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Table of Contents

Background

In July 2025, Congress passed the budget reconciliation act (H.R. 1), cutting federal Medicaid spending and establishing community engagement requirements (also known as work requirements) for adults ages 19-64 applying for or enrolled through Medicaid expansion or minimum essential coverage under certain Section 1115 demonstration waivers.

Section 71119 of the law mandates states to verify work, education, training, or volunteer participation for these Medicaid enrollees while defining required exemptions and optional short‑term hardship exceptions. The statute also categorically excludes people age 65 and older, people eligible for Medicare, people eligible based on SSI, or through other mandatory pathways. These requirements are codified at 42 U.S.C. 1396a(xx) and must be implemented by January 1, 2027.

Congress also required the Centers for Medicare and Medicaid Services (CMS) to issue an Interim Final Rule (IFR) providing additional guidance to define terms and help states operationalize work requirements. The IFR was issued in June 2026 and takes effect July 31, 2026.

Work requirements create administrative barriers that lead to improper terminations and disrupt access to health care. Older adults, people with disabilities and chronic health conditions, and family caregivers face heightened risk of losing Medicaid coverage because these administrative hurdles, reporting requirements, and narrow exemption processes can improperly terminate people who have fluctuating health, caregiving duties, or limited access to technology and transportation. Documentation requirements and policies based on ability to work or that overly rely on employment verification are especially likely to penalize older adults and others with intermittent work histories, chronic conditions, and/or caregiving responsibilities.

Although required statutory exemptions for people who are “medically frail” (42 U.S.C. 1396a(xx)(9)(ii)(V)) and family caregivers (1396a(xx)(9)(ii)(III)) are intended to protect these populations, the IFR makes clear that such exemptions will fail to reach the people they were meant to protect due to complex paperwork, narrow interpretations, and reliance on automated data checks that fail to fully capture eligible individuals.

Additional Restrictions in the Interim Final Rule

The IFR provides further direction on how states must define and verify eligibility for exemptions, including medically frail and family caregivers. For the “medically frail or special medical needs” exemption, the IFR includes the categories listed in H.R. 1 but adds the requirement that individuals must also be unable to meet the community engagement requirements, significantly limiting the statutory exemption. In other words, a person must show that their disability or health condition prevents them from working.

Although states must rely first on ex parte data like Medicaid claims data or other electronic data sources to verify medical frailty, the extent to which a condition impairs the ability to work is rarely captured in these records. When data checks fail, individuals must submit other documentation, creating recurring paperwork burdens for people with disabilities and chronic health conditions. These administrative layers increase the likelihood that individuals who are medically frail as defined in H.R. 1 may still be subjected to work requirements or lose coverage due to missed deadlines or incomplete documentation.

The IFR’s guidance on the family caregiver exemption similarly introduces hurdles that can limit the exemption. While H.R. 1 defines family caregiver broadly, the IFR adopts a much narrower definition. Specifically, the IFR limits the exemption only to caregivers who either live with the care recipient or are related to the individual, which includes parents, grandparents, siblings, stepparents and stepsiblings, aunts, uncles, first cousins, nephews or nieces. However, this definition excludes “chosen family” caregivers, neighbors, and others who provide older adults and people with disabilities with essential care.

Additionally, while the statute includes language that exempts caregivers of dependent children age 13 or under and individuals of any age with disabilities, chronic conditions, or functional impairments, the IFR limits the exemption to family caregivers of dependent children age 13 or under and individuals with disabilities only. These restrictions pose great risk not only to caregivers, but also the older adults who rely on their caregiving to live safe and independent lives.

Despite these restrictions, the IFR still gives states some discretion to further define many exemptions. For example, states can use a variety of diagnoses to define “serious or complex medical conditions” and “disabling mental disorders” for the medically frail exemption, so long as the condition significantly impairs the individual’s ability to comply with the community engagement requirements.

The principles below were initially drafted based on the statutory language, prior to the IFR. Relevant updates based on the IFR are now included, with citations to the Code of Federal Regulations (42 CFR 435.550 et seq.)

