By Adam Alver, Policy Director
Medicaid Work Reporting Requirements Are Here
Major changes to Medicaid are already reaching patients in several states. Beginning no later than January 1st, 2027, certain adults will have to show they are working, attending school, volunteering, or taking part in another approved activity to enroll in or keep their Medicaid coverage. This special report includes practical steps you can take to protect your coverage from being terminated as these new rules go into effect. Read to the end for more information about your state’s Medicaid health insurance program and how to help ensure you remain covered.
What the New Requirements Mean
The One Big Beautiful Bill Act (also known as “OBBBA,” “OB3,” or “HR1”) was signed into law on July 4th, 2025. It requires certain adults between the ages of 19 and 64 to complete and report approved activities for at least 80 hours each month, including:
- Working at a job;
- Participating in an approved work or job-training program;
- Completing community service or volunteer work;
- Attending school at least half-time; or
- Combining more than one of these activities.
A person may also meet the requirement by earning an amount equal to 80 hours of work at the federal minimum wage. In 2026, that amount is $580 per month.
HFA opposed these changes because Medicaid is health coverage, not a test of whether a person can successfully navigate a new reporting system. Many people with bleeding disorders can work precisely because they have continuous coverage and treatment. A lapse could cause their health to worsen and make it harder or impossible to continue working or regain coverage.
The federal government calls these “community engagement requirements.” We will refer to them as “work reporting requirements” in this report because the primary stated focus of these policies is to increase employment for people enrolled in Medicaid.
The new rules mainly apply to adults in the Affordable Care Act’s Medicaid expansion group and to certain adults covered through federal “waivers,” which are special approvals that allow states to run parts of Medicaid differently. Federal officials estimate that 43 states and Washington, D.C. will have at least group negatively impacted by the new rules.
States must first use information they already have, like wage records, school enrollment, or Medicaid claims. If a state cannot confirm compliance or an exemption, it must send a notice to the person enrolled and provide 30 days to respond. Otherwise, an application may be denied or coverage may end.
Where State Implementation Stands
Although the nationwide deadline is Jan. 1, 2027, several states chose to move forward early. As of this article’s publication:
- Georgia continues its Pathways to Coverage program and will transition to the new federal requirements in January
- Nebraska began on May 1, with existing members entering as their coverage comes up for renewal
- Montana began on July 1 and reviews compliance when deciding whether someone remains eligible;
- Arkansas began a “soft implementation” on July 1 but will not end coverage for noncompliance before Jan. 1, 2027; and
- Iowa plans to begin with new applicants on Dec. 1 and existing members during renewals scheduled for February 2027 or later.
Other states are still developing their systems, and details may change as federal direction is issued and state systems are tested. These examples are a snapshot, rather than a full overview of every change.
Twenty-five states and Washington, D.C., have sued over the federal regulatory definition of “medically frail,” arguing that the Centers for Medicare and Medicaid Services (CMS) narrowed the term beyond what Congress intended. A judge declined to pause the rule in July but did not resolve the underlying case, so implementation continues.
Who Does Not Have to Meet the Requirements?
Federal law excludes several groups from the requirements. These include parents or caretakers of children under age 14, people caring for someone with a disability, certain former foster youth, American Indians and Alaska Natives, pregnant and postpartum patients, veterans whom the Department of Veterans Affairs has rated as totally disabled, and people participating in a drug or alcohol treatment program.
The law also excludes people who are considered “medically frail” or who otherwise have special medical needs. This does not mean someone must be bedridden or receive Social Security disability benefits. It is a legal term used to decide whether a health condition should exempt someone from the requirements.
What “Medically Frail” Means
As mentioned above, the federal rule issued by CMS in June interprets “medically frail” more narrowly than HFA believes is appropriate. A condition must significantly affect the person’s ability to comply, and the person must also fall into at least one of these groups:
- They are blind or have a disability recognized under federal law
- They have a substance use disorder
- They have a disabling mental health condition
- They have a physical, intellectual, or developmental disability that significantly limits daily activities; or
- They have a serious or complex medical condition.
A serious or complex condition may be life-threatening or seriously disabling; cause significant pain or interrupt daily life; require frequent monitoring or multiple specialists; affect multiple body systems; or require treatment carrying a risk of serious complications.
States must develop lists of conditions that may qualify, but those lists cannot be the only route to an exemption. A state cannot deny someone solely because their diagnosis is missing from its list or claims data. It must allow the person to submit medical information for individual consideration.
HFA remains concerned that eligible people will be missed because a database, diagnosis code, notice, or reporting process fails to recognize them.
