In 2025, Congress passed HR 1 which made many changes to Medicaid including new Medicaid community engagement requirements (CE), also known as “work requirements.” In June 2026, the Centers for Medicare and Medicaid Services (CMS) issued an Interim Final Rule (IFR) on how states must implement these requirements, with some decisions left up to individual states. States must implement CE requirements by January 2027.
This FAQ provides answers to common questions about community engagement requirements. While many details will be provided by individual states, this resource answers policy questions that apply across all states. Advocates should turn to their state Medicaid agency for specific details on how their state is implementing community engagement requirements.
Table of Contents
Individuals Subject to CE Requirements
CE requirements apply to “applicable individuals.” These are adults ages 19-64 enrolled in ACA Medicaid expansion. Individuals enrolled in certain Section 1115 waiver programs that provide minimum essential coverage may also be subject to work requirements. CMS has identified thirteen 1115 waivers in eight states that are subject to CE in 2027, and may identify additional 1115 waivers in the future. As of January 2027, 43 states will have applicable individuals subject to CE requirements. See 42 C.F.R. § 435.551.
Note: While many older adults and people with disabilities are enrolled in Medicaid expansion and considered applicable individuals, they may instead be enrolled in Medicaid based on age or disability. Individuals enrolled in other Medicaid pathways, including age or disability, are not considered applicable individuals.
Do people receiving SSI have to meet the CE requirements?
No, people who are on SSI-based Medicaid are not applicable individuals subject to CE requirements. Anyone receiving Medicaid because of a disability or due to pregnancy is also not subject to these requirements.
Note: People enrolled in ACA Medicaid expansion who have applied for but have not been approved for disability benefits like SSI or SSDI will be subject to CE requirements unless they qualify for an exclusion (see Question 10 below). See 42 C.F.R § 435.553.
Do people enrolled in Medicare have to meet the CE requirements?
No, people who have both Medicaid and Medicare (also known as dual eligibles) are not applicable individuals subject to CE requirements. See 42 C.F.R § 435.553.
Compliance Requirements
What is required to comply with these new requirements?
To enroll in or continue to qualify for Medicaid, an applicable individual must either engage in a qualifying activity for at least 80 hours/month or receive an income that is at least 80 times the federal minimum hourly wage each month ($580). The $580 can be earned or unearned income and can be deemed or applied to other members of the Medicaid household.
For example: John (age 65) is a retired Medicare enrollee while his wife Ruth (age 62) is on Medicaid expansion. John receives $1600 monthly from Social Security. When the state checks for Ruth’s compliance with the CE requirements, they will apply John’s Social Security income to Ruth’s Medicaid renewal since she and John are part of the same Medicaid household. Since John’s income is more than $580, even though it is unearned income, Ruth will be considered compliant with the CE requirement and can continue receiving Medicaid. See 42 C.F.R § 435.552.
How does someone show they are complying with the CE requirements?
The state must first conduct an ex parte review to determine if an applicable individual meets the requirements. Ex parte means the state must first check data sources available to them, like payroll data or tax filings. If the state cannot verify compliance using their ex parte review, then the Medicaid enrollee will have to submit documentation.
For 2027, states may choose to accept an individual’s self-attestation that they are meeting the CE requirements when the state’s data sources do not verify compliance. However, starting in 2028 states must use ex parte data or receive documentation to verify compliance. States policies vary widely and advocates should look to their state Medicaid agency to review their policies on reporting and demonstrating compliance. See 42 C.F.R § 435.557(a) & (b).
Note: States will decide which data source and documents to use to verify compliance with the CE requirements for each qualifying activity.
How often do people have to report their compliance with the CE requirements?
States must verify that someone is meeting the CE requirements at least at renewal every 6 months. The reporting period for complying with CE requirements is known as the “review period.” However, states can require individuals to report their CE compliance as often as monthly. See 42 C.F.R § 435.557(a)(2)
How do these Medicaid CE requirements work with Supplemental Nutritional Assistance Program (SNAP) or Temporary Assistance for Needy Families (TANF) work requirements?
The Medicaid CE requirements are separate and distinct from other programs’ work requirements including SNAP or TANF. However, individuals who are compliant with TANF work requirements or members of a SNAP household subject to SNAP work requirements are excluded from the Medicaid CE requirements.
Qualifying Activities
What are qualifying activities?
Eligible qualifying activities are employment (including paid work, in-kind work, self-employment, and unpaid internships), community service, enrollment in an educational program at least half-time, or participating in a job-training program. Someone can also engage in a combination of qualifying activities to meet the 80-hour requirement.
Note: Unlike some other work requirement programs, job seeking is not a qualifying activity. See 42 C.F.R § 435.552.
Community service means unpaid work with a structured program that is done for the direct benefit of the community with a public or nonprofit organization. Community service can be voluntary or as part of a court mandate. The organization providing the community service must track the hours and types of activities being done. See 42 C.F.R § 435.552.
Exclusions
People who are otherwise “applicable individuals” may be excluded from having to complete CE activities if they meet certain criteria.
Do people with disabilities enrolled in Medicaid expansion have to comply with CE requirements?
People with disabilities or health conditions who are enrolled in ACA Medicaid expansion and meet the “medically frail” exclusion criteria do not have to meet the CE requirements. Meeting this exclusion means a person is not considered an “applicable individual” for that eligibility period. Refer back to question 2 for more information about people with disabilities enrolled in SSI or disability-based Medicaid pathways. See 42 C.F.R § 435.554.
How does someone get the “medically frail” exclusion?
There are two prongs someone must meet for this exclusion.
