Building the Backbone for Compliance: Using a CLRS for the New Medicaid Community Engagement Mandate
A federal “community engagement” mandate is on the horizon for State Medicaid agencies. Beginning January 1, 2027, the One Big Beautiful Bill Act requires states to implement new requirements for their Medicaid expansion populations. This introduces a complex framework for verifying activities, managing a long list of exemptions, and ensuring compliance without creating undue burdens on beneficiaries or state staff.
While the operational challenge is significant, the solution doesn’t require building expensive, custom IT systems. States can meet this mandate efficiently and effectively by leveraging a proven technology already at the heart of social care: the closed-loop referral system (CLRS).
Read on to learn how a CLRS strategy powered by Findhelp transforms a complex mandate into a manageable, transparent, and auditable process.
The implementation challenge: Understanding the new federal law
The statute creates a detailed and prescriptive framework. For states, the complexities involve:
- Tracking and verification: States must verify that individuals complete 80 hours per month of qualifying activities (work, community service, education, or a combination). The law strongly encourages using ex parte data from sources like payroll systems and encounter data to streamline verification.
- Managing exemptions: The community engagement mandate outlines a comprehensive list of automatic and optional exemptions, including for caregivers of young children, individuals with disabilities, veterans, pregnant women, those in substance use treatment, and many others. Each must be identified and tracked.
- Strict notice requirements: The statute mandates specific 60-to-90-day windows for non-compliance procedures, appeals, and quarterly outreach to affected individuals, requiring a robust communication and case management system.
- Conflict of interest prohibition: Crucially, the law prohibits a managed care organization (MCO) or its contractors from making the final determination of a beneficiary’s compliance, necessitating a clear separation of duties.
The solution: A navigator-powered CLRS workflow
Findhelp’s platform provides the ideal infrastructure to manage these requirements. While the state must retain final authority on eligibility determinations, it can delegate the functions of support, navigation, and data collection to trusted partners like MCOs, health systems, and community-based navigators.
This approach leverages existing care coordination expertise and technology, creating an efficient workflow that fully adheres to the law’s conflict-of-interest provision.
Assessment & exemption identification
A navigator or care manager uses a standardized assessment within the CLRS to screen beneficiaries. The system makes it simple to identify and electronically document if an individual meets any of the law’s numerous exemptions (e.g., caregiver status, medically frail, participating in a SUD program).
Personalized plan & referral
The navigator works with non-exempt individuals to create a personalized plan. Using the CLRS, the navigator makes direct, trackable referrals to community partners that offer qualifying activities, such as job training, volunteering, or education. Navigators can also address social barriers to work, like childcare and transportation.
Verification (closing the loop)
The community partner (e.g., a job training or volunteer organization) uses the system to confirm the beneficiary’s participation and log their hours. This “closed loop” provides the verified, third-party data the state needs for its ex parte compliance review, minimizing beneficiary burden.
Informing state determination
The CLRS aggregates this data into a clear, auditable compliance record, generating the necessary reports for states and federal oversight.
Key benefits for state regulators
Adopting a CLRS-based strategy is the most direct path to successfully implementing the new federal community engagement mandate.
Meet deadlines and ensure compliance: By leveraging existing, proven technology and established community networks, you can meet the January 1, 2027 deadline with confidence.
Maximize federal funding: This strategy allows states to allocate their share of federal grants toward vital support services and community capacity building, rather than divert them to expensive and time-consuming IT development.
Reduce administrative burden: Automating the complex tracking of hours, exemptions, and verifications through a single system frees up state personnel from manual data entry and follow-up, allowing them to focus on oversight and complex cases.
Enhance program integrity and audibility: The CLRS creates a secure, time-stamped, and auditable record for every assessment, referral, and completed community engagement activity. This provides an unparalleled level of transparency, simplifies federal reporting, and makes auditing for fraud, waste, and abuse straightforward.
Effectively support beneficiaries: This model gives individuals a simple, navigated process to meet requirements through trusted community partners. By addressing social barriers like childcare and transportation, it increases their likelihood of success and creates genuine pathways to self-sufficiency.
The path to readiness for 2027
The complexity of the federal Medicaid community engagement mandate requires a smarter implementation strategy.
By leveraging existing closed-loop referral systems, states can empower community and private sector partners to handle crucial support and data collection while retaining final determination authority. This model provides the ready-made infrastructure for tracking, verification, and reporting, offering the most direct and responsible pathway to meet the 2027 deadline.
As states and their partners prepare, they can build upon proven, existing infrastructure. The Findhelp platform powers social care networks for State Medicaid Programs, health systems, and MCOs across the country. Tapping into these established systems provides a ready-made solution, ensuring states can meet the mandate efficiently, responsibly, and on time.
To learn how Findhelp’s platform can be a cornerstone of your state’s implementation strategy, contact our team for a personalized discussion.
