The Centers For Medicare & Medicaid Services (CMS) has issued new guidance that tightens eligibility for Medicaid’s “medically frail” exemption from upcoming federal work requirements, raising concerns among patient advocacy groups. Under the guidance, having a serious illness or medical condition alone is no longer sufficient to qualify for the exemption. Beneficiaries must also demonstrate that their condition significantly limits their ability to work, attend school, volunteer, or otherwise comply with federal requirements. Qualifying conditions include cancer, behavioral health conditions, mental health disorders, and substance use disorders.
The stricter interpretation comes as CMS implements Medicaid work requirements created under President Donald Trump’s One Big Beautiful Bill Act. Beginning January 1, 2027, certain Medicaid expansion enrollees ages 19 to 64 must work, volunteer, attend school, or participate in job training activities for at least 80 hours per month unless they qualify for an exemption. The Congressional Budget Office previously estimated that 7.5 million people could lose Medicaid coverage by 2034 as states implement the requirements.
Patient advocacy groups, including a coalition of 48 organizations such as the American Lung Association, Crohn’s & Colitis Foundation, and National Alliance on Mental Illness, criticized the policy for potentially increasing paperwork and verification requirements for patients and providers. Jocelyn Guyer, senior managing director at Manatt Health, told CNN the stricter interpretation could make it harder for people with serious medical conditions to maintain coverage. CMS officials defended the approach, stating the exemption is intended to protect beneficiaries who cannot meet work requirements while preserving program integrity. States will assess whether beneficiaries meet exemption criteria using health claims data and other documentation. Beginning in 2028, Medicaid beneficiaries will face additional limits on self-attesting to exemption eligibility.
This article is an AI-assisted summary. All facts and figures are drawn from the original report: https://www.benzinga.com/news/health-care/26/06/53051112/trump-admin-raises-bar-for-medicaids-medically-frail-exemption-ahead-of-work-rules