CMS Issues Initial Guidance on Work Reporting Requirements, Leaves Key Questions Unanswered

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On December 8, the Centers for Medicare & Medicaid Services (CMS) issued a  (CIB) providing initial guidance to states as they implement Section 71119 of H.R. 1 (), which requires states to impose work and community engagement reporting requirements as a condition of eligibility for Medicaid expansion and expansion-like programs beginning January 1, 2027. Although the guidance generally tracks the requirements of H.R. 1 and incorporates several important clarifications, it remains high-level and stops short of addressing the many operational questions states must resolve as they implement these major changes to Medicaid.  

Several critical open questions include:  

• What verification standards apply when data cannot confirm compliance or exemption at renewal;  
• Whether lookback periods apply to medically frail and other “specified excluded individuals”;  
• Whether long-term medically frail exemptions will be allowed for individuals with stable or lifelong medical conditions;  
• How CMS will define community service and calculate part-time education; and  
• What types of challenges would meet CMS’s standard for granting good faith waivers?  

States and people with Medicaid coverage continue to face significant uncertainty as states work to implement these new requirements and redesign systems and processes under very compressed timelines. Notably, in November, CMS shared preliminary guidance on work requirements implementation with states during the National Association of Medicaid Directors (NAMD) conference that went beyond the information provided in the CIB. CMS is expected to issue additional guidance in the future.

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