§435.558. Noncompliance procedures. — 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

(b) The agency may elect to implement §§ 435.550 through 435.563 before January 1, 2027, under the State plan or a demonstration project under section 1115 of the Act.

(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.

(3) When the agency is unable to meet the standards for applicants who are provided a notice of noncompliance to demonstrate community engagement due to the 30-calendar day period that States must provide for the individual to respond to such notice at § 435.558.

(c) If the agency elects the option described in paragraph (a) of this section, it must provide, including as part of the noncompliance procedures at § 435.558(c)(1):

(1) Notice, as described under § 435.561(b)(3)(ii), informing applicable individuals that the State offers a short-term hardship exception from the community engagement requirement, and, for the circumstances in paragraphs (d)(2) and (3) of this section, the anticipated end date of the exception;

(2) For the circumstances in paragraphs (d)(1) and (4) of this section, the State must also provide:

(i) Notice of the method by which an applicable individual or an individual acting on behalf of the applicable individual may request a short-term hardship exception;

(ii) Notice of the timeframe for requesting a short-term hardship exception;

(iii) A timely process for determining whether a request for a short-term hardship exception will be granted;

(iv) Notice to the applicable individual of the State's determination, which shall include the anticipated end date of the exception (if granted); and

(v) A process under which the applicable individual or an individual acting on behalf of the applicable individual can appeal an adverse determination.