The Trump administration is unveiling long-awaited details about how new, more stringent Medicaid eligibility rules will be applied and raising fresh concerns about implications for people with disabilities.
The Centers for Medicare and Medicaid Services issued an this week spelling out standards for Medicaid work requirements, which most states must implement by the start of next year.
The so-called “community engagement” requirements stipulate that many Medicaid beneficiaries must prove that they are working, volunteering or going to school at least 80 hours per month in order to qualify for coverage. The new mandate was part of a sweeping law approved by Congress last summer that included nearly $1 trillion in Medicaid cuts.
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Under the legislation, individuals who are “medically frail” or who have “special medical needs” including those with physical, intellectual or developmental disabilities are supposed to be exempt from the work requirements. Parents, guardians, caretaker relatives and family caregivers of those with disabilities are also exempt.
Until now, however, it’s been unclear how states will determine who qualifies for the exemptions.
The 387-page rule published Wednesday indicates that individuals with physical, intellectual or developmental disabilities will be considered “medically frail” only if their condition “significantly impairs” their ability to perform at least one activity of daily living, or ADL, which includes bathing, dressing, walking, toileting, eating or getting in and out of bed or a chair.
“An individual with such a disability that does not significantly impair their ability to perform one or more ADLs would not qualify for this exclusion,” the rule states.
Other categories that can qualify as “medically frail” include people who are “blind or disabled,” individuals with substance use disorder, a “disabling mental disorder” or a serious or complex medical condition.
To be considered “disabled,” a person would have to be “unable to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment which can be expected to result in death or which has lasted or can be expected to last for a continuous period of not less than twelve months.”
The Trump administration is hailing the new effort citing a study from the U.S. Department of Health and Human Services indicating that work requirements could reduce poverty by 1.6 to 2.9 million people.
“This rule helps Americans build skills and independence through work, education, job training, or community service, creating new opportunities for themselves and their families,” said CMS Administrator Mehmet Oz.
However, the rule is setting off alarm bells for disability advocates who warn that the parameters put forth by CMS for people with disabilities to claim an exemption are far more limited than the definition of disability under the Americans with Disabilities Act.
“Despite Congress’ promises that people with disabilities will be exempt from these requirements, not all people with disabilities are exempt. Disabled people will lose access to Medicaid,” said Maria Town, president and CEO of the American Association of People with Disabilities.
Advocates cited research showing that work requirements do not increase employment, but merely force people off Medicaid. When Arkansas implemented work requirements for some Medicaid recipients in 2018, they note that more than 18,000 people were cut from the program in just 7 months, in many cases because they didn’t know about the new mandate or they struggled to report work hours or obtain an exemption.
Jennifer Mathis, deputy director at the Bazelon Center for Mental Health Law, said that the rule as written appears to ignore Congress’ intent in creating certain categories that qualify as “medically frail.”
“CMS seems to be prohibiting states from exempting people based on falling into one of those categories and instead requiring some kind of individualized analysis of whether each person’s condition substantially impairs them from meeting the community engagement requirement,” she said. “That is simply unworkable and will predictably result in disenrollment of people who Congress intended to keep their Medicaid coverage.”
Notably, federal officials opted to use the broader ADA definition of disability to determine who is exempt for being a parent, guardian, caretaker relative or family caregiver. These individuals can be caring for a person with a disability of any age and multiple members of the same household can qualify, the rule indicates.
“Given that the definition for medical frailty is stricter than the definition of disability in relation to a caregiver, this will result in many instances where caregivers are exempt and can keep Medicaid, while the disabled people who rely on Medicaid to receive and pay for the caregiving they need will lose access to this critical care,” said Town from the American Association of People with Disabilities.
Per the law, the community engagement requirements must be implemented in the 41 states that expanded Medicaid under the Affordable Care Act. That means the new requirements will apply in every state except Alabama, Florida, Georgia, Kansas, Mississippi, South Carolina, Tennessee, Texas, Wisconsin and Wyoming.
Nebraska already implemented work requirements and other states are considering rolling out the mandate ahead of the Jan. 1, 2027 deadline, federal officials said.
Silvia Yee, public policy director at the Disability Rights Education and Defense Fund, said it’s important for people with disabilities to confirm that their contact information is up to date with their state Medicaid agency to ensure they receive any relevant notices. Individuals can also find out the basis for their enrollment so that they can best understand how work requirements may affect them, she said.
The interim final rule is now up for public comment until July 31.
“People with disabilities and their families should submit comments in response to the rule, letting CMS know how complex and onerous it would be for people to try to comply,” said Mathis from the Bazelon Center. She also recommended that people consult with the protection and advocacy organization in their state to ensure they are doing whatever they need to remain eligible.
“People on Medicaid should not need a lawyer just to figure out what they should be doing to avoid losing their Medicaid coverage,” Mathis said.
