Medicaid work rules start January 1. Volunteer hosts should know What Counts.

A federal rule published on June 3 lets some Medicaid adults meet a new monthly requirement by volunteering, and it sets conditions on the organizations that host them. Under the interim final rule from the Centers for Medicare & Medicaid Services (CMS), community service counts only if it is done through a structured program at a public or nonprofit organization. States must put the requirement in place no later than January 1, 2027, the rule says, and the National Council of Nonprofits (NCN) noted in its October 5 newsletter that the changes take effect that day.

What counts as community service

The requirement is at least 80 hours a month. CMS says in its fact sheet that people can combine community service with paid work or a work program to reach the total; enrollment in school at least half-time also qualifies. It applies to expansion-group adults ages 19 to 64, with many exclusions, so a host cannot tell from its roster who is covered.

The rule defines community service as work with a structured program, under the auspices of a public or nonprofit organization, that directly benefits the community. Training that is part of the service counts; CMS gives the example of a computer class taken in order to provide tech tutoring for seniors. Its examples of qualifying service include volunteering at a food bank, mentoring or tutoring youth, delivering meals to seniors and cleaning public parks.

Helping a friend move, joining a recreational club and campaigning for a partisan candidate do not count. The host does not have to be a 501(c)(3): the rule says states must not restrict community service to such organizations, and it names local government agencies, religious nonprofits and smaller social service providers as examples. NCN's newsletter refers to volunteering at 501(c)(3) nonprofits; the rule text is broader.

What the rule asks of the host

To count as a structured program, CMS wrote, the organization must oversee the activity and have a process in place to track the service: the type of activity, the dates and hours, and a point of contact who can confirm the hours.

When a state cannot verify hours from its own data, it asks the enrollee. CMS says supporting information may include the dates and hours, a description of the activity, the organization's name and address, and a contact's phone number or email. We did not find a requirement that hosts register with the state or report hours on their own; CMS recommends that states work with host organizations to set up data exchanges where possible.

What a volunteer manager can keep on file now

In our view, the rule's own list is a sensible starting point, and most of it is ordinary volunteer record-keeping:

• A log of each shift with the volunteer's name, date, hours and activity.
• A short description of each volunteer role and who supervises it, with training time recorded as part of the role.
• The organization's name and address, and one named contact with a phone number and email.
• A routine for issuing a signed statement of hours when a volunteer asks for one.

What each state decides

States determine which activities qualify as community service and how they will verify compliance, according to the rule. Applicants must show one to three months of engagement before applying, as the state chooses, and enrollees are checked at renewal or more often. If a state cannot verify compliance, it must send a notice and allow 30 calendar days to respond.

Documentation rules tighten later. Before January 1, 2028, states may require documentation or accept other information. From that date, when the state has no reliable data of its own, it must require documentation whenever it is reasonably available. A June 29 correction to the rule restated these verification sections and kept both dates.

The start date can also slip for individual states. CMS can grant temporary good-faith exemptions, which must end no later than December 31, 2028, and it expects to approve initial requests for no longer than six months.

Lawsuits are pending

Twenty-five states and Washington, D.C., sued over the rule in June, Healthcare Dive reported. In late July, U.S. District Judge Richard Stearns in Boston denied their request for a preliminary injunction, STAT reported; the denial was without prejudice and the case continues. NCN's newsletter called the case dismissed; news reports describe a denied injunction.

A second suit, filed in federal court in Maryland on September 18 by Medicaid enrollees from five states, medical groups including the American Academy of Pediatrics, and the city of Columbus, Ohio, challenges how the rule defines the medical frailty exemption, Stateline reported. Its claims are allegations that a court has not yet tested. A ruling in either case could change what states put in place.

What nonprofits should watch

Check with your state Medicaid agency before telling volunteers what a letter of hours should say, because the state decides what it will accept. Watch for state notices, court rulings and the January 1, 2028, documentation change. Readers who manage volunteers may also find our guide to a volunteer orientation people remember useful.