Principles

Advocates for older adults should weigh in now and throughout the implementation process to ensure their states are taking steps to minimize coverage losses. We recommend advocating that states employ the following principles to ensure the medically frail, family caregiver, and other exemptions are properly implemented and as protective as possible for older adults, people with disabilities and chronic conditions, and family caregivers.

Ensure Categorical Exclusions From Work Requirements Are Automatic and Permanent

States must ensure that individuals who are categorically excluded from work requirements under the law, such as people with Medicare dually enrolled in Medicaid and people eligible through the aged, blind and disabled pathways, are automatically and permanently exempted. States already have the data to identify these individuals, must not impose extra paperwork or screening on these current enrollees, and should take steps to minimize confusion or unnecessary paperwork on new applicants.

IFR Update: The IFR re-affirmed that people age 65 and older, dual eligibles, and people enrolled in aged, blind, disabled pathways are not applicable individuals for purposes of these work requirements (§ 435.551). Also, § 435.553 of the IFR lists these Medicaid populations as “mandatory exceptions.”

Ensure People Who Can Work or Are Employed Can Access Exemptions

Under the statute, eligibility for an exemption and employment are not mutually exclusive. Therefore, eligibility for the medically frail and family caregiver exemptions should be based on an individual’s medical conditions, functional impairments, or caregiving responsibilities rather than assessments of their work capacity or history. States should not require enrollees to prove they are not working or cannot work to qualify for an exemption, nor should evidence of recent or current employment be considered in determining exemption eligibility.

IFR Update: The preamble to the IFR states that if someone works 80 hours per month or otherwise meets the community engagement requirements, would not be exempt even if they meet the statutory requirements for an exemption. (see page 33373, section II.E.5(b)). For example, a worker who meets the statutory definition for medically frail would lose the exemption if they are working at least 80 hours a month. CMS also requires an individual to show that they cannot work to qualify for the medically frail exemption.

Ensure the Medically Frail Exemption Is Not Limited to Strict Disability Criteria

The statute requires states to exempt many categories of individuals well beyond Social Security disability standards, including people with a physical, intellectual, or developmental disability that significantly impairs one or more activities of daily living, a substance use disorder, a disabling mental disorder, or a serious or complex medical condition. States must not inappropriately limit the medically frail exemption to disability and must describe the exemption in a manner that ensures older adults and other eligible individuals who do not identify as disabled understand that this exemption applies to them.

IFR Update: § 435.554(c)(5)(i) of the IFR explicitly states the exemption is available to individuals whose condition “significantly impairs the individual’s ability to comply with the community engagement requirement.” While this language is very similar to the Social Security disability standard, the threshold for meeting the community engagement requirements is much lower than Social Security’s threshold. Therefore, meeting the Social Security definition of disability does not automatically exempt an individual under the IFR. For the other medically frail categories, the IFR gives states discretion to use different diagnostic codes and other clinical measures to determine medical frailty. States must carefully examine if an individual is eligible under any of the medically frail categories.

Make Explicit That the Family Caregiver Exemption Includes Caregivers for Older Adults

H.R. 1 uses the RAISE Family Caregivers Act definition to define caregivers as “an adult family member or other individual who has a significant relationship with, and who provides a broad range of assistance to, an individual with a chronic or other health condition, disability, or functional limitation.” States must implement this definition to ensure both paid and unpaid caregivers, including those caring for older adults and people with disabilities, are exempted. States must not impose restrictions like requiring the person being cared for to have a diagnosed disability, or be a dependent of or related to the caregiver. Nor should states require caregivers to be providing a minimum number of weekly or monthly caregiving hours. Finally, in describing this exemption, states should utilize the RAISE definition and specifically name providing assistance to older adults so that people who are eligible, but may not identify as caregivers, understand this exemption applies to them.

IFR Update: While § 435.554(a) limits family caregivers only to individuals who are caring for someone who meets the ADA definition of disability, CMS explicitly states in the preamble that there is no upper age limit for determining disability, and many older adults may meet the definition of disabled individual (see page 33369, section II.E.3(f)). Additionally, § 435.554(c)(3)(i) provides the exemption if the caregiver is related to or lives with the individual being cared for. Caregivers of disabled individuals who do not meet these criteria will only be exempt if they provide 80 hours of caregiving. Unpaid caregiving hours may also be combined with other community engagement activities to meet the 80-hour work requirement under § 435.552.

