§435.556. Assessing compliance with the community engagement requirement. — 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) 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.

(2) The agency must determine the monthly income based on the individual's MAGI-based income, for their MAGI-based household, as defined at § 435.603, and applied to a month in the period under § 435.556(a), as applicable for demonstrating community engagement.

(A) Which month(s) will be assessed by the State in accordance with § 435.556(a);

(1) Three months plus the number of months specified by the State under § 435.556(a)(1)—

(i) Prior to January 1, 2027, or, if applicable, prior to the State's earlier implementation date as elected by the state under § 435.559(b); or

(ii) For States that later elect to implement the eligibility group described at § 435.119, or a section 1115 demonstration project described in paragraph (a)(2) of this section, prior to the effective date of such eligibility expansion;

(iii) The number of months an applicable individual is required to demonstrate community engagement at renewal under § 435.556(a)(2)(i); and

(d) States may verify that an applicable individual has met the requirement to demonstrate community engagement more frequently than each regularly scheduled redetermination, consistent with § 435.556(a)(2)(ii).

(1) States electing to verify that an applicable individual has met the requirement to demonstrate community engagement between regularly scheduled redeterminations must comply with the requirements of this subpart to verify, consistent with this section, that an applicable individual met the requirement to demonstrate community engagement in accordance with §§ 435.552 and 435.556 or was deemed to have demonstrated community engagement under § 435.553 or, if applicable, § 435.555.

(2) For beneficiaries who were determined to be applicable individuals at their last determination or redetermination of eligibility, the agency must check all reliable information available to the State to determine if the individual newly qualifies as a specified excluded individual prior to assessing compliance or deemed compliance with the community engagement requirement each time the state conducts a more frequent verification.

(3) If the individual continues to be an applicable individual, the agency must attempt to verify that the individual demonstrated community engagement in accordance with §§ 435.552 and 435.556, or was deemed to have demonstrated community engagement, under § 435.553 or, if applicable, § 435.555, using all reliable information available to the State for all relevant months, before requesting additional information and documentation from the individual consistent with this section and initiating the noncompliance procedures under § 435.558.

(4) The agency may not reverify the specified excluded status of an individual between regularly scheduled redeterminations if the individual was determined to be a specified excluded individual at their last determination or redetermination of eligibility or during a more frequent verification of community engagement under this section unless the agency has information indicating the individual's specified excluded individual status has changed.

(iv) How often the State will verify compliance with the community engagement requirement between renewals if the State elects to conduct more frequent verifications consistent with § 435.556(a)(2)(ii);