A community health center administrator described the coming year to us as "the unwinding, again, but with homework". She was talking about the Medicaid provisions of the budget reconciliation law signed on July 4, 2025. The most consequential of them for practices is the community engagement requirement: beginning January 1, 2027, states that expanded Medicaid must condition eligibility for most adults aged 19 to 64 in the expansion group on 80 hours per month of work, job training, education or community service, or on qualifying for an exemption. The Department of Health and Human Services is required to issue an interim final rule with implementation details by June 1, 2026. States may seek a limited extension for good-faith implementation efforts, but the default date is January 1, 2027.
The same law shortens the eligibility redetermination cycle for expansion adults from twelve months to six, for renewals scheduled on or after the first quarter that begins after December 31, 2026, and it limits retroactive coverage for applications beginning in 2027. Taken together, these changes mean a large number of adult Medicaid patients will need to prove something new, more often, starting at the end of this year. Some of them will lose coverage for failing to file paperwork rather than for failing to work. The 2023 to 2024 unwinding of continuous enrollment showed what that looks like for a practice: eligibility denials, uncompensated visits, and patients who disappear from the schedule.
It is April 2026. There are eight months. This is what states are doing now and what a practice should do with the time.
Key takeaways
- The work requirement applies to expansion adults aged 19 to 64 in expansion states, with exemptions for pregnancy, parents of children 13 and under, medical frailty and several other categories. The federal rule is due June 1, 2026.
- Six-month renewals mean coverage can lapse twice a year. Real-time eligibility within two business days of every Medicaid visit, read by a person, is now the baseline.
- The medical frailty exemption will land on clinicians' desks as a form. Decide now who completes it, how fast, and how requests are logged.
- The practices that came through the 2023 unwinding best kept a list and talked to patients about coverage at every visit. Do the same, starting with a count of your exposure.
What the law requires
| Provision | Who is affected | Effective |
|---|---|---|
| 80 hours per month work, education, training or community service | Expansion adults 19 to 64 without an exemption | January 1, 2027 (extensions possible for good-faith efforts) |
| Exemptions | Pregnant and postpartum women, parents or caregivers of dependent children 13 and under, medically frail individuals, tribal members, veterans with total disability ratings, people meeting SNAP or TANF work rules, among others | With the requirement |
| Verification at application and at renewal, with a lookback period | Applicants and enrollees subject to the requirement | January 1, 2027 |
| Six-month redeterminations | Expansion adults | Renewals on or after the first quarter beginning after December 31, 2026 |
| Retroactive coverage limited | New applicants | Applications on or after January 1, 2027 |
| HHS interim final rule | States | Due June 1, 2026 |
Details on how hours are verified, how the lookback works and how exemptions are documented will come with the June rule and with each state's implementation. Georgia has run a work requirement program, Pathways to Coverage, since July 2023, and its experience with low enrollment and heavy paperwork is the reference point most analysts cite.
What states are doing this spring
State Medicaid agencies are drafting notices, building screening tools, standing up dedicated websites, holding webinars for providers and community partners, and taking comments through Medicaid advisory committees. Several have published draft timelines that put the first enrollee notices in late summer or fall 2026, ahead of the first lookback months. Some managed care organizations have begun asking network practices how they intend to help members document exemptions, particularly medical frailty, which will require a clinician's input.
If your state Medicaid agency has a provider webinar on this topic, send someone. The details will be state-specific and the people who attend will know months before the people who read about it later. Ask the managed care plans you contract with the same questions: how will you notify members, will you share renewal dates with network practices, and what form will you accept for medical frailty.
Sizing your exposure
Before you plan outreach, count. A family medicine practice we work with in an expansion state ran this in March, and the numbers surprised the owners.
| Measure | Result | Source |
|---|---|---|
| Unique Medicaid patients seen in the last 12 months | 1,840 | Practice management system, by primary payer |
| Of those, adults aged 19 to 64 | 1,120 | Date of birth filter |
| Likely in the expansion group (not pregnant, not disability-based, not dual eligible) | About 780 | Plan and aid category on the eligibility response, where available |
| Likely to have a diagnosis-based frailty exemption | About 190 | Problem list: serious mental illness, substance use disorder, complex chronic disease |
| Medicaid revenue from the 780 | About 14 percent of practice collections | Payments by payer, last 12 months |
| Visits per year by that group | About 2,300 | Encounter count |
The practice had assumed Medicaid was a small share of its business. Fourteen percent of collections tied to a group that will face new paperwork twice a year changed how much time the owners were willing to give the front desk for this. The 190 patients likely to qualify for frailty became the first outreach list, because a completed exemption protects that patient for a defined period and the practice can help.
