States will have some flexibility in requiring Medicaid beneficiaries enrolled in the expansion population to meet the new work requirements, CMS says in its initial guidance on provisions of the GOP megabill, which also allocated $200 million in Government Efficiency Grants to help states implement the new community engagement requirements. Among the completely exempted beneficiaries are former foster care children, pregnant women, certain native populations, inmates, caregivers of a 14-year-old or younger, beneficiaries diagnosed with special medical needs, and Temporary Assistance for Needy Families and Supplemental Nutrition Assistance Program enrollees. Beneficiaries enrolled in certain substance use disorder treatment and rehabilitation programs are also exempt. States will have the option to exempt beneficiaries from work requirements if they meet “certain short-term hardship events.” These are “receiving inpatient hospital services or certain other types of medical care; residing in a locality where there is a Presidential declaration of a disaster or emergency; residing in a locality with an unemployment rate over certain thresholds; or needing to travel outside of their community for an extended period of time, for themselves or their dependents, to receive treatment of a serious or complex medical condition where such treatment is not available within the individual’s community of residence.” Meanwhile, states only have to provide written notice of initial enrollment denials and fair hearing rights before dropping the beneficiary from coverage at the end of the 30-day period.