Accept Self-Attestation as Verification for Exemptions

H.R. 1 authorizes states to accept individually reported information as verification for exemptions. States should utilize this option to determine eligibility for the family caregiver and medically frail exemptions. Allowing self-attestation is important because there is no data source to identify most caregivers. Similarly, people with serious health conditions may not have medical or other formal records, especially if they are newly applying for Medicaid and do not have access to medical care. Additionally, such attestations are already a core aspect of Medicaid eligibility screening. For example, every state that currently covers a population subject to work requirements accepts self-attestation without additional verification for caretaker relative eligibility.[1] Employing screening forms and self-attestations reduces administrative barriers, speeds processing, and prevents unnecessary coverage disruptions.

IFR Update: Under § 435.557(f) states may accept screening tools like self-attestation to verify medically frail exemption if the state does not have existing data to verify eligibility. Section 435.557(b) gives states that same option to accept self-attestation for all other exemptions, including family caregivers. However, beginning in 2028, states must require documentation unless the individual is seeking a medically frail exemption in which self-attestation is allowed on a one-time basis.

Minimize Administrative Burden and Procedural Churn

H.R. 1 requires states to use an ex parte process (i.e, reviewing existing data and records) to verify compliance and mandatory exemptions and avoid requesting that individuals provide additional information whenever possible. States should utilize data such as Medicaid claims and Medicaid payment to family caregivers to identify and automatically exempt people who qualify for the medically frail and caregiver exemptions. In addition, states should use screening tools like self-attestations to create a new data point for ex parte purposes. States should also limit the frequency of reporting and reverification to federal minimums, implement ex parte renewals of exemptions, and presume medically frail and family caregiver exemptions will continue absent evidence of change. Streamlined processes reduce paperwork, shorten processing times, and keep eligible people continuously enrolled.

IFR Update: § 435.552(a)(2) requires states to utilize ex parte review for initial applications and renewals. Although CMS is giving states more time to improve their data systems for ex parte review by allowing self-attestation throughout 2027, and once for the medically frail exemption thereafter, there are still limitations. For example, an inability to meet the community engagement requirements due to medical frailty cannot be determined ex parte. Medicaid claims and other data systems will not include someone’s ability to work, volunteer, or attend school. Nonetheless, the state must be robust in its effort to verify compliance or an exemption ex parte, and if not available ex parte, require the least amount of paperwork or documentation possible.

Provide Robust Outreach and Accessible Assistance

States must conduct proactive, accessible outreach and offer multiple channels for assistance—telephone, in-person support, and varied notice formats—to help older adults, people with disabilities, and caregivers navigate changes. The unwinding of continuous Medicaid enrollment after the COVID-19 health emergency and experiences in other states that have previously implemented work requirements demonstrate that paperwork and technology barriers put older adults at risk of having their coverage improperly terminated. States should use these experiences and take steps to eliminate and minimize these procedural barriers. Early engagement and clear, plain-language materials can reduce erroneous disenrollments and preserve access to care.

IFR Update: CMS reiterates in § 435.552 that states must engage in outreach and provide accommodations for applicants and enrollees. Specifically, states must send out communications accessible for people with disabilities and with limited English proficiency to beneficiaries at least three months prior to the state implementing the community engagement requirements.

Tools and Resources

We have created a template state letter that provides recommendations for states in implementing work requirements to maximize exemptions and mitigate coverage loss among older adults, people with disabilities, and their caregivers. We encourage advocates to customize this letter to respond to your state’s situation and your organization’s advocacy priorities.

We have also created a template IFR comment which provides an outline for CMS describing the problems with the IFR and how it will impact low-income older adults. For both documents, be sure to personalize them with examples of situations and barriers your clients face to show state and federal officials why it is critical they take any actions available to minimize the barriers of work requirements. Feel free to cite the resources listed here to support your case.

Download the template letter. Download the template comment.

Additional Resources

We encourage you to email info@justiceinaging.org if you have questions or need support in minimizing disruptions and protecting access to care for older adults. minimizing disruptions and protecting access to care for older adults.

