Federal Medicaid Community Engagement Requirements: Monitoring and Evaluation Considerations and Opportunities for States 

Background  

H.R.1, also known as The One Big Beautiful Bill, which was signed into law on July 4, 2025, introduced significant changes to the Medicaid program, including instituting Medicaid community engagement, or work, requirements (CER) (for more information, please view our recent articles on H.R, 1 and implementing guidance, including the recently-released CER Interim Final Rule with Comment Period (IFC). Impacted states are moving quickly to prepare for mandatory Medicaid CER which goes into effect January 1, 2027. With evolving federal guidance and a compressed timeline, policy conversations have largely focused on state flexibility & decision-making and developing infrastructure & processes to effectively implement CER. However, there are reasons for these states to consider monitoring and evaluation, beyond what is required. This article summarizes key monitoring and evaluation considerations for CER and identifies opportunities for states to plan for robust and meaningful evaluation activities early on.  

Leveraging State Plan Amendments for Medicaid Community Engagement Requirements: Implications for Evaluation  

Historically, states have utilized Section 1115 Demonstration Waivers to seek federal authority to implement community engagement or work requirements for their Medicaid populations. Section 1115 Waivers allow states to test new approaches to eligibility, benefit expansion, and payment or delivery reforms and, as such, are subject to strict federal monitoring and evaluation requirements. States must regularly collect and report monitoring data to CMS to track implementation, performance, risks, and progress toward policy goals, and must also engage an independent evaluator to conduct a comprehensive, mixed methods evaluation to evaluate the implementation and impact of policies and programs authorized under the waiver. These evaluations generate evidence on whether the demonstration met its objectives and assess impacts on beneficiaries, providers, health plans, and state programs, including related access to care, quality, and costs. CMS and states use these findings to inform policy decisions and identify best practices. 

Under H.R.1, however, states may implement CER via state plan amendments (SPAs), which do not require the same comprehensive and independent evaluation of the policy’s implementation and impact on Medicaid populations and programs. As a result, states will not be required to rigorously evaluate whether community engagement policies are achieving intended goals or identify key lessons learned, best practices, or recommendations as they would with policy changes enacted through Section 1115 Waivers.  This limits the opportunity to generate specific evidence on the effectiveness and outcomes of community engagement requirements, especially given the significant variation across states in populations, labor markets, administrative capacity, and Medicaid operations.  

Newly Introduced CMS Monitoring Requirements  

Although states are not required by CMS to conduct independent evaluations of community engagement policies, the recently released CER Interim Final Rule includes monitoring requirements for states. Leveraging existing data reporting systems (performance indicators (PI), eligibility processing data (EP), and the transformed Medicaid and statistical information system (T-MSIS), states are required to submit data on applicants and beneficiaries across five specified categories: 

1. Enrollment totals for individuals applying for and receiving medical assistance; 
2. Application and renewal processing, timeliness, and backlogs; 
3. Outcomes of determinations and redeterminations of eligibility; 
4. Populations subject to and their compliance with the requirements; and 
5. Other such data specified by CMS. 

As stated in the IFC, CMS will review data for compliance issues by analyzing month-over-month trends within and across states and will use the findings to determine whether further outreach or compliance actions are necessary.  

Opportunities for Meaningful and Robust Monitoring and Evaluation of Community Engagement Requirement Policies  

The CER roll-out is a critical opportunity for robust evaluation and research. Medicaid CER represents a significant shift in Medicaid eligibility policy and processes and has never been implemented at the national scale mandated under H.R.1. Additionally, other Medicaid-related provisions under H.R.1, including changes to provider taxes and state directed payments, as well as redetermination timeline changes, will coincide with CER implementation, introducing additional changes to the Medicaid and larger healthcare system landscape.  

Key benefits of evaluation include: 

• Evaluation supports continuous improvement by measuring implementation progress, identifying areas for adaptation, and assessing whether policy goals are successfully met.  

• Evaluation findings provide evidence on program effectiveness, efficiency, and sustainability, enabling informed decisions about resource allocation and policy adjustments.  

• Identifying implementation successes and challenges helps states identify best practices, strategies to overcome barriers, and improve future administration.  

• Rigorous evaluation promotes accountability, transparency, and responsible stewardship of public resources while ensuring intended outcomes and minimizing unintended consequences.  

• Utilization focused, process-oriented evaluations can identify quality improvement opportunities for states quickly and early in implementation.  

Comprehensive evaluations, planned early and utilizing high-quality data, can provide critical insights for states to determine whether community engagement requirements are achieving the states’ goals, identify unintended consequences, and understand the policy’s effects on a range of key outcomes:  

• Coverage and Enrollment: Community engagement policies introduce complex changes to Medicaid eligibility requirements, and the impact to processing timelines, enrollment rates, and churn should be assessed.  

• Access to Care: Loss of coverage or disruption in continuous coverage may impact beneficiaries’ ability to reliably access care. Patterns in seeking care (routine, preventive vs. emergency or acute cate utilization) should be monitored and evaluated, including changes to acute care utilization. 

• Health Outcomes: Changes in access to care are typically linked to health outcomes. Standardized quality of care and outcome measures, such as indicators of disease management, morbidity, and mortality should be assessed.  

• Cost: The following cost indicators should be monitored and evaluated over time: 

• • Administrative cost: States anticipate incurring administrative costs to develop new required infrastructure and administer the new policy changes of community engagement requirements.  

• • Cost savings: Changes to overall enrollment may result in cost savings for state Medicaid programs.  

• • Uncompensated care: Reductions in Medicaid coverage may lead to increases in uninsured rates and uncompensated care for healthcare providers.  

• Employment: Community engagement requirements are intended to encourage labor force participation; the actual impact on employment rates, hours worked, wage increased, and other workforce-related outcomes among beneficiaries should be evaluated. 

• Employer sponsored insurance or commercial insurance: Community engagement requirements may increase transitions to employer-sponsored or commercial insurance. Assessing transitions to other types of coverage, as well as the impact to uninsured rates, if alternative coverage options are unavailable or unaffordable should be included in evaluations.   

• Subgroup analysis: The impact of community engagement requirements may vary by subgroup. Disaggregating the above outcomes to clearly identify differences in effects is key. States may consider the following subgroups in their analyses, tailored to the unique needs of each state: 

• • Demographic characteristics: including age, race and ethnicity, gender, geographic location (urban vs rural), or income 

• • Health needs or conditions: including substance use disorder, serious mental illness, or chronic disease  

As states grapple with the heavy lift of implementing CER, they can rely on several strategies to make evaluation activities manageable and reduce potential administrative burden, including leveraging existing data sources, automating data collection, and engaging experienced evaluation partners. States can leverage the existing reporting requirements outlined in the IFC to support their in-state evaluation. Additionally, evaluation approaches should be tailored to meet state’s unique needs and policy goals, focusing on the most relevant performance measures and outcomes. Early planning to align monitoring and programmatic data with evaluation needs reduces data collection challenges later in implementation.