The National Hispanic Health Foundation (NHHF), in collaboration with the Hispanic Health Professionals Network* urges the Trump Administration to simplify the work requirements for Medicaid applicants.
The Trump administration has issued final rules, based on the Big Beautiful Bill Act (HR1) to eliminate fraud and abuse in the Medicaid program, on how states should ensure that the 18.5 million Medicaid enrollees prove they’re working or completing other activities, such as job training, volunteering, or being enrolled in an educational program beginning January 1, 2027. The Congressional Budget Office has projected that almost 5 million individuals could lose coverage by 2034 under these provisions.[1]
The new rules will apply to people covered through what’s known as Medicaid expansion. Since 2014, more than 40 states and the District of Columbia have decided to allow more people into their Medicaid programs, generally low-income adults without dependents. Georgia and Wisconsin offer coverage to some people in this group, so they’ll be subject to the rules.
Children and pregnant people, as well as individuals with disabilities who receive Social Security payments — all groups that already qualify for Medicaid — won’t be subject to the rules. Nor will people determined to be “medically frail,” or too sick to work.
We believe that there are major issues with the new rules that need to be reviewed to lessen the severe loss of Medicaid enrollees that will increase chronic diseases and the loss of protection of vulnerable populations as well as raise healthcare costs for these individuals who will increase use of emergency departments and hospitals for increased late-stage disease management:
- CMS is not going to be able to make sure people who can’t reasonably be expected to work are not subject to the requirements since enrollees will eventually have to provide documentation, such as a statement from a medical professional, pay stubes and medical records to prove that a health condition keeps them from working. And each individual state will have to determine the severity of beneficiaries’ medical conditions.
- Medical frailty is a major exemption, and we feel the rules would offer a standardized definition of who counted as medically frail and not leave the decision up to states. The statute includes exemptions for individuals who are determined to be medically frail, including those with disabling mental disorders; those with substance use disorders; people with physical, intellectual, or developmental disabilities that considerably impair activities of daily living; those who are blind or meet the Social Security Administration definition of disability; and those with serious or complex medical conditions. The serious or complex medical conditions category is the most ambiguously defined of the group and has raised many policy and implementation questions.[2]
While medical frailty as a concept has precedent in Medicaid policy,[3] the prior definition operated within a coverage expansion framework as opposed to the current context of coverage restriction. This shift heightens the stakes of implementation. To minimize confusion, medical frailty identification methodologies should be as transparent as possible. Medicaid managed care organizations, clinicians, and community-based organizations support beneficiaries in enrollment and ongoing eligibility by assisting with identification of individuals with potential medical frailty and supporting appropriate documentation and data. Transparency will facilitate clear understanding by these partners and support consistent identification across settings.
Operational flexibility from CMS will be essential to ensure that medical frailty definitions align with state-specific contexts. HR 1 directs states to use existing information to verify exemptions when possible. To that end, states should use a diverse array of data sources, such as diagnosis codes, procedure codes, pharmacy data, and clinical documentation, to optimize identification of individuals with medical frailty. Streamlined processes, standardized forms, and alignment with existing workflows may reduce burden on clinicians and patients alike. Limiting the use of clinician and patient attestation to times only when other data is not sufficient will mitigate unnecessary burden.
To minimize the risk of eligible people losing coverage:
- Medical frailty should be defined to encompass the full range of health conditions and functional impairments experienced by people with disabilities and chronic illnesses
- Medical frailty should be redetermined only when an enrollee’s health condition improves, to minimize administrative burden and keep eligible people enrolled
- Data matching should be supplemented by self and provider attestation
- Individuals should not be required to show that they cannot work to qualify as medically frail
- States should explain to applicants and enrollees why health-related questions are asked and how privacy will be protected
- Adequate staff should be available to meet states’ duty to assist with application and renewal processes
- States should be prepared to offer reasonable accommodations required by federal laws that prohibit disability-based discrimination.
The medical frailty determination process will allow people living with disabilities and chronic illness to be exempted from challenging work reporting requirements and stay enrolled in Medicaid. The policy choices made in this area will shape how many individuals can qualify for this designation.
- Although Trump administration officials have publicly crusaded against fraud in government health programs, such as Medicaid, and states could face financial penalties for incorrectly granting people exemptions from the work rules. We expect states to be more cautious that will likely lead to people losing coverage who may still be eligible.
- Only certain qualifying activities count. Enrollees can satisfy the rules by working 80 hours a month. They can also be enrolled in college courses, volunteer through a community organization, or do “in-kind” work that doesn’t result in pay. The rules set out, in detail, how many academic credit hours translate to 80 hours a month — students need to be enrolled in six credit hours per semester to meet the “half-time” requirement. An unpaid internship can count toward 80 hours. We believe the use of community health workers should be a focus of work or volunteer requirements in community health organizations such as clinics where they can improve access to culturally relevant, community‑based care for Medicaid enrollees, strengthen the healthcare workforce which faces a severe shortage in rural and underserved communities, and address social determinants of health.
- Outreach needs to be done by CMS in addition to the states and especially the message about updating your address – either regular mail or email – with the state Medicaid agencies. We believe a major campaign should be done through multi-media approaches and with spokespersons such as healthcare professionals and local media and community leaders who are trusted for information by the poor and vulnerable communities to address the Medicaid application changes and encourage persons to apply and direct them where to apply.
[1] Estimated effects on the number of uninsured people in 2034 resulting from policies incorporated within CBO’s baseline projections and H.R. 1, the One Big Beautiful Bill Act. Congressional Budget Office. June 4, 2025.
[2] Ayanian JZ. Protecting Medicaid enrollees with chronic conditions amid work requirements. N Engl J Med. 2025;393(11):1044-1046.
[3] Musumeci M, Rao P, Crays A, Shachar C. How medical frailty exemption policies can offer a lifeline to people with disabilities and chronic illnesses when Medicaid work requirements are implemented. The Commonwealth Fund. December 18, 2025.
Submitted to Regulations.gov by Elena Rios, MD, MSPH, MACP, President, NHHF
Hispanic Health Professionals Network 2026
American Society of Hispanic Psychiatry
Hispanic Dental Association
Latino Caucus of Public Health
Latino Commission on AIDS
Latino Social Workers Organization
Latino Surgical Society
Latinos and Hispanics in Dietetics and Nutrition
Latinx Physicians of CA
Medical Organization for Latino Advancement
National Association Medical Spanish
National Association of Hispanic Nurses
National Association of Latino Healthcare Executives
National Hispanic Council on Aging
National Hispanic Health Foundation
National Hispanic Latino Cardiovascular Collaborative
National Hispanic Medical Association
National Hispanic Pharmacists Association
North Texas Latin American Medical Society
Physician Associates for Latino Health
Sacramento Association of Latino Physicians
University of California Latino Physician Consortium