Article 7F: Consolidated Rulemaking Decision Matrix

State regulators implementing work requirements face hundreds of granular policy decisions across exemption design, verification architecture, coordination timing, delegation authority, and tribal sovereignty. Each decision interacts with others; choices made in exemption categories ripple through verification processes, coordination timelines, and delegation structures. This consolidated matrix synthesizes all rulemaking choices from the Series 7 handbooks while cross-referencing accommodation requirements for the sixteen special populations analyzed in Series 11 and Article 4D.

The matrix is organized by decision domain, with each choice presented alongside the special populations most affected, recommended approaches, and critical interdependencies. States should read this document alongside the detailed analysis in Articles 7A through 7E, using this matrix as a decision checklist and cross-reference tool rather than a replacement for the underlying analysis.

Part I: Exemption Rulemaking Decisions

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1.1 Age-Based Exemptions

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Decision Point: Upper age threshold for automatic exemption

Recommended: Age 60 automatic exemption

Special Population Cross-Reference:

• Transitions (11G): Andre Williams lost coverage two weeks before turning 60 when his exemption expired. Grace periods should bridge to automatic age exemption.
• Non-SSI/SSDI Disabilities (11K): Older workers with partial disabilities often cannot sustain 80 hours. Lower age threshold provides earlier protection.

Interdependencies: Transition grace periods (7C) must account for approaching age thresholds. System must flag members within 90 days of age exemption to prevent termination immediately before automatic protection begins.

1.2 Social Security Disability Integration

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Decision Point: Automatic exemption for SSI/SSDI recipients

Recommended: Automatic exemption for both SSI and SSDI recipients through data matching

Special Population Cross-Reference:

• Autism/IDD (4D): Adults receiving SSI face no work requirements; those in expansion without SSI face full requirements despite similar functional limitations
• Non-SSI/SSDI Disabilities (11K): Jordan Mitchell’s TBI prevents full-time work but doesn’t qualify for SSI. The gap between SSI threshold and work requirement threshold creates coverage cliff.
• Serious Mental Illness (11B): Many with SMI denied SSI despite substantial functional impairment

Interdependencies: Data sharing agreements with SSA must be executed by March 2026. Trial work period monitoring must maintain exemption during SSDI work attempts.

1.3 Caregiver Exemptions

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Decision Point: Child age threshold for parent/guardian exemption

Recommended: Under 6 automatic; under 13 with documentation of childcare unavailability

Decision Point: Special needs extension regardless of child age

Special Population Cross-Reference:

• Pregnant/Postpartum (11A): Jessica Martinez couldn’t document childcare unavailability because waitlist screenshots weren’t accepted. Requirement should specify acceptable documentation formats.
• Caregiving (11F): Rosa Martinez cared for sister’s children after overdose plus mother with dementia. Multi-generational caregiving requires accommodation.
• Autism/IDD (4D): Parents of adults with autism/IDD need indefinite exemption for ongoing care responsibilities

Documentation Accommodation by Population:

1.4 Medical Exemption Framework

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Decision Point: Approach to medical exemption determination

Recommended: Hybrid approach

Automatic Medical Exemptions (No Application Required):

• Active cancer treatment (chemotherapy, radiation)
• Organ failure requiring transplant listing
• Psychiatric hospitalization within 90 days
• Home health services recipient
• Hospice enrollment
• Recent hospitalization (30-day automatic)

Provider Attestation Pathway:

• Single-page checkbox form
• “Patient cannot consistently meet 80-hour monthly work requirements due to medical conditions”
• No detailed diagnosis required
• 5% random audit rate

Special Population Cross-Reference:

Interdependencies: Provider payment structure (7C) must incentivize attestation completion. EHR integration must enable direct submission.

1.5 Episodic Condition Accommodations

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Decision Point: Framework for conditions with unpredictable fluctuation

Qualifying Conditions: Bipolar disorder, multiple sclerosis, rheumatoid arthritis, Crohn’s disease, lupus, severe migraines, PTSD with acute episodes

Recommended Framework:

Automated Exemption Triggers:

Hour Averaging: 60-hour average over six months acceptable (40 hours bad months, 80+ good months)

Special Population Cross-Reference:

• Serious Mental Illness (11B): Marcus Thompson was hospitalized when verification deadline passed. Hospitalization must automatically trigger exemption and deadline extension.
• Substance Use Disorders (11C): Relapse is expected disease course, not rule violation. Treatment re-entry should trigger automatic exemption.
• Complex Medical (11O): Multiple chronic conditions create unpredictable capacity patterns

1.6 Temporary Disability Rules

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Decision Point: Automatic exemption periods by condition type

Special Population Cross-Reference:

• Pregnant/Postpartum (11A): 12-month postpartum period accommodates recovery, breastfeeding, infant care establishment, childcare arrangement, postpartum depression treatment
• Complex Medical (11O): Surgery recovery periods must account for comorbidity complications

1.7 Confidentiality-Protected Exemptions

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Decision Point: Documentation requirements for domestic violence, trafficking, stalking survivors

