New Work Requirement Exemption Rules Put Medicaid Coverage at Risk for Seriously Ill Enrollees

Among the sweeping changes the One Big Beautiful Bill Act introduced to the Medicaid program was the creation of new community engagement (or work) requirements. Exempted from the new requirements are individuals considered “medically frail or otherwise having special medical needs.”

That exemption is especially important for the 5 million midlife-adult Medicaid expansion enrollees, one in five of whom report having some disability or difficulty with everyday activities. But under new rules from the Centers for Medicare & Medicaid Services (CMS), many midlife adults with serious conditions such as cancer may struggle to qualify for a medical frailty exemption, putting their Medicaid coverage and access to lifesaving care at risk.

This Spotlight explores Medicaid’s role for midlife adults with disabilities and serious or complex medical conditions. It discusses the new CMS rules for the community engagement requirements and offers policy considerations regarding the medical frailty exemption. Read the full report.

Key Takeaways:

• New Medicaid community engagement requirements under the One Big Beautiful Bill Act (OBBBA or H.R. 1) will affect nearly 5 million midlife adults ages 50–64 in the 41 states, including the District of Columbia, that have expanded their program under the Affordable Care Act.
• Congress exempted adults who are “medically frail or otherwise have special medical needs” from Medicaid community engagement requirements.
• Midlife adults have higher rates of disability and serious or complex illnesses compared to younger adults, and many have significant barriers to employment.
• New rules from the Centers for Medicare & Medicaid Services narrow the statutory exemption for medical frailty, putting coverage for midlife adults in jeopardy.