Endnotes

  1. Every state except Mississippi and Texas accept self-attestation without verification for one or more eligibility factors, such as parent caretaker relative status. See Medicaid eligibility verification plans by state: https://www.medicaid.gov/medicaid/eligibility/medicaidchip-eligibility-verification-plans. ↑

Template Letter

Template letter instructions: Download and customize this letter to respond to your state’s situation and your organization’s advocacy priorities. Edit the highlighted and bracketed text and include additional examples of situations and barriers your clients face to show why it is critical your state take steps to minimize the additional barriers of work requirements.

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Dear [state Medicaid director or other official], 

On behalf of [Organization(s)], we urge you to adopt the recommendations below for implementing Medicaid community engagement requirements to minimize harm and preserve continuous access to essential [Medicaid or state program name] services for older adults, people with disabilities and chronic health conditions, caregivers, and others. We also ask that you share these recommendations and concerns with federal officials. [Add info about organization(s)] 

In July 2025, Congress passed the budget reconciliation act of 2025 (H.R. 1) establishing federal community engagement requirements for Medicaid expansion [or your state’s program name]  enrollees between ages 19-64. The statute mandates the state to verify work, education, training, or volunteer participation for these Medicaid enrollees and defines required exemptions and optional short‑term hardship exceptions. The Interim Final Rule (IFR) published in June 2026 provides additional definitions and guidelines for implementing community engagement requirements. 

As [aging and disability] advocates, we are concerned that work requirements create administrative barriers that will lead to improper terminations and disrupted access to crucial healthcare. These burdens disproportionately impact older adults and people with disabilities who have a harder time finding work and maintaining employment due to functional limitations, changing work or caregiving responsibilities, and fluctuating health. For example, the vast majority of older adults ages 50-64 enrolled in Medicaid expansion who are retired or not working (86%) report having a health condition that prevents them from working.2 Although the statutorily required exemptions for people who are “medically frail” and for family caregivers are intended to protect these populations, in practice such exemptions frequently fail to reach or work for the people they were meant to protect in part due to complex paperwork, narrow interpretations, and reliance on automated data checks that fail to fully capture people who are eligible. Moreover, the IFR placed additional restrictions not provided in the statute that greatly limit ability to access an exemption. Nonetheless, there are several instances where states can take action to preserve coverage.  

We have provided recommendations and further considerations for implementing exemptions to minimize disruptions in coverage and access to care for older adults, people with disabilities, and family caregivers due to work requirements.  

Automatically exclude people with Medicare and people eligible through the aged and disabled pathways from work requirements. 

The state must ensure that individuals who are categorically excluded from work requirements under the law are automatically and permanently exempted, including people age 65 and older, people dually enrolled in Medicare and Medicaid, and people of any age eligible through disability and other mandatory pathways. The state should utilize existing data to identify these current enrollees without subjecting them to additional paperwork and ensure its eligibility systems are set to automatically screen out new applicants. We urge the state to take steps to minimize confusion and clearly communicate to new applicants whether or not they are subject to work requirements, particularly if they are filling out paper applications.  

Do not impose additional restrictions on exemptions not required by the statute.  

Although H.R. 1 explicitly gives five categories for meeting the medically frail exemption, the IFR added a requirement that the person’s condition or disability must significantly impair their ability to comply with the community engagement requirement. Although this added requirement is extremely limiting, it does not condense all the medically frail categories into a single disability test. Instead, the IFR preserves five distinct medically frail categories, each of which can independently qualify someone for exemption. Because of this structure, states must evaluate individuals across the full range of medically frail definitions rather than defaulting to a narrow disability determination. Proper implementation requires states adopt a broad range of diagnoses and conditions to determine whether a person meets any of the medically frail categories identified in the rule, ensuring that the exemption remains accessible to those the statute intends to protect. 

The IFR departs from the statutory language that uses the RAISE Family Caregiver Act to define family caregivers by only applying the exemption to caregivers of children age 13 or under, and individuals who meet the ADA definition of disability. However, the IFR also makes clear that disability has no upper age limit, meaning many older adults may qualify as disabled under this standard. cause the term “disability” is often understood differently by applicants and beneficiaries, states must provide a clear, inclusive, ADA‑compliant definition and make explicit that disability does not require receipt of disability‑based benefits or a formal medical determination. To ensure equitable access to the exemption, states should rely on self‑attestation whenever possible to confirm that the person receiving care is a disabled individual. When self‑attestation is not permitted, states must adopt the least burdensome verification process available, minimizing administrative barriers for caregivers. 