What This Means for People with Bleeding Disorders
In the explanation that was published with its new rules, CMS specifically named hemophilia as an example of a condition states may consider serious or complex when it significantly affects a person’s ability to comply. This recognition is important, but it does not mean every person with hemophilia or another bleeding disorder will automatically receive an exemption.
Relevant factors could include unpredictable bleeding events; joint damage, pain, fatigue, or other complications; frequent treatment, laboratory monitoring, or medical appointments; coordination between an HTC and other specialists; travel for specialized care; or treatment that requires close monitoring or carries a risk of serious complications.
Most people with bleeding disorders already work, attend school, volunteer, or participate in their communities. A patient may appear “fine” because Medicaid provides the treatment keeping them stable. That stability should not be treated as evidence that the underlying condition is no longer serious or complex.
If a patient misses a deadline, cannot document an activity, or has an unexpected bleed that prevents compliance, they could lose coverage and treatment. Even a temporary loss of coverage could interrupt access to medication, HTCs, specialists, or other necessary care that can lead to much more serious, preventable complications. Their health may then worsen, making it harder to work or reapply for Medicaid.
How State Processes Could Miss Patients
State approaches differ and may still change. Montana’s current list includes hemophilia A, B and C as well as other hereditary coagulation defects. Patients may submit documentation from a healthcare provider or self-declare their condition. Those procedures could change, however. Montana also currently has no in-state HTC, so patients who do need documentation may have to rely on an out-of-state HTC or another medical provider.
Nebraska uses Medicaid claims and diagnosis codes to identify some people automatically. Its current conditions index does not include the primary codes for hemophilia A or B, although it includes acquired hemophilia, symptomatic hemophilia A carriers, and “hereditary deficiency of other clotting factors.” Nebraska has said it will continue reviewing its codes and allows people who are not automatically identified to submit a declaration.
This does not mean Nebraska will deny exemptions to people with hemophilia A or B. It does show the risk of relying too heavily on lists and claims data. A person whose diagnosis is missing from a state list may still qualify, but community members should not assume their state will automatically recognize their bleeding disorder or protect their coverage.
Temporary Medical Hardships
Separate from the medically frail exemption, states may offer temporary hardship exceptions for certain situations. These may include months when someone receives inpatient hospital or nursing-facility care, travels outside their community for necessary treatment that is unavailable locally, lives in a federally declared disaster area, or lives in an area with unusually high unemployment. The travel exception may help patients who must travel long distances to an HTC, but these exceptions are temporary and may not be offered in every state.
What You Need to Do Now
Visit HFA’s list of state Medicaid programs to find your state’s Medicaid program and website.
Do not wait until your coverage is at risk. If you are enrolled in Medicaid:
- Keep your address, phone number, and email current with your state Medicaid program
- Open and respond to every Medicaid notice
- Learn whether your coverage is through the Medicaid expansion group or another eligibility category
- Keep records of work, school, volunteer activities, medical appointments, and periods when your condition interferes with regular activities
- Talk with your HTC or other healthcare provider about how your bleeding disorder affects your ability to meet the requirements; and
- Ask your state Medicaid program how to request a medically frail exemption or temporary hardship exception.
Medical documentation should explain more than the name of the diagnosis. It should describe bleeding events, treatment needs, complications, limitations, travel, and how those factors affect your ability to comply. This matters even if you are stable and employed. Continued treatment may be what makes that stability possible.
What HFA Is Doing About It
To be clear: HFA opposes making Medicaid coverage depend on work reporting requirements. Healthcare allows people with chronic conditions to remain healthy, work, attend school, and care for their families. Creating new ways for eligible patients to lose coverage does not support those goals.
Our primary focus remains federal. We are making clear to CMS, Congress, and other policymakers that people with bleeding disorders must be protected as individuals with serious or complex medical conditions, and that paperwork must never interrupt lifesaving treatment.
HFA is not doing this work alone. We are coordinating with the National Bleeding Disorders Foundation (NBDF), the Coalition for Hemophilia B, the Hemophilia Alliance, and the American Thrombosis and Hemostasis Network (ATHN) to oppose these changes, advocate for appropriate medical protections, and prepare community resources. We are also working with broader patient and rare disease coalitions against Medicaid policies that fail to properly protect people with serious, complex, and chronic conditions.
We will continue monitoring patient impacts and coordinating with national and state partners. Our position remains straightforward. A person should not have to lose treatment, experience preventable medical complications, or become unable to work before the system recognizes that they need Continuous Coverage for Life.
Your Role in Our Continued Work
Be aware of these changes, prepare for them, and help HFA show policymakers what is at stake. If you receive a notice, have trouble obtaining a medical exemption, or lose Medicaid coverage, please share your experience with HFA.
Stay up to date with future Word from Washington and State of the States posts, and encourage your friends, family, and local bleeding disorders organization to support us in this work.
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