Dear Secretary Kennedy and Administrator Oz,
My name is Madelaine Matej MacQueen, and I am the Budget Researcher at Policy Matters Ohio. I appreciate the opportunity to comment on the Centers for Medicare & Medicaid Services interim final rule (IFR), “Medicaid Program; Community Engagement Requirement for Certain Individuals” (CMS-2454-IFC).
Policy Matters Ohio is a nonprofit research institute with the mission of creating a more vibrant, equitable, inclusive and sustainable Ohio. One of my areas of expertise is Medicaid. I am familiar with the changes H.R. 1 made to community engagement requirements, also called work reporting requirements, and the ways in which those changes will affect Ohio.
Because Medicaid coverage improves health outcomes for Ohioans, allows them to receive preventive and acute healthcare in a timely manner,[1] and saves money,[2] Policy Matters Ohio supports policy that reduces (rather than increases) obstacles to Medicaid eligibility and access. CMS’s IFR on the community engagement requirement goes far beyond what H.R. 1 requires, thereby excluding more individuals from care.
Importantly, the IFR also marks a sudden change from months of technical assistance that CMS has provided to states, creating massive administrative burdens for states to rework existing plans and systems that have been designed to follow CMS’s technical assistance and preliminary guidance. We urge CMS to revise its IFR, bringing it in line with H.R. 1 and prior technical assistance.
Specifically, we recommend two major changes to the IFR:
- Scale back the “medical frailty” definition to what H.R. 1 mandated, namely that the criteria for medical frailty do not include a person’s ability to comply with community engagement requirements.
- Simplify required documentation for all Medicaid expansion enrollees and applicants by allowing self-attestation or auditable self-declaration documentation for all conditions that states cannot verify ex parte, as states have been planning in compliance with CMS guidance.
Medicaid Expansion in Ohio
Ohio’s Medicaid program helps 774,342 residents of our state who are enrolled via Medicaid expansion[3] lead healthier lives. Community engagement requirements that result in Medicaid disenrollments mean that fewer Ohioans will have access to the healthcare they need. Estimates range from 70,000[4] to 356,000[5] Ohioans losing coverage by the end of 2028, due to just H.R. 1’s community engagement and six-month redetermination requirements.
Implementing community engagement requirements is also expensive, predicted to cost up to $30 million per state.[6]
Studies have shown that Medicaid coverage itself increases workforce participation.[7] Conversely, work requirements tend to cause loss of Medicaid coverage, and consequently a decrease in workforce participation.[8] Congressional Budget Office analysis shows that work requirements in Medicaid have “little effect” on employment rates and have reduced benefits more than they have increased people’s earnings. Work requirements may reduce federal spending by removing people from the Medicaid rolls, often eligible people through procedural disenrollments.[9] It is imperative for CMS to minimize the burden of documentation for both enrollees/applicants and for caseworkers, so that everyone who meets eligibility requirements can efficiently demonstrate their compliance and maintain their health insurance.
In February 2026, the Deputy Director of the Ohio Department of Medicaid (ODM) presented on characteristics of Ohio’s Medicaid expansion population (also known as Group VIII) in relation to work requirements.[10] Based on available data, of Ohio’s Group VIII enrollees as of July 2025, fully 42.5% were already working. When accounting forenrollees who met requirements through an exemption, at least 77.7% of Ohio’s Group VIII enrollees likely already met statutory requirements. Those flagged by ODM as likely to meet exemptions included:
- Less than 1% exempt due to age
- 18.4% exempt due to medical frailty
- 2.2% exempt as a parent of a child aged 13 or younger
- 1.9% exempt because of being pregnant, incarcerated, or a former foster care youth
- 3.0% exempt because of “other qualifying activity”
- 9.6% exempt because they could be moved to a different Medicaid category (other than Group VIII)[11]
With the majority of Ohio’s Group VIII enrollees likely already meeting statutory requirements, increased administrative barriers run a real risk of disenrolling qualified people for no other reason than difficulty navigating the red tape.
