O. Monitoring

Section 1902(a)(6) of the Act and implementing regulations at § 431.16 require States to submit all reports required by the Secretary, in such form and containing such information as instructed by the Secretary, and to comply with provisions necessary to assure the correctness and verification of such reports. In addition, section 1902(a)(75) of the Act requires States to submit a report that contains any other data reporting determined necessary by the Secretary to monitor enrollment and retention of individuals eligible for medical assistance under the State plan or under a waiver of the plan. Under section 1904 of the Act, the Secretary may take corrective action to limit Federal payments, after reasonable notice and opportunity for hearing, based on findings that the State failed to comply substantially with section 1902 of the Act in the administration of the plan. We interpret the statutory requirements in sections 1902(a)(6) and (a)(75) of the Act to provide authority to require States to submit data that allow for monitoring of their eligibility and enrollment processes. Under these authorities, States already routinely submit eligibility and enrollment data to CMS on a monthly, basis through three established data collection efforts: the Medicaid and CHIP Performance Indicator (PI) data, the Medicaid and CHIP Eligibility Processing (EP) data, and the Transformed Medicaid Statistical Information System (T-MSIS) data. These data sets provide CMS, States, and the public increased insight and transparency into State Medicaid and CHIP eligibility and enrollment operations, and the data allow CMS to identify potential compliance or program integrity issues to rapidly engage with State agencies.

As described in this IFC, the community engagement requirement under section 1902(xx) of the Act will impact eligibility and enrollment for those subject to it, and we believe that States' processing of eligibility and enrollment actions for all other applicants and beneficiaries may be indirectly impacted as States implement requirements in this IFC to verify that an individual demonstrates or is deemed as demonstrating community engagement or is a specified excluded individual. Under authority in sections 1902(a)(6) and (a)(75) of the Act, we are requiring in this IFC at § 435.562 that States submit timely, complete, and accurate data (data of sufficient quality) to support monitoring of State eligibility and enrollment operations concerning the implementation and impact of the community engagement requirement. This data reporting will assist CMS to maintain high levels of program integrity to ensure States implement the community engagement requirement under section 1902(xx) of the Act and maintain timely and accurate determinations and redeterminations of eligibility for all applicants and beneficiaries.

To the extent possible, we will develop a community engagement report using existing data elements reported by States through the PI, EP, and T-MSIS data collection efforts, and States will use the same submission portals currently used for any modified or new data collection gathered through the PI, EP, and T-MSIS data sets. We anticipate that there will be a need to modify existing data elements in these data sets or create new, additional data elements in key categories described further in this section to capture data that reflect activities associated with implementation of and the impact of the community engagement requirement. While this IFC outlines the requirement for States to submit data for monitoring ( printed page 33425) of the community engagement requirement, we will notify States of any specific updates to existing data elements or new data elements through existing PI, EP, and T-MSIS communications for these data collection efforts and related data dictionaries or technical specifications documents. In addition, any modified or new data elements to these existing data collection efforts will be subject to public review and comment processes established under the Paperwork Reduction Act.

We expect States to report timely, complete, and accurate data to monitor community engagement, and in this IFC at § 435.562(b), we define terms that describe how States must submit data and ensure the quality of data collected that will be used to monitor community engagement under section 1902(xx) of the Act. We define the term “timely,” at § 435.562(b)(1) to mean that all data for community engagement monitoring are submitted according to the cadence and not later than the deadline specified by CMS. We define the term “complete” at § 435.562(b)(2) to mean that all required community engagement data are reported by the State. We define the term “sufficient quality” at § 435.562(b)(3) to mean that all required data elements are reported in a form and manner that adheres to specifications prescribed by CMS.

In § 435.562(c), we establish that States must provide timely and complete data that is of sufficient quality to monitor enrollment, retention and eligibility processes for community engagement activities that begin January 1, 2027, (or earlier date specified by the State). In § 435.562(d), we require that States submit data elements for applicants and beneficiaries applying for and receiving medical assistance, including individuals subject to the requirements of section 1902(xx) of the Act through five specified categories. These five specified categories are: (1) enrollment totals of individuals applying for and receiving medical assistance; (2) application and renewal processing, timeliness, and backlogs; (3) outcomes of determinations and redeterminations eligibility; (4) populations subject to and their compliance with the requirements of section 1902(xx) of the Act; and (5) other such data specified by CMS in regulation, guidance, or technical specifications to monitor implementation and the impact of community engagement.

We also notify States in § 435.562(e) that failure to submit data or submission of data that indicate compliance issues may result in corrective action under section 1904 of the Act, additional data collection, or additional outreach noticing as described at § 435.561(b). In § 435.562(e)(1) and (2), States may be subject to such actions if reported data are not timely, complete, or of sufficient quality (as defined in this section), if reported monitoring data indicate a failure to comply substantially with section 1902(xx) of the Act, or determination and redetermination outcomes indicate a need for increased outreach. This includes when data indicate program integrity issues, such as determination outcomes in a State that would make them an outlier, like large percentages of individuals who are excluded or meet a particular exclusion or exception. When reviewing data for evidence of compliance issues, we will review data trends within a State month-over-month as well as how a State's data compare to analogous data from other States to determine whether additional information from the State is needed to understand and interpret the data. We will assess whether further outreach or compliance action may be necessary based on findings identified through this data-driven, interactive process with the State and will provide reasonable notice and opportunity for hearing before any financial withholding is taken under section 1904 of the Act. We will also assess the monitoring data and determine if additional beneficiary outreach is necessary in a State that reports outcome data, such as higher numbers of procedural terminations at renewal compared to other States, that suggest such action may be needed to ensure beneficiaries understand how to demonstrate community engagement.