragraph (b)(1)(iii) of this section;

(ii) Information from other State or local agencies;

(iii) Information related to community engagement from Federal agencies and other data sources provided through the electronic service established by the Secretary, in accordance with § 435.949;

(iv) Information in the State's eligibility system;

(v) Information in the individual's case record;

(vi) Payroll data;

(vii) Claim(s) relevant to the individual that have been adjudicated in the preceding 12 months, including those that have been paid, pended or denied; and

(a) If a State is unable to verify that an applicable individual has met the requirement to demonstrate community engagement under §§ 435.552 and 435.556, or is deemed compliant under § 435.553 or, if applicable, § 435.555, as specified in paragraph (b) of this section, the State must:

(1) Provide such individual with the notice of noncompliance described in paragraph (c) of this section;

(2) 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 consistent with paragraph (c)(4) of this section, to make a satisfactory showing to the agency—

(i) Of compliance with such requirement (including, as applicable, by showing that such individual demonstrated or should be deemed to have demonstrated community engagement under § 435.553 or, if applicable, § 435.555, for each month required under the State plan); or

(ii) That such requirement does not apply to such individual on the basis that such individual does not meet the definition of applicable individual under § 435.551, including by meeting the criteria for one or more of the categories of a specified excluded individual as defined at § 435.554.

(3) Continue to furnish Medicaid for an enrolled beneficiary until the individual is determined ineligible consistent with § 435.930(b).

(a) Unless granted an exemption under § 435.560, the agency must require applicable individuals, as defined at § 435.551, to comply with the requirement to demonstrate community engagement under §§ 435.552 and 435.556, or be deemed to have demonstrated community engagement under § 435.553 or, if applicable, § 435.555, as a condition of eligibility for medical assistance furnished on or after January 1, 2027.

(a) CMS temporarily may exempt a State from the requirement to implement §§ 435.550 through 435.559 and 435.561 through 435.563 in accordance with § 435.559 if—

(1) A State submits a request that includes information on all of the criteria specified in paragraph (b) of this section; and

(2) CMS determines that, based on the information submitted, the State is demonstrating a good faith effort to comply with the implementing the requirements of §§ 435.550 through 435.559 and 435.561 through 435.563.

(v) Upon request by CMS, if State-reported monitoring data under § 435.562 or other information indicate a need for increased outreach or a potential compliance issue with §§ 435.550 through 435.562, consistent with § 435.562(e)(2).

(c) For data about activities described in §§ 435.550 through 435.563 occurring on or after the State's implementation date under § 435.559, each State must submit to CMS the required data for the data elements described in paragraph (d) of this section to monitor enrollment, retention, and eligibility processes. Such data must be timely, complete, and of sufficient quality.

(5) The individual engages in any combination of the activities described in paragraphs (a)(1) through (4) of this section, for a total of not less than 80 hours; however, States are not permitted to combine educational program hours with another activity if the individual is enrolled in an educational program at least half-time.

(5) The individual engages in any combination of the activities described in paragraphs (a)(1) through (4) of this section, for a total of not less than 80 hours; however, States are not permitted to combine educational program hours with another activity if the individual is enrolled in an educational program at least half-time.

(5) The individual engages in any combination of the activities described in paragraphs (a)(1) through (4) of this section, for a total of not less than 80 hours; however, States are not permitted to combine educational program hours with another activity if the individual is enrolled in an educational program at least half-time.

(5) The individual engages in any combination of the activities described in paragraphs (a)(1) through (4) of this section, for a total of not less than 80 hours; however, States are not permitted to combine educational program hours with another activity if the individual is enrolled in an educational program at least half-time.