Specifics on the IFR
The following are provisions we ask CMS to revise and/or eliminate from the rule:
- Qualifying Activities: Definitions – 42 U.S.C. § 1396a(xx)(9)(B), (D): The definitions in the IFR are overly specific in some ways and overly vague in others. The requirement that “community service must be completed with a structured program under the auspices of public or nonprofit organizations”[12] excludes community service performed for organizations outside of those categories. Additionally, the administrative burden on these public or nonprofit organizations is too heavy. The IFR says that the organization, “Must provide oversight of the activity, which must not serve a partisan purpose, and have a process in place to track the community service completed by individuals, including the type of community service activity, dates and hours the community service is completed, and a point of contact who can confirm the hours completed.”[13] Similarly, the definition of “work program” is too narrow, because it includes only government-sponsored work programs and excludes all Medicaid-covered employment services and non-governmental work programs.[14]
- Mandatory Exceptions to Work Reporting Requirement: Medical Frailty – 42 U.S.C. § 1396a(9)(A)(ii): CMS’s expansion of the “medically frail” definition to mean “an individual whose physical, mental, or behavioral health condition significantly impairs the individual’s ability to comply with the community engagement requirement”[15] is an overreach and a significant departure from preliminary guidance and technical assistance CMS released between the passage of H.R. 1 and the publication of the IFR. H.R. 1 did not require proof that a medical condition impair an individual’s ability to comply. The IFR’s definition requires states to rework systems already well under development in alignment with prior CMS guidance, so that they can now verify both the existence of a medical condition and whether it impairs the individual’s ability to comply with the community engagement requirement. In Ohio and beyond, health care access leaders are concerned that CMS has not specified how to demonstrate inability to work. This is because proving an individual’s inability to comply may be difficult, if not impossible. Assessing an individual’s ability to comply with government requirements is likely outside the scope of practice for many medical professionals. The expanded definition also fails to include people with chronic or intermittent conditions, who may be able to work some of the time but not all of the time. People with limited access to healthcare — including many Ohioans living in rural areas, people without homes, or people with communication disorders or limited mobility — will face additional challenges securing documentation. Congress promised with the passage of H.R. 1 that the law (and its application) would protect Medicaid coverage for the most vulnerable people, including those with illness or disability. This rule reneges on that promise, instead dropping coverage for any sick or disabled person who cannot prove and document their inability to work.
- Household Composition: The above contraction of the “medically frail” definition also creates apparent contradictions for households whose residents hold different statuses. The IFR says, “…if a person is able to demonstrate community engagement by performing 80 hours per month of qualifying community engagement activities, notwithstanding their physical, mental, or other behavioral health condition, they would not qualify as medically frail and would not be a specified excluded individual.”[16] If meeting the community engagement requirement excludes someone from being designated as medically frail, what happens in households that meet the community engagement requirement and also contain members who otherwise would meet the definition of medical frailty?
- Recertification: The IFR additionally requires people who meet the medical frailty definition to re-certify their medical frailty at least every 12 months.[17] This is an unreasonable burden for people with health issues and a costly administrative inefficiency for caseworkers. CMS must allow for a permanent certification of medical frailty for people with permanent medical conditions.
- Optional Exception for Short-Term Hardship Events – 42 U.S.C. § 1396a(XX)(3)(B): Regarding the optional exception for an individual who must travel outside of their community to receive medical services,[18] the IFR does not define “outside of their community.” Is a community a city, a metropolitan statistical area, a county, a zip code, a census tract, or something else? How far outside of a community counts as far enough?
- Verifications & Self-Attestation (in All Cases Except Medical Frailty): The IFR puts burdensome restrictions on self-attestation. Self-attestation, also called auditable self-declaration documentation, is an important tool for collecting information that has not been documented in any system available to the state. Importantly, it also facilitates better access for populations who may not have had access to consistent medical care or who do not have personal records. Specifically, the requirement for documentation beginning on January 1, 2028 needs to include self-attestation among the allowable forms of documentation.
- Medical Frailty Verifications & Self-Attestation: The IRF places another undue limitation on medically frail individuals by only allowing a single use of self-attestation after January 1, 2028, and then requiring subsequent documentation.[19] There are many reasons that someone with medical frailty might not be able to provide third-party documentation of their medical condition or inability to work. CMS must allow self-attestation for verifying medical frailty.
- Short-Term Hardship Verifications: The IFR is unclear on whether self-attestations are allowed for short-term hardship verifications. Some hardships may be harder to document: for instance, a caregiver proving they had to take leave from employment to assist in care related to their dependent’s medical travel.