The IFR further restricts eligibility by requiring that the caregiver either be related to or live with the individual receiving care. This limitation excludes a wide range of caregivers who play essential roles in supporting disabled individuals but do not share a household or familial tie. Under the IFR, these caregivers must meet a separate threshold by providing 80 hours of caregiving, or a combination of caregiving and other community engagement activities. This structure creates an arbitrary distinction in which caregivers who do not meet the relationship or residency requirement face significantly higher burdens, at the expense of the individual they are caring for, despite providing crucial support. 

Real world application [insert your own example or customize this one]: Robin, age 49, is a caregiver for her father who has several health conditions and lives by himself. Robin lives about 20 miles away and visits her father several days a week to help him with groceries, meal preparation, and to take him to doctors’ appointments. Recently, after her father fell and broke his leg, Robin made the difficult decision to transition to part time at the retail store where she works so that she can spend more time helping her father. Robin lost her health coverage and is applying for Medicaid. 

Here, Robin meets the the caregiver exemption and the state should approve her Medicaid application based on her -declaration in her application that she is a caregiver to her father who relies on her support. The state should not require her to submit any documentation of her caregiving duties throughout 2027 when she applies for or renews Medicaid coverage. Beginning in 2028, the state may be required to accept documentation to verify caregiving status, but that documentation must be as minimally burdensome as possible, and only be required if the state is not able to verify ex parte. Notably, if Robin was providing the same care to her godfather or close family friend instead of her father, she would have to meet 80 hours of caregiving and other community engagement activities despite providing the exact same caregiving services.  

Utilize screening questions and ex parte verification to minimize administrative burden and procedural churn.  

To reduce administrative barriers for both Medicaid enrollees and the state, screening questions based on an applicant’s declaration should be accepted as verification for medically frail and caregiver exemptions, as the statute permits. [name of your Medicaid program] already uses self-declarations without additional verification for caretaker relative eligibility [add other eligibility categories that your state accepts self-declaration for].3  

Real world application [insert your own example or customize this one]: Marsha, 56, is applying for Medicaid. She has diabetes and arthritis which significantly limit her mobility and have forced her to go weeks without working. Marsha qualifies for a medically frail exemption since one of her activities of daily living are limited. She does not own a car or have access to public transportation, and, being uninsured, she does not have a primary care provider. Last time she ran out of insulin, she ended up in the emergency room. 

In Marsha’s case, individual -declaration would be the most accessible and efficient method for verifying she is eligible for the medically frail exemption. If the state required medical or other documentation of her condition, then Marsha would be in an impossible position where she cannot access Medicaid without first getting health care from a provider to verify she is medically frail. Marsha would have to either pay out-of-pocket to get documentation or potentially go to the emergency room. This creates expensive and burdensome delays for both Marsha and the state. Beginning in 2028, the state will only be able to accept self-attestation once before requiring documentation if ex parte data cannot verify eligibility. The state should allow Marsha to utilize self-attestation as long as is allowable and then rely on claims data and other records to confirm medical frailty. While claims data likely will not state whether she can engage in 80 hours of community engagement requirements, the state should be generous in using existing data to make reasonable assumptions that her medical conditions prevent her from meeting community engagement and not require additional documentation. We also urge the state to reduce administrative burden by limiting eligibility determinations for exemptions only as frequently as is required by the IFR, 12 months for the medically fail exemption and 6 months for all other exemptions.   

