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The Centers for Medicare and Medicaid Services (CMS) published a provisional guide this Monday outlining which groups will be exempt from the new Medicaid work requirements, meeting the deadline set by the “One Big Beautiful Bill” advocated by President Donald Trump.
According to the guideline published by CMS, starting on January 1, 2027, adults aged 19 to 64 enrolled in the Medicaid expansion will be required to work, study, volunteer, or participate in job training for at least 80 hours per month to maintain their health coverage.
The regulation applies to 42 states and the District of Columbia.
Who is exempt?
The guide establishes the following exempt groups:
-pregnant women and those in the postpartum period.
-parents or caregivers of children aged 13 years or younger.
-veterans with disabilities.
-people with disabilities.
-people considered "medically fragile."
-those who suffer from substance use disorders.
- Native Americans and Alaska Natives.
-who already meet work requirements for programs such as the Supplemental Nutrition Assistance Program (SNAP) or Temporary Assistance for Needy Families (TANF).
The regulation does not include an exemption for homeless individuals, which has sparked additional criticism.
During 2027, beneficiaries will be able to self-declare on their renewal forms that they qualify for an exemption without submitting documentation.
Starting in 2028, states will be required to verify those exemptions using medical claims data.
The controversial definition of "medically fragile"
One of the most controversial points is the restrictive definition of "medically fragile."
The CMS links this category to the ability to work: it is not enough to have a serious diagnosis; the condition must "significantly impede" the fulfillment of 80 hours per month.
“It will no longer be enough to be in active treatment for cancer. Now it has to be a two-step process: you need to be in treatment and that treatment must prevent you from meeting work requirements,” explained Kinda Serafi, a Medicaid expert from Manatt Health.
Patient groups rejected the interpretation.
Lisa Lacasse, president of the Cancer Action Network of the American Cancer Society, was direct: "Cancer will not wait while Medicaid offices process paperwork."
Carl Schmid, from the Institute of HIV and Hepatitis Policy, warned that "this additional requirement was not in the law and jeopardizes the health of individuals living with HIV and viral hepatitis."
Millions could lose their coverage
The projections indicate massive losses.
The Congressional Budget Office estimated that requirements will leave about five million people uninsured by 2034, primarily due to administrative hurdles.
The CMS itself calculated between 3.1 and 3.3 million per year until 2036, while the Urban Institute projected between 4.9 and 10.1 million in 2028.
The Democratic representative Frank Pallone (New Jersey) criticized the measure: “Millions of Americans will lose their health care not because they aren’t working, but simply because they are buried in paperwork.”
The position of the administration and the cost for the states
The CMS administrator, Dr. Mehmet Oz, defended the policy as a way to redirect resources to those who need them most.
"These people are saturating programs that were originally designed for those who truly need them," he stated.
About possible frauds in self-declarations, Oz was emphatic: «We are understanding, but we are not naive».
States will receive a total of 200 million dollars in subsidies to support implementation.
Six Democratic governors sent a letter to the Trump administration last Friday requesting a delay if the final rules differed from their planning assumptions.
The Florida Senate approved a law in March that introduces similar work requirements for certain Medicaid beneficiaries.
Nebraska has, for its part, already become the first state to implement the new requirements as of May 1, 2026, compiling a list of nearly 300 pages of medical codes to determine which conditions qualify as "medically fragile," potentially affecting around 72,000 beneficiaries.
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