- Notice of Noncompliance – 42 U.S.C. § 1396a(xx)(6)(B): CMS has not set requirements for how notices should be written (for example, at what grade level or in what languages) and what obligations states have (i.e., a state call center etc.) for providing people with assistance if they have questions about notices related to eligibility.[20]
- Procedure for Noncompliance: Denial or Disenrollment – 42 U.S.C. § 1396a(xx)(6)(A)(iii): The law specifies that states may not deny enrollment or disenroll a “specified excluded individual,” even if they do not make a “satisfactory showing” of compliance. Some individuals (as outlined above) may meet the medically frail definition but lack documentation to make a “satisfactory showing.
,” Under statute, these individuals should be allowed to obtain and maintain Medicaid coverage. How can a state fairly and efficiently operationalize this requirement in such cases?[21] - Role of Managed Care Plans: Prohibiting Conflicts of Interest – H.R. 1 § 71119(c): States need further guidance on what managed care “support activities” will be permissible in the context of work reporting requirements.[22]
In summary, by simplifying the requirements and allowing the broadest range of documentation types, CMS can reduce administrative burden for Medicaid enrollees and applicants and help states and counties process applications in an efficient, accurate and cost-effective manner. This will help ensure that that as many Medicaid-eligible people as possible are successfully enrolled in, and able to benefit from, the program.
Conclusion
Thank you again for the opportunity to comment on the interim final rule CMS-2449-P. If any additional information is needed, please be in contact.
[1] Kate Sopko, “Fallout from federal budget cuts will last years,” Policy Matters Ohio, November 13, 2025.
[2] America’s Essential Hospitals estimates that the provisions in H.R. 1 combined with the expiration of enhanced premium tax credits will increase hospital uncompensated care costs nationwide by $466 billion between 2025 and 2034. “Projected Increases In Hospital Uncompensated Care After Recent Legislation,” America’s Essential Hospitals, June 2026.
[3] Patrick Beatty, “Medicaid Work & Community Engagement Requirements,” Ohio Department of Medicaid, February 2026, page 7.
[4] Scott Partika, “H.R. 1 (OBBBA) Updates,” Ohio Department of Medicaid, February 19, 2026, page 12.
[5] This estimate accounts for work requirements and six-month redeterminations. Matthew Buettgens et al., “Projected Reductions in Medicaid Expansion Enrollment Under OBBBA’s Work Requirements and Six-Month Redeterminations National and State Estimates for 2028,” Urban Institute, March 2026.
[6] Kiersten Zinyengere, “Inside the Work Reporting Requirement Implementation Guidance: How CMS’s New Rule Decimates Health Care Access for Millions,” Families USA, June 11, 2026.
[7] Stacy Chen, Becky Staiger, “Medicaid expansion increased income among newly eligible adults,” Health Affairs Scholar, Volume 3, Issue 5, May 2025.
[8] Julia Bonavitacola, “Medicaid Work Requirements Set to Leave Millions Without Insurance,” American Journal of Managed Care, November 4, 2025.
[9] “Work Requirements and Work Supports for Recipients of Means-Tested Benefits,” Congressional Budget Office, June 2022.
[10] Patrick Beatty, “Medicaid Work & Community Engagement Requirements,” Ohio Department of Medicaid, February 2026.
[11] Ibid.
[12] Robert F. Kennedy, Jr., “Medicaid Program; Community Engagement Requirement for Certain Individuals,” Federal Register, June 3, 2026, corrected June 29, 2026.
[13] Ibid.
[14] Ibid.
[15] Ibid.
[16] Robert F. Kennedy, Jr., “Medicaid Program; Community Engagement Requirement for Certain Individuals,” Federal Register, June 3, 2026, corrected June 29, 2026.
[17] Amaya Diana, Jennifer Tolbert, and Robin Rudowitz, “The Medical Frailty Exemption from Medicaid Work Requirements: Key Takeaways from the CMS Interim Final Rule,” KFF, June 23, 2026.
[18] Robert F. Kennedy, Jr., “Medicaid Program; Community Engagement Requirement for Certain Individuals,” Federal Register, June 3, 2026, corrected June 29, 2026.
[19] Robert F. Kennedy, Jr., “Medicaid Program; Community Engagement Requirement for Certain Individuals,” Federal Register, June 3, 2026, corrected June 29, 2026.
[20] “Medicaid Work Reporting Requirements: Implementation Update after CMS’ Interim Final Rule,” Families USA, accessed July 14, 2026, page 23.
[21] Ibid, pages 23-24.
[22] Ibid, page 27.