Starting in January 2027, the Medicaid expansion-eligible population will be subject to new mandatory community-engagement requirements, also called work requirements.
Under the One Big Beautiful Bill Act of 2025 (OBBBA), such individuals would need to demonstrate that they are engaged in 80 hours per month of work, community service, or work program participation, are enrolled in an educational program at least half-time, satisfy minimum monthly income requirements, or qualify for an exemption. For more, read the AMA’s summary of the bill’s Medicaid community-engagement requirements (PDF).
Exemptions include parents of children under 14, guardians, or other caretakers, disabled veterans, those participating in a drug addiction or alcoholic treatment and rehabilitation program, inmates, pregnant or postpartum individuals, and medically frail individuals.
The OBBBA does not fully define medical frailty. However, the law does provide that medically frail individuals include those who:
- Are blind or disabled.
- Have a substance-use disorder.
- Have a disabling mental disorder.
- Have a physical, intellectual or developmental disability.
- Have a serious or complex medical condition.
The OBBBA requires the Department of Health and Human Services to issue an interim final rule on work requirements by June 1. CMS has issued some limited preliminary guidance but there are still many key unknowns, including the level of discretion states will have in defining and implementing work requirements, including the rules for defining and implementing medical frailty and other hardship exemptions.
Need for flexibility
As part of its commitment to protect patient access to care as the OBBBA (PDF) is implemented, the AMA continues to engage with CMS, support state and specialty medical associations, and develop advocacy resources for AMA members. The AMA recently sent a letter (PDF) to CMS on the OBBBA community-engagement requirements provisions. In the letter, the AMA recommended actions that CMS can take to minimize unwarranted coverage disruptions for eligible Medicaid enrollees as a result of new work requirements.
In particular, the AMA asked CMS to build in sufficient flexibility for states and individual enrollees, leverage existing national and state data sources and technologies to streamline verification processes while reducing burden, and to ensure clear and robust processes to appropriately exempt eligible individuals from these requirements—including people who are medically frail.
The AMA also cautioned against taking an overly restrictive approach to defining medical frailty, particularly in the initial years of implementation, and encouraged CMS to give states and individual enrollees an opportunity to request medical frailty exemptions based on state-specific programs and individual circumstances. These include frailty based on having multiple chronic conditions or geographic considerations, such as being located far from a specialist needed to manage a particular condition.
Since the Medicaid-expansion population has a high prevalence of chronic conditions, the AMA emphasized the importance of ensuring that the medical frailty and other exemptions are implemented in a manner that is not overly burdensome on either patients or physicians. Since sending the letter, the AMA has been in touch with senior CMS officials to establish a dialogue on the issues raised in the correspondence in preparation for the impending guidance.
Dan Brillman, the CMS Director of Medicaid and CHIP, also spoke at the 2026 AMA National Advocacy Conference on the important role that leveraging technology and data will have on automating Medicaid eligibility verifications and medical frailty exemptions.
The AMA Advocacy Resource Center has put together an issue brief summarizing what is known so far on Medicaid work requirements’ medical frailty exemption (PDF), which will be updated as more information becomes available.
You can also learn more about the OBBBA’s changes to Medicaid, the ACA and other key provisions in the law. Explore how changes that the law created are reshaping care in 2026, and stay up to speed with this implementation timeline (PDF) for OBBBA’s many health care-related provisions.
