NCD comment on Medicaid community engagement rule

Dr. Mehmet Oz
Administrator
Centers for Medicare & Medicaid Services
Department of Health and Human Services
7500 Security Boulevard
Baltimore, MD 21244-1850

July 31, 2026

Re: [CMS-2454-IFC] Medicaid Program; Community Engagement Requirement for Certain Individuals

Dear Dr. Oz:

I am writing to submit written comments on behalf of the National Council on Disability (NCD) regarding CMS-2454-IFC, the interim final rule (IFR) published by the Center for Medicare & Medicaid Services (CMS) on June 3, 2026. The IFR implements the community engagement requirement that applies to certain Medicaid applicants and beneficiaries. ¹ NCD is an independent federal agency that advises the President, Congress, other federal agencies, and State and local governments on disability policy to advance the goals of the Americans with Disabilities Act (ADA): equal opportunity, full participation, independent living, and economic self-sufficiency for people with disabilities.

NCD has consistently stated that every American with a disability who can and wants to work should be fully supported to do so. ² Employment and education play a critical role in helping Americans with disabilities achieve economic self-sufficiency, become part of the middle class, and live out the American Dream. NCD has also found that “Medicaid is a lifeline for people with disabilities who are less likely to have access to employer-sponsored health coverage, are more likely to have low incomes and may not be able to cover their healthcare costs independently. Even with private insurance, [people with disabilities] may not be able to get the care they need since private plans typically do not cover the range of services available through Medicaid.” ³

Considering the vital role Medicaid plays in the independence, health, and lives of people with disabilities, NCD has several questions about the provisions of the IFR and the impact it will have. We urge CMS to clarify the questions raised below through swift guidance or technical assistance, and in supplemental rulemaking. These comments will also be filed electronically through regulations.gov.

A. Questions about the Verification Process for Individuals Who Are “Medically Frail” or Otherwise Have “Special Medical Needs”:

1. What objective, nationally consistent standards will CMS require states to use when determining whether an individual’s disability significantly impairs their ability to comply with the community engagement requirements? How will CMS ensure these determinations are not arbitrary or inconsistent across states?

2. How will state agencies have the resources and expertise to conduct an individualized assessment of each beneficiary’s ability to comply with the community engagement requirements?

3. How will people with disabilities get the documentation required to verify their “medically frail” status, particularly with the limitations their medical condition may cause, limited provider availability, and wait times to obtain a medical appointment?

4. How will providers be able to meet the need for documentation of “medical frailty,” particularly given their lack of expertise with the employment of people with disabilities, low Medicaid reimbursement rates, high patient volume, and limited time? Has CMS considered the potential risk that this additional burden will reduce the number of providers that are willing to see patients on Medicaid?

5. Why are states limited to using information from the preceding 12 months when verifying that an individual is “medically frail” or has “other special medical needs”? ⁴ Has CMS considered the impact of this requirement on people who have static disabilities that began many years prior and may not be currently receiving medical treatment for their disability? Has CMS considered the impact of this requirement on people with medical conditions that began or recurred towards the end of the 12-month period whose claims may not have been submitted or processed yet?

6. Why has CMS imposed a limitation on self-attestation that is not found in the statute? The IFR provides that states may rely on a statement provided under penalty of perjury to verify an individual’s eligibility for the “medical frailty” exclusion only once during the individual’s period of enrollment. After that, the individual must provide documentation demonstrating their “medical frailty.” ⁵

7. Why is the “medical frailty” exclusion subject to more restrictive documentation requirements than other exclusions? For example, the IFR acknowledges that in some circumstances, such as if someone provides regular assistance for their disabled parents, or in the event of a flood, documentation may not be reasonably available. It further acknowledges that an individual might experience circumstances that prevent them from accessing the documentation. ⁶ In these circumstances, CMS has required states to accept other information that the states deem sufficient in lieu of documentation. ⁷ However, similar flexibility does not appear to be permitted for the “medical frailty” exclusion. Why is verifying an individual’s status as “medically frail” treated as an “exception to the policies” that require other information to be accepted in lieu of documentation? Has CMS considered that people who qualify for the “medical frailty” exclusion,” like those that qualify for other exclusions or exceptions, may not have documentation that is reasonably available, or might experience circumstances that prevent them from accessing the documentation?