Recommended Framework:

Location Protection Requirements:

• Employer name NOT required for verification; industry category sufficient
• Residential address NOT required; P.O. box or confidential address program accepted
• Phone number alternatives including shelter voicemail systems accepted
• Portal access without SMS two-factor authentication available

Special Population Cross-Reference:

• Confidentiality (11H): Lisa Martinez was found by her abuser after providing employer information. Verification must permit location-protecting alternatives.
• Human trafficking survivors: Trafficker monitoring makes any location data dangerous
• LGBTQ in hostile environments (11N): Disclosure of workplace may reveal identity to hostile family/community

Interdependencies: Verification systems (7B) must include location-protected pathways. Appeals processes must maintain confidentiality throughout.

Part II: Verification Rulemaking Decisions

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2.1 Core Architecture

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Decision Point: Distributed submission authority vs. centralized individual reporting

Recommended: Distributed submission authority as primary pathway

Special Population Cross-Reference:

• All populations: Centralized reporting places documentation burden on individuals whose conditions may impair documentation capacity
• Serious Mental Illness (11B): Executive function impairment prevents multi-step documentation
• Autism/IDD (4D): Cognitive processing differences make form completion impossible without support
• Homelessness (11E): No stable address, phone, or document storage for individual reporting

2.2 Large Employer Integration

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Decision Point: Mandatory payroll integration threshold

Recommended: 100+ employees mandatory; smaller encouraged

Technical Requirements:

• API integration or credentialed payroll processor (ADP, Gusto, Paychex, Workday)
• Monthly submission: SSN/Medicaid ID, hours worked, pay period dates
• Integration deadline: October 2026

2.3 Small Employer Solutions

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Decision Point: Verification pathways for employers under 100 employees

Recommended: All pathways available; employer chooses

Special Population Cross-Reference:

• Geographic Isolation (11I): Rural employers may lack internet access. Paper attestation pathway essential.
• Seasonal Workers (11Q): Agricultural employers need seasonal batch reporting
• Gig Economy: Platform partnerships eliminate employer-by-employer verification

2.4 Self-Employment Verification

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Decision Point: Documentation requirements for self-employed individuals

Accommodation: First 6 months of new business counts automatically (business plan development, licensing, setup)

Special Population Cross-Reference:

• Geographic Isolation (11I): Self-employment may be only option in employment deserts
• Justice Reentry (11D): Self-employment may be necessary when employers won’t hire
• LEP (11J): Self-employment common in immigrant communities; may lack formal documentation

2.5 Gig Economy and Platform Work

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Decision Point: Verification pathway for platform workers

Recommended: Pursue platform partnerships aggressively Q1 2026; bank statement fallback; self-attestation only when neither available

Special Population Cross-Reference:

• Substance Use Disorders (11C): Gig work offers flexibility for treatment schedules but generates fragmented documentation
• Justice Reentry (11D): Gig work may be only available employment with criminal record
• Homelessness (11E): Day labor through apps creates no paper trail

2.6 Seasonal and Irregular Work

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Decision Point: Accommodation for employment patterns that don’t match monthly requirements

Recommended: Hour banking as primary; request federal waiver for annual averaging; known off-season exemptions for clearly seasonal industries

Special Population Cross-Reference:

• Agricultural/Seasonal Workers (11Q): May work 160+ hours monthly peak season, zero off-season
• Geographic Isolation (11I): Tourism-dependent areas have inverse seasonal patterns
• Caregiving (11F): Care needs may be seasonal (school year vs. summer)

2.7 Alternative Documentation Standards

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Decision Point: Acceptable verification when standard documentation unavailable

Special Population Cross-Reference:

• Homelessness (11E): Christina Robinson worked day labor with cash payment. No paystubs exist. Self-attestation with audit must be accepted.
• LEP (11J): Cash employment common; may have documentation in non-English
• Undocumented family concerns (within 11H): Fear of documentation creating immigration trail

2.8 Communication Infrastructure Requirements

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Decision Point: Accessibility of verification systems

Special Population Cross-Reference:

• Geographic/Digital Isolation (11I): Tom Henderson had no internet and no transportation to internet. Phone and paper pathways essential.
• LEP (11J): Portal must support threshold languages; phone interpreters for 200+ languages
• Autism/IDD (4D): Plain language, visual aids, navigation support required

Two-Factor Authentication Alternative: SMS-based 2FA excludes people without phones. Email-based or security question alternatives required.

