The NCSL Blog


By Haley Nicholson

Last month the Centers for Medicare and Medicaid Services (CMS) issued a letter to state Medicaid directors announcing a new policy regarding work and community engagement requirements as an option for Medicaid eligibility. The Trump administration had prioritized these requirements early on, and CMS Administrator Seema Verma brings expertise on this issue from her previous work.

But What Exactly Is Included in the Guidance, and What Does It Mean for States?

patient's chart. Credit The Washington Post.This CMS guidance applies to 1115 section waivers. These waivers are used by states to propose different demonstration projects within their Medicaid program. CMS provided several examples that would fulfill engagement opportunities such as: volunteer work, job searching and caregiving. among others. They also outlined which populations would not fall under these requirements including: people with disabilities, the medically frail, the elderly, children, pregnant women and those suffering from substance use disorder (SUD). States are directed to identify these populations under federal law, and, if necessary, in consultation with a patient’s doctor. 

This Announcement Raises the Question: What Share of Responsibility Will States Have in Administering These New Requirements?

  • CMS is encouraging states to administer the requirements in a similar way to their SNAP and TANF programs, but it will not allow Medicaid to be streamlined into these programs.
  • States are left to determine what additional documentation a person must provide to prove they are part of a nonqualified population.
  • States are given the flexibility to determine how they will track those who leave the Medicaid system because of  not fulfilling these requirements, or because they have found full-time employment.
  • CMS has explicitly outlined that states must show the ways in which they will help individuals to meet work and community engagement requirements, but cannot do so with Medicaid funds.

Next Steps

Since the announcement of the policy, CMS has approved two waivers with work and community engagement requirements. A few days following the announcement they approved an 1115 waiver in Kentucky that included work requirements and premium sharing. Last week, Health and Human Services Secretary Alex Azar announced the approval of Indiana’s work and community engagement requirements that were added as part of the state’s Medicaid expansion model. Several states with similar proposals have pending applications including Arizona, Arkansas, Indiana, Kansas, Maine, New Hampshire, Utah and Wisconsin.

What it will take for states to make these programs successful, and what share of federal responsibility will be a part of implementing them remains a work in progress? Read more details of the policy.

Haley Nicholson is a policy director, health, in NCSL's State-Federal program based in Washington, D.C.

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This blog offers updates on the National Conference of State Legislatures' research and training, the latest on federalism and the state legislative institution, and posts about state legislators and legislative staff. The blog is edited by NCSL staff and written primarily by NCSL's experts on public policy and the state legislative institution.