CMS published its interim final rule for Medicaid work requirements June 1, setting the stage for a significant shift in who qualifies for Medicaid coverage.
Under HR 1, most able-bodied, nonpregnant Medicaid recipients between ages 19 and 64 must work, participate in community service or attend school — or some mix of all three — for at least 80 hours per month. The requirements apply to expansion states and some states with section 1115 demonstrations. The rule’s public comment period runs through July 31.
Here are five things from the rule that are most relevant to ASC operations:
1. A federal tool is being built to streamline verification
CMS is developing a federal electronic eligibility tool called Emmy — short for Eligibility Made Easy — to help states verify whether a Medicaid recipient is subject to work requirements and whether they have met them. The rule directs states to use available data sources first before contacting beneficiaries directly. That process, once operational, could reduce disruptions for patients who have met requirements but have not yet been formally verified.
2. Self-attestation is allowed for now — but not indefinitely
Through 2027, states may accept self-attestation from recipients to confirm compliance or eligibility. Starting in 2028, self-attestation will be limited: states can rely on it only once during a recipient’s enrollment, and only for confirming medical frailty or special medical needs exemptions — and only under penalty of perjury. For ASCs scheduling Medicaid procedures in 2027 and beyond, patients who relied on self-attestation may face additional verification steps that could affect scheduling timelines.
3. No lock-out periods for noncompliant patients
States cannot establish waiting or lock-out periods that permanently bar a recipient from coverage after a compliance failure. For ASCs, this means patients who lose coverage due to noncompliance can restore eligibility and return for scheduled procedures — a relevant consideration for preauthorization workflows and scheduling holds.
4. The medical frailty exemption has a specific two-part test
This exemption is likely to affect a meaningful share of surgical patients. To qualify, an individual must first fall into one of five diagnostic categories: blindness or disability, substance use disorder, a disabling mental disorder, a physical or developmental disability that impairs activities of daily living, or a serious or complex medical condition. That condition must also “significantly impair” the individual’s ability to meet the 80-hour monthly requirement. ASC leaders and their revenue cycle teams should understand this standard, as patients presenting for elective or semi-elective procedures may need documentation confirming exemption status before their Medicaid coverage can be confirmed.
5. The hardship exception now covers home- and community-based services
CMS expanded the inpatient short-term hardship exception to also cover home- and community-based services, citing a need to avoid favoring institutional care over lower-acuity settings. The rule language states that limiting the exception to institutional settings “would fail to account for the realities of current service delivery methods.” The expansion signals that CMS intends the hardship protections to follow the patient across care settings — a framing that could be relevant as ASCs engage with state Medicaid offices on outpatient coverage policy.
Nebraska has already implemented work requirements through a state plan amendment; Montana is set to follow in July.
At the Becker’s 32nd Annual Meeting: The Business and Operations of ASCs, taking place October 29-31 in Chicago, ASC leaders, surgeons and healthcare executives will explore strategies to drive growth, enhance operational performance, navigate reimbursement challenges and prepare for the future of ambulatory surgery. Apply for complimentary registration now.