How Many Adults Could Be Subject to Medicaid Community Engagement Requirements?

Introduction: Why Community Engagement Requirements Matter Now 

States are once again evaluating how to prepare for implementation of Medicaid Community Engagement (CE) requirements. While federal direction continues to evolve, history shows that when CE policies move forward, they introduce a significant operational challenge for Medicaid agencies. Even small changes to eligibility criteria or documentation pathways can produce major downstream effects for members, caseworkers, managed care plans (MCOs), and state oversight teams. 

Community Engagement requirements hinge on a simple question: which adults in Medicaid must document work or qualifying activities, and which are exempt. Although the policy concept is straightforward, the administrative reality is complex. It involves cross-program data checks, exemption logic, documentation capture, workflow redesign, and intensive member communication. States that plan ahead will mitigate unnecessary churn and prevent compliance risks. 

This blog provides a practical, directional estimate of how many adults may fall into the CE cohort in each state. Using publicly available expansion enrollment data and a consistent planning assumption, we estimate that up to 25 percent of expansion adults could ultimately be subject to CE requirements after exemptions and reasonable overlap reductions are applied. This is not an eligibility prediction. It is an operational planning baseline. 

The Operational Challenge States Must Prepare For 

CE requirements affect much more than a single verification step. They reshape core Medicaid processes: 

• Eligibility workflows that must incorporate new exemption checks
• Attestation pathways that must accept digital documents, signatures, and explanations
• Notices and CRM systems that must communicate CE expectations clearly and consistently
• Caseworker queues that may see surges in documentation volume
• Systems integration across Medicaid, SNAP, TANF, and potentially workforce agencies
• PERM exposure if exemption logic or documentation handling is inconsistent

Without advance preparation, even a modest CE population can strain systems and staff. States that rely heavily on manual processes face higher risks of delays, inconsistent determinations, and potential member harm. 

Protecting Members While Ensuring Compliance 

Member protection is one of the most significant operational considerations in CE implementation. In previous CE initiatives, states observed that: 

• Members may not understand what documentation is required
• Notices can be confusing if not written with clarity and consistency
• Members with unstable housing, limited digital access, or caregiving responsibilities may miss deadlines
• Many exemptions, including medically frail status, can and should be verified through administrative data rather than requiring member action

A well-executed CE program reduces these risks by automating what can be automated, pre-clearing exemptions through data, and minimizing unnecessary member burden. A poorly executed CE program can result in eligible adults losing coverage due to process challenges rather than eligibility determinations. 

The Role of Automation in Reducing Risk 

States that invest early in automation, data-first verification, and configurable workflows are positioned to handle CE requirements with greater accuracy and less friction. Several capabilities are particularly important: 

• Administrative data matching that clears SNAP- or TANF-aligned exemptions without requiring member action
• System-driven identification of medically frail individuals using existing indicators
• Streamlined digital attestation and document upload tools that reduce paperwork errors
• CRM and targeted outreach tools that ensure clear communication
• Strong audit trails that protect states during PERM reviews

These capabilities reduce caseworker burden, improve member experience, and ensure consistency across counties and regions. 

Why Estimating the CE Cohort Size Matters 

Regardless of how CE requirements are ultimately structured, states benefit from an early estimate of the potential population affected. Knowing the size of the CE cohort allows agencies to: 

• Determine whether staffing adjustments or overtime policies will be needed 
• Estimate the number of notices, reminders, and required follow-ups
• Project expected call center or field office volume
• Identify which MMIS or IES modifications will be required 
• Prioritize automation investments to reduce manual workload
• Set realistic implementation timelines and training plans

This type of planning reduces the likelihood of rushed implementation or unintended disenrollment. 

Methodology: A Practical, Transparent Planning Approach 

This analysis uses publicly available Medicaid expansion adult enrollment data from KFF and CMS as of December 2024. To establish a consistent baseline across states, we apply a simple assumption: 

Estimated CE Cohort = Expansion Group Enrollment × 0.25 

The 25 percent assumption reflects directional modeling of typical exemption patterns across medical, caregiving, cross-program alignment, temporary exemptions, and overlap reductions. The actual CE population in any state will depend on final policy decisions, state-specific administrative data, and the structure of reasonable cause or hardship pathways. 

Non-expansion states are listed as N/A because they do not have an ACA expansion adult baseline. If such states implement alternative CE models, the underlying population will differ and will require separate estimation. 

Findings: Potential CE Cohort by State 

The table below presents the estimated number of adults in each state who may be subject to CE requirements under the 25 percent planning assumption. These values provide a directional sense of scale and should be refined using state-specific administrative data. 

Full State Table: Expansion Group Enrollment and Estimated CE Cohort 

Conclusion 

Community Engagement requirements present both operational and member-facing challenges. A clear understanding of potential workload, paired with early planning and modernized workflows, can help states implement CE requirements in a way that protects eligible members, reduces administrative risk, and ensures consistent, compliant operations. The state estimates provided here offer a foundation for that planning.

State teams preparing for CE can request a planning workbook or a short working session with CITIZ3N to refine estimates and discuss operational strategies tailored to their specific environment. 

sales@citiz3n.com

Sources
KFF analysis of Medicaid enrollment data collected from the Centers for Medicare and Medicaid Services (CMS); URL: https://www.medicaid.gov/medicaid/national-medicaid-chip-program-information/medicaid-chip-enrollment-data/medicaid-enrollment-data-collected-through-mbes/index.html