The medical frailty exemption will land on your desk
Of all the exemptions, medical frailty is the one that requires a health care provider. The law's definition includes people with disabling mental disorders, substance use disorders, serious or complex medical conditions, and physical, intellectual or developmental disabilities that significantly impair the ability to perform activities of daily living. How a patient proves it will depend on the state, but every version we have seen involves either a diagnosis-based determination from claims data or a form completed by a clinician.
Prepare for the form. Decide now who in the practice completes it, how a request is logged, how quickly it is returned, and whether the visit at which it is completed is billable. Waiting until January to work this out means a stack of forms in the same weeks patients are losing coverage. Our suggestion is a 48-hour turnaround standard, one staff member who logs every request and its return date, and a rule that the clinician who knows the patient signs, not whoever is in the office that day.
Protecting the revenue cycle
- Know your exposure. Count the adult Medicaid patients aged 19 to 64 seen in the last year and the revenue they represent. Segment by managed care plan. This is the number at risk.
- Verify eligibility every visit. With six-month renewals, coverage can lapse twice a year instead of once. Real-time eligibility within two business days of every visit, read by a person, is no longer optional for Medicaid patients.
- Collect and confirm contact information. The unwinding taught everyone that procedural terminations happen because the renewal notice went to an old address. Confirm mailing address, mobile number and email at every check-in, and tell patients the state will be writing to them.
- Build the outreach list. When your state publishes its notice schedule, identify the patients whose renewal falls in each window and send a reminder a month ahead: "Your Medicaid renewal is due; the state will ask about work hours or exemptions; here is who can help." A text is enough.
- Connect with enrollment assisters. Community health centers, hospitals and navigator organizations in your area will be helping people file. Know who they are and have their contact information at the front desk.
- Prepare the self-pay conversation. Some patients will lose coverage. Decide your sliding fee or prompt-pay policy for them before it happens, and document that a good faith estimate is provided as the No Surprises Act requires.
What we think
Honestly, the practices that came through the 2023 unwinding best were not the ones with the cleverest software. They were the ones that talked to patients about coverage at every visit and kept a list. The same will be true here, with the added complication that clinicians will be asked to document frailty for patients who may not have thought of themselves that way. Handle those requests promptly and accurately, and get counsel's view on any state form whose attestation language concerns you.
We also think the six-month renewal cycle will do more damage to practice revenue than the work requirement itself, because it doubles the number of times a patient can miss a letter. Build the eligibility habit for that reason even if your state ends up with a generous exemption process.
Questions we hear
We are in a state that did not expand Medicaid. Does this affect us?
The work requirement applies to the expansion population, so its direct effect is limited in non-expansion states. Other provisions of the law, including changes to provider taxes and state-directed payments, may affect Medicaid rates in every state over the next several years. Watch your state's budget and managed care contract announcements.
Can a practice help patients report their hours?
Practices can inform, remind and refer. Completing a patient's attestation for them is not a practice function and creates liability. Point patients to the state portal and to enrollment assisters.
How does this connect to our billing?
Every lost month of coverage is an unpaid visit or a self-pay conversation. Eligibility workflow is where medical billing starts, and Medicaid eligibility denials are one of the first things we quantify in an RCM audit. If your practice is heavily Medicaid, a call this spring is worth more than one next January.
What to do this month
- Run the exposure count: Medicaid adults 19 to 64 seen in the last year, their share of collections, and the subset with likely frailty diagnoses.
- Register for your state Medicaid agency's provider webinar on implementation and ask your managed care plans how they will share renewal dates.
- Confirm real-time eligibility runs within two business days of every Medicaid visit and that the front desk reads the response.
- Assign an owner for medical frailty forms, set a turnaround standard, and start the request log.
- Add "has your address or phone changed?" to the check-in script for every Medicaid patient, starting this week.
