Author(s):
On July 31, 2026, the Association of Cancer Care Centers (ACCC) submitted a comment letter to the Centers for Medicare & Medicaid Services (CMS) on its interim final rule (IFR), Medicaid Program; Community Engagement Requirement for Certain Individuals, published in the Federal Register on June 1, 2026.
The passage of the Working Families Tax Cut Act (WFTC), also known as the One Big Beautiful Bill Act (OBBBA), marked a significant shift in Medicaid eligibility policy. Signed into law on July 4, 2025, the legislation established new community engagement requirements for certain Medicaid beneficiaries and applicants.1 Although Congress included exemptions intended to protect vulnerable populations, recent regulatory implementation by CMS has raised concerns among cancer care providers about how these requirements may affect patients with cancer, such as creating barriers to coverage, increasing administrative burden, and potentially disrupting care.
Under the WFTC, certain adults enrolled in Medicaid through the Affordable Care Act Medicaid expansion population, as well as some individuals enrolled through Medicaid waiver programs, must satisfy monthly community engagement requirements to remain eligible for coverage. Generally, affected individuals must participate in at least 80 hours per month of qualifying activities, such as employment, education, community service, or other approved activities.2
These requirements apply across 41 Medicaid expansion states and the District of Columbia, as well as certain waiver-based programs, affecting a total of 44 state Medicaid programs.3,4
Proponents argue that community engagement requirements encourage workforce participation and community involvement. However, patient advocates and healthcare provider organizations have expressed concerns that additional eligibility requirements may increase the risk that vulnerable individuals will lose coverage despite ongoing healthcare needs.5,6
For patients with cancer, maintaining continuous insurance coverage is particularly important. Cancer treatment frequently involves extended courses of care, multidisciplinary services, prescription drugs, imaging studies, laboratory testing, and long-term follow-up. Even short interruptions in coverage can create delays in treatment and increase financial hardship—a concern many ACCC members have expressed.
Recognizing that certain individuals face substantial health-related challenges, Congress included a medical frailty exemption in the WFTC. The statute exempts individuals who are considered “medically frail or otherwise [have] special medical needs” from the community engagement requirements.
Importantly, the law includes individuals with a “serious or complex medical condition” among those who may qualify for this exemption.7 Patients with cancer may fall within this category depending on the nature and stage of their disease, treatment status, symptoms, and overall functional limitations.
However, CMS’s IFR added a new requirement that was the focus of ACCC’s comments. Under the IFR, an individual must not only fall within one of the statutory categories of medical frailty but must also have a condition that “significantly impairs” their ability to comply with the community engagement requirements.8 This additional requirement narrows the statutory exemption and creates uncertainty for patients and providers attempting to determine eligibility.
In its comment letter, ACCC expressed concerns that this requirement could negatively affect certain Medicaid beneficiaries with cancer and made the following requests of CMS:
Remove the IFR requirement that a condition must “significantly impair” an individual’s ability to fulfill the community engagement requirements, as it was not contained in the statute and imposes challenging administrative burdens on patients and their healthcare providers.
If CMS retains the “significantly impair” standard, ACCC asks that it be amended to reflect the real experiences of patients with cancer who are or may become Medicaid beneficiaries, and those of the healthcare providers who serve them. The IFR or any upcoming CMS guidance should minimize administrative burden on patients and providers, as well as the potential for inappropriate losses or interruptions in coverage.
ACCC appreciates that, in developing the IFR, CMS considered whether cancer and certain other serious conditions should automatically qualify for the “serious and complex” condition exemption and decided against it.9 ACCC respectfully submits that, if a cancer diagnosis alone is insufficient, clarifying guidance should be issued that provides implementing states, patients, and providers with a reasonable and practicable method of determining patient eligibility.
The IFR’s standards may create challenges for both patients with cancer and the providers who serve them. Patients may need additional documentation from physicians and cancer care teams to establish that their condition significantly impairs their ability to comply with community engagement requirements. This process could be particularly difficult for patients whose symptoms fluctuate or whose functional status changes during treatment.
Providers may also face substantial administrative burdens. Cancer programs and oncology practices could find themselves spending additional time preparing supporting documentation, answering eligibility questions, and assisting patients in navigating Medicaid requirements. These activities consume clinical and administrative resources that might otherwise be directed toward patient care.
Moreover, delays, interruptions, or losses of Medicaid coverage may lead some patients to postpone screenings, diagnostics, treatment, or follow-up care. For patients with cancer, even temporary disruptions in care can have significant clinical consequences.
ACCC supports efforts to implement the WFTC in a manner consistent with congressional intent while protecting vulnerable patients. However, concerns remain that the IFR’s interpretation of the medical frailty exemption, particularly the addition of the “significantly impair” requirement, may create unnecessary barriers for patients with cancer and increase administrative burdens on providers.
Accordingly, ACCC respectfully urges CMS to clarify the medical frailty standards, provide practical guidance regarding eligibility for individuals with serious and complex medical conditions, and preferably remove the “significantly impair” requirement altogether. As states prepare to implement community engagement requirements in 2027, ACCC hopes CMS will address these concerns to help ensure that patients with cancer maintain access to the coverage and care they need.
Read ACCC’s full comment letter to CMS here.
Nicole Tapay, JD, is the former Director of Cancer Care Delivery and Health Policy for the Association of Cancer Care Centers in Chevy Chase, Maryland.
