Healthcare organizations — including a group of 48 nonprofit, nonpartisan patient associations — are expressing concern over the Centers for Medicare & Medicaid Services’ (CMS) interim final rule requiring “80 hours per month of qualifying activities, such as employment, participation in certain work programs, or community service, or [enrollment] in educational programs at least half time” for adults from 19 to 64 years old who are Medicaid enrollees without qualifying exemptions.
CMS issued the interim final rule on June 1. Comments are being accepted through July 31, the day the provisions go into effect.
The agency added that states “must generally implement this requirement no later than Jan. 1, 2027.”
ALS Association, NORD among organizations concerned about coverage loss
Forty-eight nonprofits released a June 2 joint statement of concern, saying, “Throughout the legislative process, lawmakers repeatedly promised that the patients we represent would not be harmed by the policies that terminate Medicaid coverage for millions of people in Public Law 119-21. Our organizations are deeply concerned the interim final rule does not protect people with serious or complex health conditions and would instead dramatically and inappropriately increase the number of people who will lose their healthcare coverage.”
The organizations — including mobility-related groups such as the ALS Association, Muscular Dystrophy Association, National Multiple Sclerosis Society, National Organization for Rare Disorders (NORD), and the Parkinson’s Foundation — objected to the new, laborious documentation work they now expect to fall on patients and providers.
“Redefining the law’s medical frailty exemption to only apply to individuals who can prove they cannot work and drastically limiting the ability of states to accept self-attestation from patients about compliance and exemptions starting in 2028 clearly conflicts with the law,” the statement said. “These policies will place massive paperwork burdens on patients and providers, upend months of planning by states, and create chaos just months away from the January 2027 implementation deadline.”
The associations urged CMS “to adopt a definition of medical frailty and processes to document compliance that protect patients and are consistent with the law.”
LAC: Interim final rule exceeds CMS’s authority
The Legal Action Center (LAC), a national nonprofit public policy organization, said in a June 2 announcement that the rule “imposes restrictions that exceed the agency’s statutory authority and will inevitably cause far more than the 5.3 million people initially projected by the Congressional Budget Office to lose Medicaid coverage when the law was first enacted.”
“Adding unnecessary and very burdensome work reporting requirements to Medicaid was bad public policy to begin with,” said Paul N. Samuels, LAC’s director and president. “This rule makes a harmful policy even worse by flouting clear statutory protections that Congress deliberately included to safeguard people with chronic health conditions, including substance use disorders, whose health and stability depend on uninterrupted access to care. CMS is exceeding its authority by narrowing the law’s medically frail exemption in ways that are not supported by the statute and that directly contradict Congress’s intent to protect vulnerable individuals in need of medical care from losing coverage.”
Easterseals noted in its June 2 announcement that the healthcare industry has already seen the impact of the work requirement in Arkansas.
“Yesterday’s rule from CMS on work requirements will reshape Medicaid for millions of Americans, and we want to be clear-eyed about what comes next,” said Easterseals President/CEO Kendra Davenport in a June 2 announcement. “We have already seen how this kind of policy plays out when it is implemented without strong protections. In Arkansas in 2018, around 18,000 people lost their Medicaid in just a few months — not because they didn’t qualify, but because the paperwork was impossible to navigate. People who were working lost coverage. People with disabilities who were exempt lost coverage. The reporting system itself became the barrier.”
National Health Law Program, KFF weigh in
“While the full impact of the rule will depend on both the federal guidance and state implementation decisions, the National Health Law Program (NHeLP) warns that new administrative barriers could make it significantly harder for eligible people to enroll in or maintain the healthcare coverage they rely on,” the nonprofit public interest legal and policy advocacy organization said on June 1.
“Work requirements and other new administrative barriers are bad policy,” said David Machledt, director of Medicaid delivery systems at NHeLP. “They do not make people healthier, help people find jobs, or improve access to care. Their primary effect is to make health coverage harder to get, harder to keep and easier to lose.”
“At nearly 400 pages, the rule is quite long and complex and will require time to fully assess its implications,” said Jennifer Tolbert, deputy director, program on Medicaid and the uninsured at KFF (formerly the Kaiser Family Foundation), on June 1. “Given the complexity of the provisions in the rule, states will likely face significant challenges in operationalizing the requirements in the next six months.
“Significantly, the rule adopts a restrictive definition of medical frailty that differs from states’ early expectations,” Tolbert added. “States have been eagerly awaiting clarification on how to define medical frailty. Early indications from CMS offered through informal meetings with states hinted that the federal definition might mirror an existing medical frailty definition used for determining individuals who are exempt from receiving an alternative benefit package, and that states would be given flexibility to go beyond the federal definition.”
That is not what happened, Tolbert said.
“On both counts, the rule adopted a more restrictive approach, first tying medical frailty specifically to the ability to comply with the community engagement requirement (i.e., the ability to work) and prohibiting states from adding categories of individuals to the medical frailty definition,” Tolbert noted. “To operationalize this definition, the rule requires states to develop lists of health conditions, but prohibits them from categorically exempting people with those conditions without considering an individual’s ability to meet the community engagement requirement based on their health.”
Tolbert said the interim rule “does not provide states with a list of diagnoses or criteria for measuring severity or ability to meet new requirements.” The rule does not allow states to exempt all people diagnosed with cancer, HIV, Parkinson’s disease, or multiple sclerosis.