H.R. 1 requires states to use an ex parte process to verify exemption eligibility and avoid requesting individuals to provide for additional information whenever possible. The state should maximize such data‑driven verification by linking and cross‑checking existing state sources to identify people who qualify for the medically frail exemption, such as [Medicaid claims, Managed Care Organization (MCO) records, long-term services and supports and other disability and aging services data, and behavioral health records]. Similarly, the state may be able to use existing data to exempt some caregivers, such as those being paid under Medicaid Home- and Community- Based Services (HCBS) programs. Ex parte data that confirms an individual meets a statutory exemption should be applied automatically without requiring the applicant or enrollee to provide additional documentation confirming their exemption status. Importantly, even when maximizing these data sources, the state must accept declarations   since most family caregivers are not identified in existing data sources and many people who qualify for the medically frail exemption, like Marsha, cannot easily document their condition, especially without Medicaid. 

Ensure accessibility, due process, and operational safeguards. 

Given the extensive and confusing nature of these work requirements, it is essential for the state to provide clear and accessible information to applicants and enrollees. This includes plain‑language, accessible notices in multiple formats and languages explaining the reporting requirements, exemptions, and information about requesting accommodations. It is especially important that the state test applications and any technology and include older adults among the testers.  

Medicaid enrollees should also have accessible options, such as a well-staffed hotline, to reach trained and knowledgeable staff to ask questions or get additional information. The state should also be explicit about enrollees’ right to appeal adverse decisions, including an opportunity to temporarily continue coverage pending appeal and an opportunity for a hearing. This includes providing clear deadlines for requesting appeals and for agency decisions, and ensure beneficiaries receive timely notice of those deadlines. Beneficiaries should also be offered assistance, including help completing forms, requesting continuations, and obtaining representation or advocacy support. 

[Additional topics to raise if relevant to the state (e.g., utilizing Beneficiary Advisory Committees and other stakeholder engagement opportunities; data sharing responsibilities, role of MCOs and third-party contractors, privacy concerns and proper use of data, etc.)] 

Conclusion 

We appreciate your careful consideration of these recommendations and urge the state to adopt these policies and practices to protect access to care while implementing work requirements. Establishing clear exemption rules and processes consistent with Congress’s intent to exempt people with disabilities, serious or complex health conditions, and family caregivers for older adults, prioritizing screening tools and ex parte renewals, and providing robust due process rights will reduce wrongful terminations and help preserve health and independence for older adults, people with disabilities, and their caregivers. 

[Add request for meeting and/or individual contact info] 

Template Comment

Template comments instructions: Use this outline as a template to respond to the IFR. You are free to edit the entire document, but be sure to edit highlighted and bracketed text and include additional examples of situations and barriers your clients face to show the damaging effects of implementing work requirements.

You can submit your comments online. Comments are due July 31, 2026.

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Centers for Medicare & Medicaid Services 
Department of Health and Human Services 
Attention: 2454-IFC 
7500 Security Boulevard 
Baltimore, MD 21244-1850 

Re: Community Engagement Requirement Interim Final Rule (CMS-2454-IFC) 

On behalf of [Organization(s)], we appreciate the opportunity to comment on the Community Engagement Requirement Interim Final Rule (IFR). [Description of organization(s)]. We write in strong opposition to several policies in the IFR, in particular the restrictive definitions and added administrative barriers which will jeopardize coverage for older adults, people with disabilities, and the family caregivers who support them. 

Congress created broad exemptions in H.R. 1 to protect people who are medically frail, caregivers, and other populations facing barriers. Yet, the IFR narrows these protections beyond what the statute permits. The IFR adds rigid disability standards, relationship and residency tests for caregivers, and burdensome verification processes that risk improper terminations and disrupts access to care. These populations already face fluctuating health and limited work capacity, which would worsen without Medicaid coverage. By tightening rules for already vulnerable groups, the IFR threatens continuity of care for those who rely on Medicaid most. 

Excluding non-applicable individuals from community engagement requirements: 

  • CMS must ensure states automatically and permanently exempt individuals categorically excluded by law: people 65+, those dually enrolled in Medicare and Medicaid, and those eligible through disability or other mandatory pathways. 
  • Because overburdened Medicaid offices may send forms to all enrollees, CMS must ensure states use existing data to identify exempt individuals and screen out new applicants without extra paperwork. 
  • CMS should require states to clearly communicate whether new applicants are subject to work requirements, especially for those using paper applications. 

Additional IFR restrictions on medically frail exemption is inconsistent with ex parte review and will result in people with disabilities and older adults with serious health conditions losing coverage. 

