In partnership with the National Council for Mental Wellbeing and our State stakeholders, RCPA is excited to share with members that a federal court has struck down a key portion of a provision of the H.R.1 community engagement rule. The requirement mandated that people who receive Medicaid through the expansion of the program created in the Affordable Care Act must work, volunteer, or go to school for 80 hours a month to keep their benefits, but it exempted people too medically frail to work. The challenge was based upon the requirement that medically frail individuals would have to prove their condition significantly impaired their ability to comply with the new work and community engagement rules.
The court ruled that CMS “lacked the authority to impose that condition and vacated that part of the rule.” For people with serious behavioral health needs, this decision removes one more hurdle between them and the care they rely on. For providers, it means one less layer of paperwork and less administrative burden to aid clients in maintaining eligibility.
The ruling blocks only the “medical frailty” portion of the law and leaves in place the remainder of the Medicaid work requirements, which will be enforced nationally beginning in January. For Pennsylvania, these eligibility requirements will begin February 1, 2027.
“This is an important legal decision that specifically helps those with significant needs who are being impacted by H.R. 1,” stated Richard Edley, President and CEO of RCPA. “The implementation continues, but with additional protections for those who are medically frail. I am proud that Pennsylvania joined with other states in this fight.”
“Today’s decision removes an unnecessary barrier to Medicaid coverage for people with serious behavioral health needs,” said Chuck Ingoglia, President and CEO of the National Council for Mental Wellbeing. “We were proud to stand with our partners in challenging this requirement. As communities navigate major changes to Medicaid, we will continue working alongside our members to protect access to care and find a path forward.”
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The below section is from the National Council for Mental Wellbeing:
What Changes and What Doesn't
The broader community engagement requirements under H.R. 1 are still in effect, and so is the January 1, 2027, implementation deadline. The court also upheld two other parts of the rule: the 12-month limit on claims and encounter data used to assess medical frailty, and self-attestation restrictions beginning in 2028.
The court did pause enforcement of medically frail determinations for six months for the plaintiff states, including Pennsylvania, which gives those states time to adjust their systems. For states that are not parties to the lawsuit, the requirement that an individual prove their medically frail status substantially impair their ability to comply with the community engagement requirement is no longer in effect. However, these states will not receive the six-month stay of enforcement granted to the plaintiff states. The plaintiff states that will receive a six-month stay of enforcement for determining medical frailty are: Arizona, California, Colorado, Connecticut, Delaware, the District of Columbia, Hawaii, Illinois, Kentucky, Maine, Maryland, Massachusetts, Michigan, Minnesota, Nevada, New Jersey, New Mexico, New York, North Carolina, Oregon, Pennsylvania, Rhode Island, Vermont, Virginia, Washington and Wisconsin.
This may not be the final word. Either side has 60 days to appeal, and the decision stays in effect unless the court puts it on hold while a reconsideration request or appeal is pending.
Another lawsuit challenging the policy, filed by medical groups and the city of Columbus, Ohio, remains pending in a Maryland federal court. National Council and our partners also plan to file an amicus brief challenging provisions of the rule in this case.
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RCPA’s Next Steps:
How this ruling directly impacts Pennsylvania’s current plan for the implementation of the Community Engagement Requirements (CER) is yet to be seen, but RCPA, working with several state-wide steering committees, will seek DHS guidance in the coming weeks.
As the state’s provider advocacy leader, RCPA will also be conducting a series of H.R. 1 Medicaid webinars that will provide updates and trainings to assist members in navigating the Medicaid changes. The first will include a tutorial from the Office of Medical Assistance Programming (OMAP) on the utilization of the PROMISe EVS system to access expansion recipient eligibility and redetermination status.
Visit the RCPA website for coverage of Medicaid changes. We will continue to amend our documents and guides to keep you, our members, up-to-date as more information becomes available.
