CMS issues guidelines on mandating work and community engagement under Medicaid and approves the first work requirement waiver

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On January 11, 2018, the Centers for Medicare and Medicaid Services (CMS) distributed a State Medicaid Director letter outlining new guidelines for states about mandating work and other community engagement activities for adult Medicaid beneficiaries who are not aged, disabled, or pregnant. CMS defines community engagement broadly, as encompassing activities such as job search, education, skills training, caregiving, volunteer service, and treatment for substance use disorders; and suggests that such activities may be linked to better health outcomes. 

CMS indicates that it could permit states, on a case-by-case basis under demonstration waivers pursuant to section 1115(a) of the Social Security Act, to test research hypotheses that requiring certain categories of adult Medicaid recipients to participate in specified work or community engagement activities could lead over time to improved health, well-being, and self-sufficiency. States could mandate beneficiary participation in such activities as a condition of Medicaid eligibility, a condition for coverage of services, a condition of receiving additional or enhanced benefits, or as a condition of reduced premiums or cost-sharing.  

CMS also addresses issues such as:

  • Aligning state Medicaid work and community engagement requirements with requirements under the Temporary Assistance for Needy Families (TANF) and Supplemental Nutrition Assistance Program (SNAP);
  • Availability of child care and transportation;
  • Exemptions for persons such as the medically frail and others with medical conditions;
  • Access to treatment for substance abuse disorders and opioid addiction;
  • Protections and supports – including reasonable accommodations - for persons who need additional help to meet Medicaid work and community engagement requirements;
  • Frequency and extent of enrollee participation in work and community engagement activities;
  • Enrollee reporting requirements on their participation in such activities;
  • Enrollee process rights;
  • Program monitoring and evaluation protocols; and
  • Information technology systems enhancements needed to support demonstration activities.


Almost immediately following the issuance of the guidance, CMS approved the first work requirement waiver in the nation. Kentucky
received approval of a broader waiver including a work requirement on January 12, 2018.

Kentucky will require most adult enrollees to fulfill a “community engagement” requirement as a condition of Medicaid eligibility. Former foster care youth, pregnant women, primary caregivers, medically frail individuals and those with acute medical conditions that prevent compliance, and full-time students will be exempt. Others will have to complete eligible activities for at least 80 hours per month and most would have to document their compliance monthly. Eligible activities include: employment, education, job skill training, job search, community service, volunteer, community service, caregiving, and participation in substance use disorder treatment. Those who fail to meet requirements would have eligibility suspended until requirements are met.

With similar waiver requests pending in nine other states and under consideration in others, and lawsuits expected, there is likely to be much discussion of work requirements to come.