Patient advocates, providers, health plans and others across the Medicaid community are raising concerns that upcoming work requirements as part of new federal Medicaid changes required by the One Big Beautiful Bill Act (HR 1) are likely to create undue administrative barriers and leave eligible Medicaid beneficiaries at risk of losing coverage.
In response to a recent interim final rule (IFR), leading health organizations urged CMS to revise the rule’s medical frailty and verification requirements, preserve flexible approaches such as self-attestation, and provide states with greater flexibility and clearer implementation guidance to prevent eligible people from losing coverage because of paperwork or systems challenges.
More than 43,000 comments were submitted in response to the IFR, underscoring the impact of these policies across the Medicaid community. Here’s what several Modern Medicaid Alliance partners are saying about the rule:
Patient & Consumer Advocates
- American Cancer Society Cancer Action Network (ACS CAN): “While most cancer patients would like to continue working during treatment, most experience disruptions in their work hours, and many must stop working for a period of time in order to receive their treatments…Numerous studies have shown that additional paperwork requirements dramatically increase the likelihood of procedural denials of coverage. For cancer patients, this will cause gaps in health insurance coverage for the very people this exception was supposed to protect – people who are medically frail and need to maintain access to Medicaid.”
- National Alliance on Mental Illness (NAMI): “The [medically frail definition’s] “significantly impairs” requirement will also subject people with mental illness and other chronic conditions to an additional burden and a higher standard than is required for other specified excluded individuals…If [a beneficiary’s] mental health deteriorates, they will have to figure out how to submit the right documentation to demonstrate they can no longer work as their mental health worsens – the exact time that they are most likely to struggle with navigating bureaucracy and paperwork.”
- National Consumers League (NCL): “NCL advocates for increased access to high-quality healthcare, and is extremely concerned that CMS’s definition of the medically frail exemption and its restrictions on self-attestation unnecessarily increase the risk of avoidable coverage losses. This policy will leave millions more Americans uninsured, increase delays in needed healthcare, drive higher levels of medical debt, and ultimately make it more difficult for many individuals to achieve long-term financial independence.”
- National Health Council (NHC): “Even relatively brief interruptions in coverage can disrupt established treatment plans, impede access to medically necessary care, delay diagnostic testing or follow-up appointments, complicate disease management, and increase health and financial instability for patients and families…eligible individuals should not lose Medicaid coverage because of administrative barriers rather than true ineligibility.”
- National Hispanic Health Foundation (NHHF): “We believe that there are major issues with the new rules that need to be reviewed…To minimize confusion, medical frailty identification methodologies should be as transparent as possible…Medical frailty should be defined to encompass the full range of health conditions and functional impairments experienced by people with disabilities and chronic illnesses; [and] should be redetermined only when an enrollee’s health condition improves, to minimize administrative burden and keep eligible people enrolled.”
- National Kidney Foundation (NKF): “NKF is deeply concerned that community engagement reporting requirements…could cause people living with kidney disease, kidney failure, and kidney transplants to lose Medicaid coverage because of complex documentation barriers or state system failures…Loss of Medicaid coverage will accelerate progression to kidney failure, increase avoidable emergency department use and hospitalizations…”
- National Patient Advocate Foundation (NPAF): “NPAF is deeply concerned that the IFC’s community engagement framework will fall hardest on Medicaid beneficiaries already experiencing health conditions and financial hardship as well as the family caregivers who help them stay connected to coverage and care…Coverage interruptions caused by these procedural burdens can have severe downstream effects for people with financial hardship even when they are not ill.”
Aging, Disability & Caregiver Advocates
- American Association on Health & Disability (AAHD): “[The One Big Beautiful Bill Act] was supposed to exempt family caregivers from the community engagement requirement…Penalizing caregivers for not meeting an additional work requirement ignores the economic and social value of the care they already provide. If caregivers lose Medicaid coverage, the people with disabilities who depend on them are also harmed. The result may be avoidable health crises, caregiver burnout, loss of community stability, and increased risk of institutional placement.”
- Justice in Aging: “We are deeply concerned about the impact of the [IFR] on older adults, people with disabilities, and the caregivers they rely on for crucial support…It is crucial the community engagement requirements are implemented in a manner that minimizes improper termination or denials.”
- National Alliance for Caregiving: “NAC appreciates the CMS’ recognition of the critical role family caregivers play and strongly supports the agency’s decision to exclude family caregivers from Medicaid community engagement requirements…At the same time, we are concerned that parts of the rule may unintentionally leave some caregivers and care recipients without the protections Congress intended.”
Healthcare Providers
- American Psychological Association (APA): “People’s ability to meet and document [work requirement/community engagement] requirements will also fluctuate, requiring people to prove they are unable to work to keep their Medicaid coverage at times when they need care the most. For millions of Americans, [mental health/substance use disorder] treatment — made possible by public or private insurance — is a prerequisite for being able to work.”
- American Association of Nurse Practitioners (AANP): “While this IFC considers the burden it may place on states, there is no assessment of the implications of the verification requirements on providers such as NPs. Specifically, as it relates to certification of medical frailty, much of the burden is placed on health care providers. The IFC as proposed does not provide clarity on a process for this certification, does not establish a clear national minimum standard for medical frailty, relies on states’ interpretation of federal guidance, and does not clarify a health care provider’s role if a patient’s eligibility status is contested. Further, for patients with serious and challenging medical conditions, the proposed requirements and timeframes for recertification are unnecessary and present a tangible burden.”
