What the New Work Rules Require
The CMS interim rule takes effect on July 31, 2026. States must start the new eligibility checks by January 1, 2027. The public comment period [pdf] also closes July 31.
The rule applies mainly to adults ages 19 through 64 in Medicaid expansion programs. Each month, they must complete 80 hours of work, service, training, or combined activities. Half-time education or enough monthly earnings can also meet the rule [pdf].
New applicants must show compliance for one to three earlier months. Current enrollees must prove compliance during renewal. States may demand more months or check more often. They must allow 30 days to respond before denying or ending coverage.
Exemptions Leave Major Gaps
Congress and CMS excluded several groups from the work rules. These include certain tribal members, former foster youth, caregivers, veterans, and people receiving addiction treatment. The rule [pdf] also excludes pregnant people and people whom states identify as medically frail.
The medical frailty category covers some disabilities, serious conditions, substance use disorders, and disabling mental disorders. Yet a diagnosis alone does not qualify someone. The condition must greatly limit the person’s ability to meet the rule.
People receiving cancer treatment or living with HIV may not qualify automatically. Their condition must impair their ability to complete qualifying activities. This approach could leave people with changing illnesses at risk.
Evidence Warns About Coverage Loss
Homelessness alone is no longer sufficient to create an exemption. People experiencing homelessness must show another qualifying condition and its effect on daily function. Unstable records, phones, transportation, and housing can make that proof much harder.
Federal officials frame the policy as a guardrail against waste and long-term dependence. They argue that work, education, or service can support independence.
However, Arkansas tested a similar policy in 2018. Research found major coverage losses but no clear employment gains. Reporting barriers caused many losses, rather than a lack of qualifying activity.
Patients Could Lose Care When They Need It
CMS forecasts [pdf] 2.3 million fewer enrollees in fiscal year 2027. It forecasts annual losses of 3.1 million to 3.3 million afterward. These estimates include people who qualify but cannot prove it.
Coverage gaps can interrupt medicines, cancer treatment, HIV care, and follow-up visits. They can also increase medical debt and force patients to delay care. Arkansas participants reported both debt and problems affording care.
CMS estimates that 7% of affected people may lose coverage for paperwork reasons. That group includes people who work or qualify for exemptions. The rule may therefore remove eligible patients, not only people who miss the standard.
Broader Medicaid Cuts Deepen Uncertainty
The 2025 law cuts federal Medicaid spending by about $911 billion through 2034. CMS says this rule alone cuts federal spending by $350.3 billion. CBO expects 7.5 million more uninsured people in 2034.
The full law still raises federal deficits by about $3.4 trillion. Large revenue cuts outweigh its reductions in Medicaid and other spending. Medicaid faces less support even as the overall federal debt grows.
States must balance their budgets and cannot easily replace lost federal funds. Some already plan cuts to optional services, including home-based long-term care. These choices affect older adults, people with disabilities, and family caregivers.
State Choices Will Shape the Damage
Maryland proposed sharp wage cuts for some paid family caregivers. Several other states have considered similar limits or lower payments. These cuts may force families toward debt or institutional care.
States can also change provider payments, optional benefits, enrollment support, and enforcement practices. Federal rules set the floor, but state choices will shape patient harm. A patient’s access may increasingly depend on where they live.
Future Medicaid support now carries deep uncertainty. The law sets major cuts, but budgets, lawsuits, and later federal action may change implementation. Health systems should plan for coverage losses and wide state differences.
Clinicians Become Eligibility Gatekeepers
States should first use claims and other records [pdf] to identify exemptions. When those records fall short, patients may need clinical documentation. States, not clinicians, will make the final decision.
Clinicians should record the diagnosis, severity, treatment, side effects, and expected course. They should connect symptoms directly to the 80-hour monthly test. Useful details include stamina, cognition, attendance, lifting, pain, daily activities, and flare patterns.
Health systems should create templates, referral paths, and rapid appeal support. They should train teams without turning every visit into an eligibility exam. Doctors already fear harm to trust, time, and access. The rule may simply shift costs onto patients, families, states, and clinical teams.
Ben King