CMS Offers Mitigation. States Still Need the Evidence.

SPECIAL BRIEFING

A state cannot connect a required data source in time. Its application has been revised, but the online workflow has not. Its eligibility notices need changes while staff are preparing for additional verification work.

These are implementation problems with consequences for people seeking or keeping Medicaid coverage. They also raise a practical control question: when a temporary workaround becomes the process, what evidence will demonstrate that the state followed the authorized approach?

A CMS mitigation checklist circulated to state Medicaid directors with an October 21 email puts that question directly before state leaders. The email asked states to identify deficiencies, proposed mitigations, and implementation timelines in advance of discussions beginning in November. The accompanying checklist describes potential strategies across community engagement, application and renewal processing, and fair hearings. [1]

Health Management Associates reported on November 4 that CMS plans to begin meeting with states this month about their mitigation plans. As of November 5, we found no public confirmation of an individual state’s submission or approval under the October checklist.

The checklist separates community engagement implementation deficiencies, related processing deficiencies, and optional strategies to address operational or system challenges. Depending on the strategy, CMS identifies state plan authority, section 1902(e)(14) authority, or approved enforcement discretion as possible routes. Listing a strategy in the checklist does not establish approval for an individual state. [1, p. 1]

Its potential mitigations include temporary self-attestation where a state lacks a required data connection, manual review of claims information, and certain enrollment approaches followed by exclusion verification. Other options address notice inserts, outreach, staffing, and processing delays. The checklist also identifies a temporary one-month community engagement review period for states with longer review periods, subject to the stated authority and conditions. [1, pp. 2–11]

These approaches can preserve access and keep work moving while permanent capabilities are completed. CMS’s public community engagement resource page independently acknowledges the substantial changes to systems, policy, and operations that implementation requires. [2]

The checklist says states must comply with approved mitigation plans to avoid formal compliance action under section 1904 for the associated deficiencies. It expects quarterly updates on milestones, progress toward full compliance, and newly identified risks or barriers. CMS may request more information, more frequent reporting, or additional mitigations. [1, p. 1]

That gives mitigation an operational life beyond the submission. A state needs to connect the approval to the instructions staff receive, the system rules they use, and the cases those rules affect.

Consider a hypothetical state authorized to accept self-attestation temporarily for a particular verification gap. A reviewer should be able to establish:

A planned interface is not evidence that an interface operated. A revised procedure is not evidence that staff followed it. A completed milestone is not, by itself, evidence that the resulting decisions were accurate.

The checklist’s optional strategies include using SNAP gross income and certain other information to support financial eligibility renewal. It separately reminds states that an applicable individual’s community engagement compliance, deemed compliance, or exclusion must still be assessed. [1, pp. 11–12]

CMS’s November 2024 guidance provides useful public background. It discusses documenting SNAP gross-income use in verification policies and procedures and additional analysis for certain uses involving other programs or non-MAGI populations. [3]

The operational question is specific: what fact does the information establish, and what does the state still need to determine? An income finding and a community engagement determination answer different questions.

The supplied checklist describes mitigation approval and compliance oversight. It does not establish blanket protection from PERM findings or federal funding consequences. Nor does its use of temporary strategies establish that every affected payment is improper. [1]

Our operational conclusion is that states should retain the applicable approval, its conditions, the evidence supporting the decision, and the record of required follow-up together. Questions about how a particular mitigation will be treated in PERM should be resolved with CMS and documented, rather than inferred from the existence of a mitigation plan.

Maintain one register linking each deficiency to the requested strategy, approval, accountable owner, effective period, affected workflow, reporting requirements, and permanent fix. Track proposed, approved, implemented, and tested as distinct statuses.

Then test a small set of cases against the approved process. Include cases near effective and expiration dates, cases requiring follow-up, and cases that should fall outside the mitigation. Use the results to correct the process before a reporting milestone becomes an unsupported assertion of completion.

CMS mitigation can give a state a practical path through an implementation problem. The state’s assurance work is to demonstrate that it followed that path—and that eligible people received the protections the process was intended to provide.

[1] CMS, Proposed State Mitigation and Optional Strategies to Support Implementation of Community Engagement and Other Eligibility & Enrollment Provisions of the Working Families Tax Cut (WFTC) Legislation, 13-page fillable checklist supplied to PERM Insights; accompanying Anne Marie Costello email dated October 21, 2026. A public CMS posting of this exact checklist was not located in the November 2 review. The email’s recipient list is not reproduced.

[2] CMS, Community Engagement resources, reviewed November 2, 2026.

[3] CMS, Use of Unwinding-Related Strategies to Support Long-Term Improvements to State Medicaid Eligibility and Enrollment Processes, November 14, 2024. Historical background; individual strategies remain subject to applicable current authority.

Timing note: This discussion concerns the supplied mitigation framework. The October 29 medical-frailty ruling and related enforcement relief require separate consideration. The Massachusetts Attorney General’s October 29 announcement describes that ruling. Applicable court orders, subsequent stays, and CMS guidance must be checked before relying on a particular implementation or enforcement date. This article does not treat January 1 as an unchanged enforcement date for every state.

PERM Insights & Perspectives · Education not Advocacy