First, the individual must have at least one of the following:
- Meet the Social Security definition of blind or disabled
- A substance use disorder and not be in stable recovery of 5 or more years
- A disabling mental disorder
- A physical, intellectual, or developmental disability that impairs the ability to perform at least one activity of daily living (eating, bathing, dressing, toileting, and mobility)
- A serious or complex medical condition
Second, the individual’s condition must “significantly impair” their ability to meet the CE requirement. See 42 C.F.R § 435.554(c)(5).
Note: CMS gives states the authority to further define these conditions under the first prong for the medically frail exclusion.
How would somebody show their condition meets the “significantly impairs” prong for medical frailty?
CMS issued guidance to states on how they can determine if certain conditions meet the second prong. The guidance advises (but does not require) states to develop a list of diagnoses and health conditions to identify people who may meet the medically frail exclusion. States must then triage diagnostic codes into three tiers. Tier 1 conditions are those that the state can confirm significantly impairs their ability to meet the CE requirements. Individuals with Tier 2 conditions may be considered significantly impaired for purposes of the exclusion, but the state will need more information. Individuals with Tier 3 conditions will have to undergo an individualized review and submit additional documentation to show if they meet the exclusion. CMS leaves a lot of discretion to States to determine which conditions fall under which tier and advocates should look to their state Medicaid agency for how their state categorizes different conditions.
Note: It is unclear what documentation individuals will have to provide for Tier 2 and Tier 3 conditions and will likely vary greatly by state.
What kind of documentation will be required to show medical frailty?
States must first conduct an ex parte review of existing data sources like Medicaid claims data, to verify medical frailty and assign the conditions to a specific tier (see question 12). Aside from that, states will determine which documents individuals will need to submit to meet the exclusion. Individuals may also be able to self-attest that they meet the medically frail exclusion but only for a limited time (see question 18). See 42 C.F.R § 435.557(f).
Is someone who was found disabled by the Social Security Administration for SSI or SSDI automatically excluded under medical frailty?
Not necessarily. Although someone who meets the Social Security definition of disability meets the first prong for medically frail, they must also show they meet the second prong. A state could still find that their disability does not substantially impair their ability to engage in the qualifying activities like attending school or volunteering. This is because Social Security’s test for determining disability is based only on someone’s ability to engage in paid employment. The Medicaid CE requirements look at qualifying activities beyond employment. So even though Social Security finds an individual cannot work, a state could find they can engage in other qualifying activities.
Consider this hypothetical: Carl is approved for SSDI due to a serious back injury after working in construction for several years. He applies for Medicaid during his 24-month waiting period for Medicare coverage to begin. His monthly SSDI benefit is over the income limit for disability-based Medicaid, so Medicaid expansion coverage is his only option. Although Social Security found his disability prevents him from doing anything close to full-time employment, the state must make its own determination that his disability substantially impairs his ability to engage in other qualifying activities like part-time schooling, job training, or volunteering to start his coverage.
What is the caregiver exclusion?
A caregiver qualifies for the exclusion if they are a parent, guardian, caretaker relative, or family caregiver providing care to a dependent child age 13 or under or a disabled individual of any age. The IFR clarified that a care recipient is disabled for purposes of the exclusion if they meet the ADA definition of disability. See 42 C.F.R § 435.554(a).
Note: The ADA defines disability as someone with a physical or mental impairment, or who is perceived as having such an impairment, that limits one or more major life activities.
Who is a family caregiver for the caregiver exclusion?
Under the IFR a family caregiver is someone who is either related to a dependent child or disabled individual (of any age) or lives with a dependent child or disabled individual, and provides a broad range of assistance to the care recipient. These caregivers do not need to complete a set number of caregiving hours to be excluded from the CE requirements. However, a caregiver who is not related to or living with the disabled adult must complete 80 hours of caregiving in order to qualify for the exclusion. There is no age limit for the disabled individual receiving care.
Note: Definition of relative for purposes of the family caregiver exclusion includes the disabled individual’s spouse, parent, stepparent, grandparent, son, daughter, stepson, stepdaughter, sibling, stepsibling, grandchild, aunt, uncle, first cousin, nephew or niece. CMS gives states the option to expand the definition to others related by blood, marriage, or adoption. See 42 C.F.R. § 435.554(c)(3).
What kind of documentation does someone need to show that they qualify for the caregiver exclusion?
As with other exclusions, CMS must first conduct ex parte review using existing data sources to determine if someone meets the caregiver exclusion. If there is no existing data, then states must request documentation beginning in 2028. States have the option of accepting self-attestation of caregiving in 2027 (See question 19). See 42 C.F.R § 435.557(b).
Note: It’s unlikely states have data available to them for most family caregivers caring for adults. If documentation is needed, states have discretion to determine the types of verification documentation that is required.
How often do individuals need to show they qualify for the medically frail or caregiver exclusions?
States cannot review an individual’s eligibility for any exclusion more than every 6 months. States must verify someone’s medically frail status at least every 12 months. See 42 C.F.R. § 435.556(c)
Can someone self-attest that they meet the medically frail or caregiver exclusions?
For the medically frail exclusion, states may accept self-attestation throughout 2027. In 2028, states can only accept self-attestation one time for the entire period the individual is enrolled in Medicaid, even if that is several years. After that, the state must conduct ex parte review or receive documentation to verify eligibility for the exclusion.
For the caregiver exclusion, states may accept self-attestation only if they cannot verify compliance with the exclusion using either ex parte verification or documentation provided by the Medicaid enrollee. Advocates should look to their state Medicaid agency to see whether their state allows self-attestation. See 42 C.F.R. § 435.557(b) and (f).
Additional Resources
Justice in Aging Webinar: Understanding New Medicaid Work Requirements Rules
Justice in Aging: Mitigating the Harms of Medicaid Work Requirements for Older Adults: Tools for State Advocates
State Health & Value Strategies: Medicaid Work Reporting Requirements Member Scenarios
