Medicaid Rules 2026: A new federal Medicaid rule is making doctors, patient groups, and state officials nervous. The Centers for Medicare and Medicaid Services, or CMS, says certain adults in Medicaid expansion plans between the ages of 19 and 64 must do 80 hours a month of work, school, volunteering, or another approved activity unless they qualify for an exemption. CMS says states must usually put the rule in place by January 1, 2027.
CMS also says some people are exempt, including those who are medically frail or have special medical needs that “significantly impair” their ability to comply. That wording is the part now causing the biggest worry. People expected a medical diagnosis to be enough, but the new guidance says a diagnosis by itself is not enough. Patients must show that their condition seriously limits their ability to work, study, volunteer, or care for someone else.
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Why Are Doctors and Advocates Alarmed?
Doctors and advocates say this rule can turn into a paperwork trap. Medical records may show that a person has cancer, COPD, asthma, heart failure, diabetes problems, HIV, or another serious illness.
People on Medicaid expansion plans who are 19 to 64 years old will need to prove that they work, volunteer, or do community service for at least 80 hours each month. They can also qualify if they are studying in school at least half-time, reported AP News. But some people do not have to follow these rules, including those who are medically frail or receiving addiction treatment, among other exempt groups.
But those records do not always prove whether the person can keep up with 80 hours of activity every month. CMS says states should use existing data where possible, but advocates say that still may not solve the main problem.
Dr. Ben Pezeshki of Sequoia Quality Health in Los Angeles said, “Having a work requirement for patients with cancer, frail or not, puts them in a precarious position,” Dr. Ben Pezeshki, medical director of Sequoia Quality Health in Los Angeles, told POLITICO.
He added, “Sometimes they can’t keep a job because of their illness and if they lose their job and their coverage, then Stage 1 becomes Stage 4.”
Jennifer Hoque of the American Cancer Society Cancer Action Network said states may be able to identify some people through diagnosis codes and claims data, but the hardest part is proving who is “unable to work.” Vin Gupta, a pulmonologist and managing director with Manatt Health, said, “Physicians are increasingly being asked to function not simply as clinicians but as arbiters of this very complex bureaucratic eligibility,” Dr. Vin Gupta, a pulmonologist and managing director with Manatt Health, told POLITICO.
Even people with HIV/AIDS, cancer, or end-stage kidney disease may still have to report their work hours under the new rule. They would only be exempt if their illness is serious enough to stop them from working or volunteering regularly.
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Patients fear losing care in the middle of treatment
The rule could hit people whose health changes from day to day. That includes patients going through cancer treatment, people with chronic lung disease, and others who may feel okay one week and very sick the next. CMS says states must check compliance when people apply and renew coverage, and if the state cannot verify it, the person gets 30 days to prove compliance or prove that the rule does not apply to them. If they cannot, they may lose coverage.
“The AMA believes that patients with serious illnesses and complex medical conditions should not face unnecessary barriers to maintaining health coverage. Neither should their caregivers,” said Melissa J. Garretson, MD, a member of the AMA Board of Trustees. “Medical frailty exemptions must reflect clinical realities and protect vulnerable patients while avoiding burdensome administrative requirements that can interfere with care.”
DeAnna Brandon, a 48-year-old multiple myeloma survivor in North Carolina, told the Associated Press that she worries the rule could threaten the Medicaid coverage that pays for her maintenance chemotherapy. She said, “It’s hard to explain to people you can’t push through it.” She also said, “It’s not that easy, you may have to go through four doctors. If you’re already battling an illness like this, you don’t have the physical or the mental or the emotional energy to do that all the time.”
Supporters say the work rules help protect taxpayers and keep Medicaid focused on the people who need it most. Critics say the sickest patients may end up facing the most paperwork, and some could lose coverage not because they are healthy, but because they cannot prove they are sick enough.
