How States Can Effectively Communicate Upcoming Medicaid Work Requirements

With work requirements for Medicaid taking effect in 2027, some beneficiaries are at risk of losing coverage. In most cases, it's not that they don't want to work; it's because they don't know about or understand the new requirements.

Starting Jan. 1, 2027, certain beneficiaries will be required to regularly demonstrate that they're either working, volunteering, or participating in approved community engagement programs (e.g., educational programs) to maintain their Medicaid coverage. Per federal guidance, states must notify beneficiaries about work requirements by either regular or electronic mail and at least one additional form of communication. Initial outreach to existing beneficiaries must begin no later than three months prior to the first month the work requirement must be met. (The time period may be longer, depending on how many months of compliance each state will require beneficiaries to demonstrate.)

For this new national policy-also known as "community engagement requirements"- states will need a comprehensive outreach strategy that involves trusted stakeholders, clear language, and a variety of communication methods. This will be a challenging task for states but, fortunately, there are lessons from past efforts that can help.

Reaching Medicaid Beneficiaries is Challenging

While this is the first time Medicaid community engagement requirements will apply nationally, 13 states received waivers from the Centers for Medicare & Medicaid Services (CMS) in 2018 to implement similar requirements. Most of these waivers were not fully implemented because of court rulings or federal or state actions. However, the states' experiences provide important information about what works-and what doesn't-in reaching beneficiaries.

States that implemented or planned to implement work requirements in 2018 used many different methods to inform beneficiaries of the change, including mail, phone calls, door-to-door campaigns, radio advertisements, email, public forums, and text messages. Phone calls and mail, in particular, were ineffective in reaching beneficiaries on a large scale. There were many reasons for this, including inaccurate phone numbers and addresses, hesitancy to answer out-of-state or unknown phone numbers, reluctance to share Medicaid ID or Social Security Numbers over the phone, general mistrust in government, and more.

Although states used a variety of outreach approaches, many beneficiaries still lost coverage or risked losing coverage because they did not understand the community engagement requirements, did not comply with the documentation requirements and/or the actual work requirement, or had to navigate complex verification systems. Further, some states began outreach too late, had limited resources for outreach, or were unable to match beneficiary data from payroll data, Medicaid enrollment data, or other sources.

Creating Successful Outreach Strategies

States' past experiences can inform the development of effective outreach strategies for the new requirements.

Develop a Structured Timeline

States must begin beneficiary outreach at least three months prior to Jan. 1, 2027, the implementation date. The specific start date for outreach depends on whether the state will require beneficiaries to demonstrate one, two, or three consecutive months of work or community engagement.

In all options, states should conduct regular outreach, ideally monthly, from the initial outreach date through December 2026 to ensure beneficiaries have sufficient time to meet the community engagement requirement before implementation.

Partner with Stakeholders

In the early stages of planning their outreach strategies, states should collaborate with a variety of trusted stakeholders, including beneficiaries and their advocates, health care providers, community-based organizations, and managed care organizations. This will ensure that outreach is both community-informed and responsive to local needs. Examples of trusted stakeholders and their potential roles include:

• Community-based organizations (CBOs) can help create targeted messaging for at-risk populations such as the homeless, hearing and vision impaired, recently incarcerated, and those who speak English as a second language. CBOs can also assist with outreach logistics and provide direct communication to their clients.
• Beneficiary Advisory Councils within state Medicaid agencies can help test whether outreach messages are easy to read and understand. These councils can also serve as an avenue for outreach and answering beneficiary questions.
• Managed care organizations (MCOs) can collaborate with states to draft scripts for case managers and customer service representatives who interact regularly with Medicaid beneficiaries. MCOs can also help members who are potentially medically exempt from work requirements.
• States can develop tip sheets, posters, and scripts for providers, including outpatient clinics, health centers, and hospitals patient services/front office staff.

Use a Variety of Outreach Methods

Given the challenges of reaching beneficiaries, states should use a wide range of communication methods. For example, they could post "how-to" videoson state Medicaid websites and on social media channels demonstrating how to fill out the paperwork. States can also "piggyback" messages about community engagement requirements with communications from other programs that Medicaid beneficiaries tend to use, such as Supplemental Nutrition Assistance Program or Temporary Assistance for Needy Families.

States should also consider tailoring messages to beneficiaries based on whether they are exempt from community engagement requirements. For instance, states should use different messaging for beneficiaries who risk losing coverage and need to take action as opposed to those who are exempt from community engagement requirements because of eligibility status or because they already meet the requirements.

Use Simple, Accessible Language and Strategically Timed Messages

Regardless of the outreach methods states use, they should:

• Explain work requirements clearly and in plain language at a 4th-6th grade reading level;
• Provide information on how non-English speaking beneficiaries can request language assistance, including directions for accessing the language line; and
• Send multiple outreach messages so that beneficiaries receive information on a continuum, with more detailed information that conveys a sense of urgency and next steps close to when they need to take action to maintain coverage.

Implementing work requirements at a national level is a major shift in Medicaid policy that will pose administrative and operational challenges for states. AIR can assist states in thinking through a strategic and deliberate outreach plan to help minimize confusion, reduce loss of coverage among eligible beneficiaries, and avoid spending public resources on ineffective strategies.