§ 435.561 — State requirements for outreach.

§ 435.561 State requirements for outreach.

(a) Outreach. The agency must provide notice, in a manner and frequency described in this section, of the requirement to demonstrate community engagement under this subpart to individuals who are—

(1) Eligible to enroll or are enrolled under § 435.119; or

(2) Otherwise eligible to enroll or are enrolled in a demonstration project under section 1115(a)(2) of the Act that provides coverage equivalent to minimum essential coverage requirements as defined under § 435.4, and are—

(i) At least 19 and under 65 years of age;

(ii) Not pregnant;

(iii) Not entitled to or enrolled for benefits under part A of title XVIII or enrolled for benefits under part B of title XVIII; and

(iv) Not otherwise eligible to enroll under the State plan.

(b) Frequency of outreach. The agency must notify individuals described in paragraph (a) of this section of the requirement to demonstrate community engagement—

(1) Three months plus the number of months specified by the State under § 435.556(a)(1)—

(i) Prior to January 1, 2027, or, if applicable, prior to the State's earlier implementation date as elected by the state under § 435.559(b); or

(ii) For States that later elect to implement the eligibility group described at § 435.119, or a section 1115 demonstration project described in paragraph (a)(2) of this section, prior to the effective date of such eligibility expansion;

(2) Upon enrollment, during the period of time between the initial outreach notice and implementation of the community engagement requirement described in paragraph (b)(1) of this section; and

(3) Periodically as follows—

(i) When such individual is determined or redetermined eligible at application, at renewal described at section 1902(e)(14)(L) of the Act and § 435.916, or based on a change in circumstances;

(ii) When the State elects the short-term hardship exception under § 435.555(a);

(iii) On each occasion on which a short-term hardship exception relating to an event described in § 435.555(d)(2) becomes available to applicable individuals or the State effectuates the short-term hardship event described in § 435.555(d)(3);

(iv) When the State reduces a beneficiary's eligibility and sends the advance notice described in § 431.211 of this subchapter for:

(A) The deselection of the short-term hardship exception under § 435.555(a);

(B) The anticipated expiration of a short-term hardship event described in § 435.555(d)(2) and (3); and

(C) The loss of a beneficiary's status as a specified excluded individual under § 435.554; and

(v) Upon request by CMS, if State-reported monitoring data under § 435.562 or other information indicate a need for increased outreach or a potential compliance issue with §§ 435.550 through 435.562, consistent with § 435.562(e)(2).

(c) Content of outreach notice. The notice required under paragraph (a) of this section must be provided in a manner consistent with § 435.905(b) and include information on—

(1) How to comply with the requirement to demonstrate community engagement under 1902(xx) of the Act, including—

(i) An explanation of the exceptions to such requirement under § 435.553, including short-term hardship exceptions under § 435.555, if elected by the State;

(ii) Who is an applicable individual as defined at § 435.551, including an explanation of exclusions from such definition under § 435.554;

(iii) The number of months an applicable individual is required to demonstrate community engagement at renewal under § 435.556(a)(2)(i); and

(iv) How often the State will verify compliance with the community engagement requirement between renewals if the State elects to conduct more frequent verifications consistent with § 435.556(a)(2)(ii);

(2) The consequences of noncompliance with the community engagement requirement on Medicaid eligibility and eligibility for advance payments of the premium tax credit (APTC) and the premium tax credit (PTC) used to pay for coverage through a Health Insurance Exchange; and

(3) How to report to the State any change in the individual's status that could result in the individual qualifying or no longer qualifying—

(i) For an exception under § 435.553;

(ii) For a short-term hardship exception under § 435.555, if elected by the State; or

(iii) As a specified excluded individual under § 435.554.

(d) Modalities for delivering outreach notice. The notice must be provided to the individual—

(1) By regular mail, or, if elected by the individual, in an electronic format consistent with § 435.918; and

(2) In one or more of the following additional modalities:

(i) The individual's electronic account;

(ii) Telephone;

(iii) Text message; or

(iv) Other commonly available electronic means.

(e) Coordination of outreach and other notices. The agency may—

(1) Provide the outreach notice described in this section with an eligibility determination notice described in § 435.917 or other communication from the agency to the individual.

(2) Utilize managed care organizations (MCOs), prepaid inpatient health plans (PIHPs), prepaid ambulatory health plans (PAHPs), primary care case managers (PCCMs), and PCCM entities, as defined at § 438.2 of this subchapter, to notify their enrollees of the requirement to demonstrate community engagement consistent with this section through one or more of the modalities described in paragraph (d)(2) of this section.