The Trump administration has finalized a rule that delineates key details for states in the nationwide rollout of work requirements in Medicaid.
Under HR-1, or the One Big Beautiful Bill Act, work requirements will be in place beginning Jan. 1, with the option to make changes earlier if states choose. The new federal rule outlines exemptions and other eligibility details for the requirements as well as details on state reporting requirements.
Able-bodied and non-pregnant adults aged 19 to 64 will be subject to the requirements, with exemptions in place for the medically frail, disabled and others who are unable to meet the mandates. Individuals can meet the requirement by working, completing community service or participating in a work program for at least 80 hours per month.
People who are enrolled in an educational program for at least half-time each month also meet the requirements, per the Centers for Medicare & Medicaid Services.
CMS officials told reporters on a press call late Monday that a key component of the implementation of the work requirements is supporting states in making critical investments in technology and data integration, which will make it far more efficient to manage the requirements in the long term.
Part of that initiative includes commitments from key tech vendors to offer $600 million in discounted and free services to states during the rollout.
CMS Administrator Mehmet Oz, M.D., said during the call that states spend billions each year on antiquated technologies, and investing in these upgrades now will save critical dollars in the program in the future. With that in mind, the agency is being "strict" on the vendors in the program to ensure states "are not taken advantage of."
"Governors want support on the tech side," Oz said. "That's why there's been so much effort made by CMS to be able to provide that support."
Dan Brillman, Director of the Center for Medicaid at CMS, said during the call that the agency is targeting Jan. 1, 2028 for states to have a "data-first" system in place.
For example, officials said that an individual who may qualify for a medical frailty exemption will be able to self-attest to their needs if they newly enroll or renew on Jan. 1, 2027. That is also applicable for mid-year renewals, per CMS.
Beginning in 2028, however, these individuals can self-attest once — either when they enroll or first renew — and then they will need to have more formal documentation to prove their eligibility on later renewals. Ideally, this would be a claim that corresponds with their condition that states can track, or enrollees will need to provide documentation themselves, such as a doctor's note.
Brillman said that the goal is to both confirm eligibility for the exemptions as well as encourage patients with complex needs to engage with the healthcare system.
Oz said that these protocols aim to balance ensuring individuals that need these exemptions can get them, while also aligning these efforts with the broader push to root out fraud, waste and abuse across the federal government.
CMS is "serious about the consequences of dishonesty in self-attestation," Oz said.
"We think, directionally, we’re appropriately going after problem areas and doing it in a way that’s compassionate, forgiving," Oz said, "but we don’t want to be fools."
Per the rule, if a state cannot verify that an individual has either met the requirement or qualifies for an exemption, they must offer 30 days for the individual to do so. If someone is disenrolled because they failed to meet the work requirements, they will be able to reapply for Medicaid, CMS said.
States also have freedom within the national framework to customize their programs, but having federal standards in place ensures that the work requirements are administered "fairly and consistently," Brillman said.