Work Requirements Unveiled
The Centers for Medicare and Medicaid Services (CMS) have announced their interim final rule on Medicaid work requirements and community engagement. This rule outlines how the HR1 work requirements will be implemented. This will impact people living in the 43 states participating in ACA Medicaid Expansion and partial expansion waiver programs. About 20 million people will be forced to comply with work reporting requirements to retain their coverage, forcing new barriers to healthcare and systemic challenges for states.
Even though the majority of adult Medicaid recipients do work, these requirements are expected to leave people uninsured due to administrative burdens alone. Employment rates may even decrease for disabled people due to the rule changes.
Here we review some of the major proposed changes you’ll need to know, and their potential impact. Public comment on these rules is open through July 31, 2026 on the Federal Register.
Impacts to Disabled People Claiming the Medical Frailty Exemption
Some people with disabilities and medical conditions should be exempt from work requirements in order to retain their Medicaid coverage. Under the interim rules, this “Medical Frailty” exemption would require people to demonstrate their inability to work. This change is more restrictive than the original language proposed in HR 1.
States are instructed to compile lists of diagnoses that might indicate eligibility for this exemption. However, a relevant diagnosis alone would not be enough to claim the exemption. Instead of simplifying the exemption through an automated determination, a person with a disability would still need to show that they cannot work. However, it can be a challenge to offer up evidence that would meet the requirement of the rule. Unless a person already has the needed documentation from a medical professional, they could risk losing the health coverage they need to access a relevant diagnosis.
For a temporary period, the rules allow people to self-declare a work requirement exemption through 2027. States will be allowed to have people self-declare that they are unable to work at least once during the 2027 enrollment period. However, individuals will need to provide documentation when they renew, which could happen quarterly in some states. Self-attestation would end entirely by 2028.
Impacts to Disabled Workers
There are many disabled working adults who rely on Medicaid for their health coverage, since they cannot work full-time. This would force many of these people to take on the additional administrative burden of completing Medicaid verification paperwork regularly, even if they have a life-long disability or medical condition. Some of these individuals may be working 80+ hours per month. However, a health condition could restrict someone’s ability to work that number of hours depending on their current health status. If a person is relying on consistent coverage in order to work part-time at all, the Medicaid rules would put their coverage at risk on a monthly basis. Without consistent coverage, this could put essential healthcare and Home- and Community-Based Services at risk for people with disabilities.
This explainer video from Nicole Jorwic at Caring Across Generations explains how these changes would impact employment and community living for disabled people:
With the changes to work requirements underway, the Urban Institute has predicted up to 7 million eligible people could lose their health care by 2028, including those who qualify for an exemption or are actively meeting work requirements. People with disabilities who are self-employed, people who qualify for an exemption based on their health, and caregivers of people with disabilities are the most at risk of losing their coverage. Individual advocates and organizations are encouraged to share a public comment on these proposed rules through July 31, 2026. Submit your comment through the Federal Register.
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