Medicaid Work Requirements
What Families With Disabled Adult Children Need to Know
Medicaid work requirements are not a new idea. Arkansas tried them in 2018, and a federal judge halted the program in 2019 - but not before roughly 18,000 people lost coverage. Now they're back, written into federal law this time, and if you're like me, your first thought was something like: “Great, now what do I need to do?”
In theory, individuals with disabilities should not be affected. This means most of you reading this are not the primary targets of these rules. But "most" is not the same as "safe," and the details matter more than the headlines suggest - including for families who assume they're out of scope.
What the law does
H.R. 1,1 signed into law on July 4, 2025, requires states to implement community engagement requirements - the official term for work requirements - for certain Medicaid enrollees no later than January 1, 2027. I wrote about the broader Medicaid cuts driving this law earlier this year. Work requirements are one piece of a much larger set of changes reshaping the program.
If you live in Alabama, Florida, Kansas, Mississippi, South Carolina, Tennessee, Texas, or Wyoming, your state has not expanded Medicaid, and the work requirements in this bill do not apply to your state’s program. Georgia and Wisconsin have partial expansion programs, and residents enrolled through those programs are in scope. Everyone else - 41 states plus Washington, D.C. - has a fully expanded Medicaid program, and this is where the rules take effect.
The requirement applies to adults ages 19 to 64 who are enrolled through the Affordable Care Act (ACA) Medicaid expansion - specifically, people who qualify for Medicaid based on income rather than through a disability or age-based pathway. To keep their coverage, they must document 80 hours per month of qualifying activities: working, volunteering, attending school, or participating in a job training program.
Who is not in scope
As I read the rule, if your adult child is enrolled in Medicaid through SSI or a disability-based pathway - not through ACA expansion - they should fall outside the definition of who these rules apply to. The rule defines “applicable individuals” as adults enrolled in the Medicaid adult group, which I’m taking to mean the ACA expansion eligibility category. SSI recipients and others enrolled through disability-based pathways get their Medicaid through a separate categorical pathway, which puts them outside that definition.
I want to be clear: I’m not an attorney, and I’m not reading this as settled. What I am saying is that the pathway your family member is enrolled through matters - a lot. Know which category they’re in, be able to name it, and be prepared to go to bat for your child if a renewal notice comes back wrong. The law being clear on paper has never guaranteed that a state eligibility worker gets it right.
Where it gets even more complicated
HR 1 defines “medically frail” in five subcategories. One of them is directly relevant to those reading this: “a physical, intellectual, or developmental disability that significantly impairs the ability to perform one or more daily living activities.” For many adults with significant disabilities, that description fits - and under the law as written, it should qualify them for an exemption.
The problem is that the rule CMS published on June 1, 2026, to implement that definition takes a different approach. Rather than applying the law’s five subcategories on their own terms, the rule layers an additional test over all of them - requiring that the condition significantly impairs the person’s ability to comply with the work requirement itself. Legal scholars and state officials have argued publicly that this goes beyond what the law authorizes and that it makes the standard harder to meet than even the SSI or SSDI disability test. States are building their eligibility systems around the rule. Families who should qualify under the law may be denied under the rule.2
Whatever the final definition turns out to be, the exemption is not automatic. It requires documentation. Your family member - or you, on their behalf - will need to submit proof and have it reviewed at both the initial application and each renewal cycle. Don’t wait for a notice to start gathering records.
Know what HR 1 actually says, not just what your state’s eligibility system tells you. If your family member is denied a medical frailty exemption and you believe they qualify under the statute, that decision is worth pushing back on in writing.
COMMENT DEADLINE: July 31 2026
The public comment period on the CMS rule closes July 31. If you want to weigh in before states finalize their implementation systems, the window is open now.
What to do right now
The first step is knowing which Medicaid pathway your family member is enrolled in. If you’re not certain, call your state Medicaid office and ask directly. That one piece of information tells you whether work requirements apply at all.
If you live in a Medicaid Expansion state and your family member may need the medically frail exemption, start building your documentation file now. Medical records, a letter from their treating physician, and any existing disability determinations are all relevant. Don’t wait for a renewal notice to gather this.
Make sure the address on file with your state Medicaid agency is current. The law requires states to reach out to enrollees between June 30 and August 31, 2026, to explain the requirements, who is exempt, and what documentation is needed. If your family member might be in scope and you haven’t heard anything, contact the agency rather than waiting.
We saw what happened during the COVID-19 unwinding, when millions lost Medicaid, not because they were ineligible, but because of paperwork failures. A six-month renewal cycle doubles that exposure.3
If your family member receives a notice that appears to require work documentation despite being enrolled through SSI or a disability-based pathway, do not ignore it and assume it will resolve itself. Contact your state Medicaid office in writing, reference the specific enrollment pathway, and ask for a formal review. Errors like this are correctable, but they require someone to push back.
States have until January 1, 2027, to implement, but some are already moving. Nebraska went live in May. If your state hasn't communicated a timeline yet, I’d reach out and ask.
The bottom line
The work requirements, as written, don’t appear to be aimed at your disabled adult child if they’re enrolled through SSI or a disability-based Medicaid pathway. But the administrative consequences of this law - more renewals, more paperwork, more chances for procedural disenrollment - affect every family in the system. And if your family member’s Medicaid pathway is not what you assume it is, the cost of not knowing that is high.
Stay tuned, I’m going to cover a gap in these rules that no one seems to be talking about yet - one that puts a specific group of caregiving parents at real risk.
Centers for Medicare and Medicaid Services, "Medicaid Community Engagement Requirement for Certain Individuals Interim Final Rule with Comment Period," June 2026.
“Medical Frailty Rule Contravenes HR 1, Burdens The Health Care System, And Threatens Public Health,” Health Affairs Forefront, June 12, 2026. DOI: 10.1377/forefront.20260610.271080
California Health Care Foundation, "Key Takeaways from Medi-Cal Redetermination Data," November 2023, updated November 2024.