New Futures' Comments on CMS's Interim Final Rule for Work Requirements

Dear Administrator Oz:

New Futures appreciates the opportunity to submit comments on the Centers for Medicare and Medicaid Services’ (CMS) Interim Final Rule (IFR) implementing Medicaid community engagement requirements. New Futures is a nonpartisan, nonprofit organization that works to solve New Hampshire’s problems through policy change. In this role, we work extensively with policy makers, health care providers and families to increase access to quality, affordable health care across the Granite State.

As an advocacy organization dedicated to the health and well-being of Granite Staters, we write to express our deep concerns regarding the operational hurdles and coverage losses this rule will inflict on low-income residents in New Hampshire. New Hampshire has previously attempted community engagement requirements under the Granite Advantage Program.¹ These experiences show that rigid reporting mandates penalize vulnerable residents who fall out of compliance because of administrative complexity rather than a lack of desire to work.

I. CMS's restrictive definition and verification of “medical frailty” will cause substantial coverage losses for Medicaid beneficiaries.

Under the IFR, CMS narrowly interprets “medical frailty” by requiring not only a qualifying clinical diagnosis (such as a substance use disorder, a disabling mental health disorder, or a serious/complex medical condition), but also proof that the condition significantly impairs the beneficiary’s ability to work.² This requirements create an unnecessary and burdensome barrier for low-income beneficiaries.

Consider a beneficiary in the early stages of recovering from a substance use disorder. Intensive outpatient treatment often involves multiple weekly counseling sessions, medical appointments, and other recovery supports. While substance use disorder is explicitly listed as a qualifying condition, CMS’s added requirement means that the beneficiary must also prove that her treatment demands and medical impairment prevent her from meeting the 80-hour monthly work requirement. This is precisely the type of beneficiary that CMS’s restrictive definition will disenroll: a patient who clearly meets the statutory intent of “medical frailty,” yet faces disenrollment due to CMS’s narrow interpretation.

CMS’s “medical frailty” definition will also overburden New Hampshire’s safety-net providers. CMS requires states to verify not only diagnoses, but also the degree to which a condition limits a beneficiary’s ability to work. This assessment will fall largely on primary care and behavioral health providers. Provider organizations in New Hampshire like Community Mental Health Centers already operate under chronic vacancy rates, often exceeding 20-50% in direct services roles.³ Forcing primary care and behavioral health providers to undertake administrative paperwork for work exemptions diverts scarce clinical capacity away from direct patient care.

Finally, New Hampshire’s prior experience with the 2019 Granite Advantage work requirement roll out demonstrates that onerous verification rules simply do not work. During New Hampshire’s brief 2019 roll out of Medicaid work requirements, although over 10,700 enrollees self-attested to being medically frail or having qualifying health conditions, fewer than 2,000 verification forms were successfully completed before the program was halted.⁴ This gap shows that burdensome paperwork, limited provider capacity, and confusion about documentation requirements create substantial barriers for otherwise eligible beneficiaries. The IFR’s upcoming restrictions on self-attestation after January 2028 will replicate these administrative issues, causing thousands of eligible Granite Staters to suffer coverage losses despite meeting statutory criteria.

II. New Hampshire’s Operational Challenges

Implementing the IFR in New Hampshire will compound the state’s existing geographic, workforce, and economic constraints. Beyond southern New Hampshire, rural counties in our state lack reliable public transportation.⁵ Medicaid beneficiaries without a vehicle or reliable transportation will face immense hurdles securing 80 monthly hours of qualifying activities, or traveling long distances to obtain the medical verification CMS requires.

Further, New Hampshire is in the midst of a housing affordability crisis, which disproportionately affects low-income individuals and families. New Hampshire’s housing vacancy rate has fallen critically low, while rents consume an outsized share of low-income household budgets.⁶ Medicaid beneficiaries experiencing housing instability face impossible choices between spending limited resources on housing, transportation, child care, and other necessary expenses. These housing barriers directly interfere with the documentation requirement of the IFR. The rule provides no hardship exemption for housing instability, despite the housing crisis New Hampshire faces.

Lastly, the fragmented health care network in New Hampshire’s rural counties will lead to unintentional disenrollment under CMS’s rule. The IFR’s reliance on 12 months of consistent claims data to verify medical frailty assumes consistent access to care, which is often unavailable in rural areas of the state. Beneficiaries who experience gaps in care due to long wait times, limited appointment availability, or health care workforce shortages will not appear medically frail in claims data, even when they otherwise meet the statutory criteria. In this respect, the IFR’s verification requirement will routinely miss eligible individuals and disproportionately affect beneficiaries in rural communities. The IFR’s operational demands will present huge challenges for states like New Hampshire with rural geography, seasonal economies, and provider shortages.

New Futures respectfully requests that CMS revise the IFR to prevent unintended disenrollment, reduce administrative burden on providers, and ensure that medically frail beneficiaries can retain access to care. New Hampshire’s 2019 failed work requirement attempt shows that complex administrative systems do not distinguish between those unwilling to work and those unable to comply due to health, transportation, or workforce barriers. CMS has the opportunity to correct these issues in the final rule. We urge you to adopt a more workable definition of “medical frailty” and flexible verification standards that protect vulnerable Granite Staters.

Samuel Burgess
Health Care Policy Director
New Futures

References

1. See, e.g., New Hampshire Fiscal Policy Institute, Federal Court Halts New Hampshire Medicaid Work Requirements (July 30, 2019), https://nhfpi.org/blog/federal-court-halts-new-hampshire-medicaid-workrequirements/.
2. Centers for Medicare & Medicaid Services (CMS), Community Engagement Requirement for Certain Individuals, 91 Fed. Reg. (June 3, 2026).
3. University of New Hampshire Carsey School of Public Policy, The Early Childhood Behavioral & Mental Health Workforce at New Hampshire’s CMHCs: Staff Vacancies, Mar, 2023), https://carsey.unh.edu/sites/default/files/media/2023/03/nh_pdg_cbmh_workforce_staff_vacancies_final.pdf.
4. Princeton University State Health and Value Strategies, The Disability Gap in Medicaid: Implications for the Federal Work Requirement Proposal (Jun. 20, 2025), https://shvs.org/the-disability-gap-in-medicaid-implicationsfor-the-federal-work-requirement-proposal/.
5. University of New Hampshire Survey Center, New Hampshire Resident Views on the Use, Availability, and Need for Public Transportation (UNH Institute on Disability, 2005); see also New Hampshire Fiscal Policy Institute, New Hampshire Policy Points: Health (Feb. 2025).
6. New Hampshire Fiscal Policy Institute, Low Vacancy Rates Push Rental Housing Costs Up in New Hampshire (Apr. 14, 2022), https://nhfpi.org/resource/low-vacancy-rates-push-rental-housing-costs-up-in-nh/.