  • H.R. 1 lists five categories for determining medical frailty, but the IFR adds an additional requirement, which was not in the statute, requiring the medically frail condition must significantly impair the ability to meet community engagement requirements. 
  • This added standard is overly restrictive and increases administrative burden for both enrollees and states. 
  • Although the IFR emphasizes ex parte review, medical frailty generally cannot be determined ex parte because claims data do not show whether someone can work, volunteer, or attend school. 
  • As a result, medically frail individuals will require additional verification, increasing the likelihood of improper adverse actions for eligible older adults and people with disabilities
    • [Insert your own examples or customize this one] For example, if someone has a disability that limits their mobility, they may initially qualify for a medically frail exemption through self‑attestation because at least one activity of daily living is affected. Their Medicaid claims may only show routine services—labs, physician visits, prescriptions—which do not indicate whether they can meet 80 hours of community engagement per month. Once self‑attestation ends, they must undergo a burdensome process to prove they cannot meet the requirements, even though state data already shows they are medically frail. This undermines the purpose of ex parte review by forcing unnecessary documentation and increasing the likelihood of improper terminations. 
  • [Additional examples to consider including: 
    • People with fluctuating health conditions that prevent them from working some weeks or months, but not others 
    • Older adults who are forced to retire early because their health conditions do not allow them to continue their jobs 
    • People with serious health conditions who have to wait months or years to see specialists and get diagnoses 
    • Experiences with health care providers being unwilling to provide documentation of ability to work] 

Family caregivers are at risk of losing coverage due to IFR restrictions 

  • Although H.R. 1 uses the RAISE Act definition of family caregiver, the IFR narrows it by limiting exemptions to caregivers of disabled individuals who meet the ADA definition of disability. 
  • While ADA disability is broad, the RAISE Act also includes individuals with chronic impairments or functional limitations which CMS rejected in the IFR. Because “disability” is often interpreted differently by applicants, states must use a clear, inclusive, ADA‑compliant definition and clarify that disability does not require disability‑based benefits or a formal medical determination. 
  • CMS should also ensure states are describing this exemption in a way that clearly notifies caregivers of older adults that they are eligible for the exemption, even if the older adult does not identify as disabled.
  • The IFR also requires caregivers to be related to or live with the person receiving care, excluding many who provide essential support outside those relationships. This arbitrary distinction harms older adults who rely on neighbors, friends, or other loved one for care, ignoring the realities of caregiving relationships. 
  • Caregivers who do not meet these criteria must document 80 hours of caregiving or combined caregiving and community engagement creating an arbitrary and significant burden. 
  • [Insert your own example or customize this one] For example, a Medicaid enrollee who provides regular caregiving to an older adult extremely close to them, like a godparent or family friend, meets the RAISE Act definition for caregiving. Under the IFR, this caregiver would be denied a caregiving exemption because they are neither related to nor living with the person receiving care. They would then be required to document 80 hours of caregiving or combined caregiving and community engagement, even though their support is essential. 

Ensure accessibility, due process, and operational safeguards. 

  • CMS has expressed the need for states to provide clear and accessible information to applicants and enrollees, including plain‑language, accessible notices in multiple formats and languages. 
  • Information must explain the reporting requirements, exemptions, and information about requesting accommodations.  
  • CMS should ensure states test applications and technology to ensure accessibility, and include older adults and people with disabilities in user testing.  
  • States must clearly explain appeal rights, including the ability to continue coverage during an appeal, deadlines for requesting appeals, and timelines for agency decisions and offer beneficiaries assistance completing forms, requesting continuations, and accessing representation or advocacy support. 
  • CMS must ensure that Medicaid enrollees are not disenrolled if states fail to provide adequate and accessible notice and due process.  

[Add additional topics to raise] 

Conclusion 

We thank you for reviewing these comments. For the reasons stated, we are deeply concerned with the additional restrictions the IFR has placed on Medicaid eligibility and request CMS  remove the burdensome paperwork requirements and ensure that older adults, people with disabilities, and their caregivers who are eligible are not improperly terminated. For questions, please contact [individual contact info- name and email].  

Respectfully, 

[Add organization(s) and/or individual contact info]