- America’s Physician Groups (APG): “APG members are long-standing proponents of, and advocates for, value-based care…To the extent that many Medicaid enrollees who are indisputably ‘medically frail’ will lose coverage due to new administrative requirements, the resulting coverage gaps will make participation in value-based care models impossible for these affected populations, as there will be no payer with which to negotiate these arrangements. The health of Medicaid enrollees who become uninsured will suffer…and to the extent that they can obtain health care at all, it is likely to be delivered episodically and reactively in hospital emergency departments, where it will drive up the costs of uncompensated care and further destabilize the delivery system.”
- American Speech-Language-Hearing Association (ASHA): “ASHA members have seen that most Medicaid-enrolled low-income adults already work or have documented reasons they cannot, including caregiving responsibilities, disability, or school enrollment. Evidence from states that have previously implemented work requirements demonstrates that such policies do not achieve their stated goal of increasing employment. Instead, they create bureaucratic barriers that cause eligible individuals to lose coverage and forgo needed care.”
- Children’s Hospital Association (CHA): “Our comments focus on the potential unintended consequences for young adults with complex conditions who are likely to face additional disruptions in coverage and care due to the administrative complexity associated with proving their eligibility for the medical frailty exclusion. We are also concerned about coverage gaps for parents and caregivers of children with complex medical conditions, as well as the operational challenges for children’s hospitals who often serve Medicaid beneficiaries from multiple states…These changes are likely to compound the challenges facing young adults with complex medical conditions and their families, making them more vulnerable to coverage loss, financial strain, and potentially devastating disruptions in their care.”
- LeadingAge: “CMS’s own regulatory impact analysis projects that this rule will reduce Medicaid enrollment by approximately 2.3 million people in FY 2027 and by 3.1 to 3.3 million in later years. Each additional definitional ambiguity, verification step, and documentation demand the IFC layers on top of the statute increases the share of that reduction borne by people who are, in fact, eligible and excluded from the requirement.”
- National Association for Behavioral Healthcare (NABH): “NABH has serious concerns that many aspects of the IFC – especially the functional impairment standard CMS applies to the medically frail exclusion – misalign with Congressional intent and statutory authority and pose extraordinary implementation challenges for providers and individuals. This will result in countless people who cannot complete qualifying activities due to a behavioral health condition being disenrolled.”
- National Association of Community Health Centers (NACHC): “We remain concerned that, when viewed collectively, the policies included in the regulation may create substantial administrative challenges for CHCs and their patients. These requirements could increase operational and financial pressures on CHCs, potentially contributing to avoidable coverage disruptions and creating additional challenges for the communities they serve.”
- National Rural Health Association (NRHA): “NRHA is concerned that key elements of the IFR rule could unintentionally undermine access to care in rural communities by creating new administrative barriers for beneficiaries and operational challenges for rural providers…In rural communities, the IFR’s reliance on individual-level exemptions are particularly problematic. Rural populations experience higher rates of chronic disease, disability, and behavioral health conditions, increasing the share of individuals who should be exempt but may be missed in practice.”
- Trinity Health: “The IFR adopts a relatively narrow framework that requires not only the presence of a qualifying condition but also a determination that the condition significantly limits an individual’s ability to meet community engagement requirements…If finalized, this policy could lead to the loss of health care coverage for individuals with chronic or complex conditions.”
Payers & Other Health System Leaders
- Alliance of Community Health Plans (ACHP): “ACHP, and many experienced state leaders, remain concerned that the rule’s approach to medical frailty creates a substantial new barrier for beneficiaries Congress intended to exclude from community engagement requirements…These requirements will increase administrative burden for states, providers and beneficiaries while creating significant risk that medically vulnerable beneficiaries lose coverage not because they fail to meet the underlying medical criteria, but because they are unable to navigate a complex documentation and review process.”
- Healthcare Leadership Council (HLC): “The IFC offers only a narrow window of flexibility for states to accept self-attestation under penalty of perjury, curtailing it beginning January 1, 2028, when a statement may be used only once during anindividual’s enrollment before documentation is required. Requirements built around documentation eligible individuals cannot readily obtain will predictably generate processing backlogs and erroneous disenrollments, with the heaviest impact on those least able to navigate the process, such as people managing complex medical conditions.”
- National MLTSS Health Plan Association: “Our members are deeply invested in an implementation approach that meaningfully carries out the statute while protecting continuity of coverage and access to care for the vulnerable populations they serve — including older adults, people with disabilities, and individuals who rely on [long-term services and supports] to live safely and independently in their communities…Additional clarity would most improve implementation, particularly [surrounding] the accurate identification of individuals who qualify for the medically frail and caregiver exemptions.”
As states move toward implementing the new work requirements, federal policymakers must provide states, providers and beneficiaries with adequate support and clear guidance so eligible individuals can get and keep the Medicaid coverage they need. For more information on Medicaid’s vital role, visit https://modernmedicaid.org/.