Part III: Coordination and Timing Decisions

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3.1 Redetermination Scheduling

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Decision Point: Synchronized vs. staggered renewal cycles

Recommended: Staggered by birth month for large states; synchronized acceptable for small states

3.2 Grace Periods

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Decision Point: Duration of grace periods across transition types

Special Population Cross-Reference:

• Transitions (11G): Andre Williams lost coverage two weeks before age exemption. Grace periods must bridge to approaching automatic exemptions.
• Serious Mental Illness (11B): Medication stabilization takes 2-6 months post-hospitalization
• Substance Use Disorders (11C): 180-day post-treatment grace accommodates recovery fragility
• Pregnant/Postpartum (11A): 12-month postpartum period prevents coverage gaps during maximum vulnerability

3.3 Warning and Escalation Cascade

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Decision Point: Timeline from non-compliance detection to coverage action

Recommended: Suspension rather than immediate termination; easy reinstatement when documentation arrives

Special Population Cross-Reference:

• Serious Mental Illness (11B): Marcus Thompson was hospitalized when deadline passed. 30-day warning period wouldn’t help someone who can’t receive warnings.
• Homelessness (11E): Mail doesn’t reach people without addresses. Phone calls don’t reach people whose phones were stolen.

Accommodation: Hospitalization, incarceration, or other institutional status automatically extends all deadlines by duration of institutional stay plus 30 days.

3.4 Appeals Timeline and Process

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Expedited Appeals Available For:

• Active treatment at risk
• Chronic condition requiring continuous medication
• Pregnancy
• Mental health crisis

Special Population Cross-Reference:

• All populations: Coverage ALWAYS continues during appeals. Burden of delay falls on state.
• Autism/IDD (4D): Appeals process assumes capacity to navigate bureaucracy. Support required.
• LEP (11J): Appeals materials in threshold languages; interpreter services throughout

3.5 Provider Payment for Exemption Documentation

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Decision Point: Compensation structure for provider attestations

Recommended: $35 flat fee primary; capitated payments to FQHCs serving high proportions of expansion adults

Part IV: Delegation Authority Decisions

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4.1 Credentialed Entity Tiers

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Tier 1: Primary Submitters (Direct State Delegation)

Tier 2: Intermediary Submitters (Aggregation Authority)

Tier 3: Community-Based Submitters (Limited Authority)

Special Population Cross-Reference:

• Homelessness (11E): Shelter case managers and street outreach workers must be credentialed as trusted intermediaries
• Substance Use Disorders (11C): Treatment program staff can verify treatment participation hours
• Faith communities serving immigrants: May be only trusted institution for LEP populations

4.2 Safe Harbor Provisions

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Employer Safe Harbor:

• Protected for submitting hours as recorded in standard payroll systems
• No liability for employee coverage loss due to accurate reporting
• No liability for good-faith errors corrected when discovered
• Exceptions: intentional false reporting, retaliation, systematic timekeeping failure

Provider Safe Harbor:

• Protected for attestations based on clinical relationship and professional judgment
• No malpractice liability for good-faith exemption attestations
• No liability if state denies exemption despite provider recommendation
• Documentation in medical record required

Special Population Cross-Reference:

• Confidentiality (11H): Employer safe harbor should NOT extend to responding to third-party inquiries about employee schedules (enables stalking)
• Substance Use Disorders (11C): Provider safe harbor must accommodate 42 CFR Part 2 confidentiality requirements

4.3 Individual Rights to Challenge Delegated Actions

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Part V: Tribal Sovereignty Decisions

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5.1 IHS Exemption Implementation

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Decision Point: Verification of IHS eligibility for automatic exemption

Recommended: IHS data match where federal agreement allows; tribal attestation as primary alternative; self-attestation with verification as fallback

5.2 Data Sovereignty Accommodations

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5.3 Tribal Administration Option

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Decision Point: Whether tribes can administer work requirements for their own members

Culturally Appropriate Qualifying Activities:

• Subsistence hunting, fishing, gathering
• Traditional ceremony participation
• Elder care according to traditional responsibilities
• Tribal program volunteer service

Part VI: Special Population Accommodation Matrix

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This matrix summarizes accommodations required for each Series 11 population across all rulemaking domains.

6.1 Pregnant and Postpartum (11A)

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6.2 Serious Mental Illness (11B)

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6.3 Substance Use Disorders (11C)

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6.4 Justice Reentry (11D)

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6.5 Homelessness (11E)

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6.6 Caregiving (11F)

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6.7 Transitions (11G)

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6.8 Confidentiality Protections (11H)

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6.9 Geographic and Digital Isolation (11I)

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6.10 Limited English Proficiency (11J)

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6.11 Non-SSI/SSDI Disabilities (11K)

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6.12 Intersectionality (11L)

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6.13 Autism/IDD (4D)

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6.14 Veterans (11M)

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6.15 LGBTQ+ (11N)

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6.16 Foster Care Alumni (11P)

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Part VII: Implementation Interdependencies

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Critical Path Dependencies

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1. Data sharing agreements (SSA, DOL, IHS, HMIS) must be executed by March 2026 before system development can incorporate automatic exemptions

2. Provider portal development requires provider payment structure finalization by April 2026 to enable training

3. Employer credentialing cannot begin until verification architecture decisions are final (May 2026)

4. MCO contract amendments require delegation authority framework by June 2026

5. Tribal consultation must produce government-to-government agreements before any tribal population provisions can be implemented

6. Special population accommodations must be coded into eligibility systems during July-September 2026 development

System Integration Requirements

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