Comment on CMS-2026-2047-0002

Re: CMS-2454-IFC; RIN 0938-AV98; Medicaid Program; Community Engagement Requirement for Certain Individuals To the Centers for Medicare & Medicaid Services: Lane Independent Living Alliance is the Center for Independent Living serving Lane County, Oregon under Title VII of the Rehabilitation Act. We operate under the Independent Living philosophy, which holds that people with disabilities are the experts on their own lives and that systems serving them should not start from a test of how impaired someone must be before they are believed. We comment on the interim final rule implementing the Medicaid community engagement requirement under section 1902(xx) of the Social Security Act, focusing on the medically frail exclusion at 42 CFR 435.554(c)(5) and its verification requirements at 42 CFR 435.557. The medically frail definition conflicts with the statutory categories: Congress authorized the Secretary to define who is medically frail or otherwise has special medical needs, but required that the definition include five enumerated categories. One category, physical, intellectual, or developmental disability, already contains a functional test limited to activities of daily living. CMS's rule adds a second, different functional test to all five categories: whether the condition significantly impairs the individual's ability to comply with the 80-hour requirement. This does not appear in the statute and risks reducing Congress's mandatory categories to examples with no independent effect. We ask CMS to remove it and treat satisfaction of any statutory category as sufficient. Verification will fall hardest on the people our network already serves: Many people we serve, particularly those with episodic, psychiatric, cognitive, or otherwise poorly documented disabilities, are unlikely to have information available to the state that reliably establishes both their condition and its functional effects, especially where the condition does not generate frequent medical billing. If a state cannot verify that an exclusion applies, the individual may receive a notice of noncompliance and 30 days to make a satisfactory showing. We ask CMS to make clear that this period cannot begin until the state has complied with 42 CFR 435.557 by checking all reliable information and considering every potential applicable exclusion and has issued an accessible notice naming what is needed and offered reasonable modifications and assistance. No one should be treated as noncompliant for a missed response before the state assesses whether it reflects disability, communication barriers, homelessness, institutionalization, or hospitalization. Although §435.557 permits statements under penalty of perjury in some circumstances, it leaves sufficiency standards to each state and restricts repeated use of that pathway beginning in 2028. We ask CMS to require acceptance of attestation, absent contradictory reliable information, whenever documentation does not exist or is not reasonably available, and set a federal minimum evidentiary standard. The family caregiver threshold: For caregivers who are unrelated to and do not reside with the person receiving care, the rule imposes an 80-hour monthly threshold at 42 CFR 435.554(c)(3)(i)(C) to qualify as excluded. Disability support networks often depend on friends and chosen family outside legal kinship or shared housing. We ask CMS to eliminate this threshold for such caregivers or let states recognize substantial caregiving based on the nature of support rather than a rigid hour count, verified by attestation rather than time records. Broader eligibility processing changes: This rule also restores pre-2024 provisions governing applications, renewals, and changes in circumstance, including 42 CFR 435.907, 435.911(c), 435.912, 435.916, and 435.919 through October 1, 2034, with conforming CHIP effects. These changes reach Medicaid applicants and beneficiaries beyond the population subject to the community-engagement requirement. We ask CMS to retain the 2024 protections except where it identifies a specific textual conflict with section 1902(xx), and to explain why displacing each protection is necessary to implement the statute, not merely convenient. People with well-established disabilities may lose coverage not because they fall outside a statutory category, but because they cannot satisfy an added functional test or navigate the process used to verify it. We ask CMS to align the medically frail definition with the statutory categories and adopt accessible, consistent verification protections. Respectfully submitted, Scott Lemons Assistant Director Lane Independent Living Alliance