8. Can CMS please clarify how frequently individuals with disabilities can be required to verify their eligibility for the “medical frailty” exclusion? The IFR states that “States must reverify that an individual is medically frail or otherwise has other special medical needs at least every 12 months, although States may reverify more frequently, such as at each renewal.” ⁸ However, the IFR also states that “States may not reverify a specified excluded individual’s status as such between regular scheduled renewals as part of the more frequent verification process (if elected by the State), unless the State has information indicating the individual’s status has changed.” What is the schedule for reverification of “medical frailty,” and what is the basis for allowing or requiring this schedule, particularly when many disabilities are permanent or unlikely to change? In Fiscal Year 2027, NCD intends to study systemic barriers within the Medicaid system, including the requirement that individuals with disabilities must re-establish their eligibility when moving between states—even if their disability is lifelong and already medically documented. The reverification requirements established in the IFR, along with the likelihood that states will implement the requirements differently, seem like they may create additional systemic barriers.

B. Questions about the Scope of the “Medically Frail” Exclusion:

1. Under what legal authority did CMS narrow the statutory definition of “medically frail or otherwise has special medical needs” by requiring that a “physical, mental, or other behavioral health condition significantly impairs the individual’s ability to comply with the community engagement requirement”? ⁹ Public Law 119-21 states that the “medically frail” exclusion is defined as “including an individual” who meets one of five specified criteria, without any further limitation or qualification for the five categories that the statute lists. ¹⁰

2. Why has CMS added an evaluation of whether an individual’s “physical, mental, or other behavioral health condition significantly impairs the individual’s ability to comply with the community engagement requirement” to the “medical frailty exclusion,” ¹¹ but not added a similar evaluation to exclusions for others who may be able to comply with the requirement despite their condition? For example, no evaluation of the ability to comply is required for the exclusions applicable to pregnant women ¹² or caregivers of 13-year-olds. ¹³

C. Questions about Nondiscrimination Obligations:

1. The IFR notes the obligation to make “reasonable modifications in implementing the community engagement requirement where necessary to avoid discrimination on the basis of disability under section 504, section 1557, and the ADA” in the preamble, ¹⁴ but this important obligation is not clearly stated in regulatory text. Is there a specific reason for this?

2. The IFR’s regulatory text generally relies on cross-references to a separate regulation to incorporate the requirement that outreach and noncompliance notices about the community engagement requirement must be accessible to people with disabilities. ¹⁵ This approach may be unclear or difficult for regulated entities to understand, especially as they are working to implement complex new requirements quickly. Unlike other sections of the rule, Section 435.916(g) includes specific language about accessibility of renewal notices. Why is more explicit language about effective communication and document accessibility not included throughout the regulatory text?

3. How will CMS ensure that the state agencies do not implement the IFR in a manner that violates Title II of the ADA or Section 504 of the Rehabilitation Act of 1973 by imposing additional burdens on people with disabilities that are not imposed on other Medicaid recipients ¹⁶ or by leading to serious risk of institutionalization? ¹⁷

D. Questions about Noncompliance with the Community Engagement Requirement or the IFR:

1. CMS seems to estimate that about 5.5 percent of people to whom the IFR applies will lose Medicaid coverage during each redetermination due to procedural reasons, such as documentation errors. ¹⁸ Is NCD understanding this regulatory impact analysis correctly? What safeguards will CMS require to ensure that eligible people with disabilities do not lose coverage?

2. How does the IFR’s regulatory impact analysis account for the potential cost that could be incurred if individuals lose Medicaid coverage under the rule, and are therefore less able to work or participate in other qualifying activities than they were while they were receiving Medicaid services? For example, personal care assistance services paid for by Medicaid may help a beneficiary get out of bed and get ready in the morning so that they can work or attend classes. If those services are discontinued, that individual may no longer be able to maintain employment or may need to withdraw from classes.

3. The IFR states, “In particular, individuals who are medically frail might not realize that they qualify for an exclusion from the community engagement requirement and will need clear, consumer-friendly information to help them understand if they are excluded.” ¹⁹ How will it be feasible for states to provide clear, consumer-friendly information to beneficiaries without further guidance on all of the questions described in this comment, particularly when some states are supposed to begin sending outreach notices as soon as this month? ²⁰ NCD urges CMS to swiftly clarify these issues. CMS should also consider extending the compliance deadlines in the IFR to allow for further clarification and refinement of the IFR.

NCD stands ready to assist CMS through our expertise and advisement to ensure that, while pursuing employment or educational opportunities to the best of their ability, individuals with disabilities can maintain the Medicaid coverage their health and lives depend on. We look forward to CMS clarifying the questions discussed in this comment through guidance, technical assistance, and supplemental rulemaking. Please have your staff contact Joan Durocher, NCD’s General Counsel and Director of Policy, at jdurocher@ncd.gov if CMS would find it helpful to discuss these comments.

Respectfully,

Neil Romano
Acting Chairman