Mitigating the Harms of Medicaid Work Requirements for Older Adults: Tools for State Advocates

Dear [state Medicaid director or other official],

On behalf of [Organization(s)], we urge you to adopt the recommendations below for implementing Medicaid work requirements to minimize harm and preserve continuous access to essential [Medicaid or state program name] services for older adults, people with disabilities and chronic health conditions, caregivers, and others. We also ask that you share these recommendations and concerns with federal officials as they finalize guidance for implementation.

[Add info about organization(s)]

In July 2025, Congress passed the budget reconciliation act of 2025 (H.R. 1) establishing federal community engagement requirements for Medicaid expansion [or your state’s program name] enrollees between ages 19-64. The statute mandates the state to verify work, education, training, or volunteer participation for these Medicaid enrollees and defines required exemptions and optional short‑term hardship exceptions.

As [aging and disability] advocates, we are concerned that work requirements create administrative barriers that will lead to improper terminations and disrupted access to crucial healthcare. These burdens disproportionately impact older adults and people with disabilities who have a harder time finding work and maintaining employment due to functional limitations, changing work or caregiving responsibilities, and fluctuating health. For example, the vast majority of older adults ages 50-64 enrolled in Medicaid expansion who are retired or not working (86%) report having a health condition that prevents them from working.^{1 Although the statutorily required exemptions for people who are “medically frail” and for family caregivers are intended to protect these populations, in practice such exemptions frequently fail to reach or work for the people they were meant to protect in part due to complex paperwork, narrow interpretations, and reliance on automated data checks that fail to fully capture people who are eligible.}

We have provided recommendations and further considerations for implementing exemptions to minimize disruptions in coverage and access to care for older adults, people with disabilities, and family caregivers due to work requirements.

Automatically exclude people with Medicare and people eligible through the aged and disabled pathways from work requirements.

The state must ensure that individuals who are categorically excluded from work requirements under the law are automatically and permanently exempted, including people age 65 and older, people dually enrolled in Medicare and Medicaid, and people of any age eligible through disability and other mandatory pathways. The state should utilize existing data to identify these current enrollees without subjecting them to additional paperwork and ensure its eligibility systems are set to automatically screen out new applicants. We urge the state to take steps to minimize confusion and clearly communicate to new applicants whether or not they are subject to work requirements, particularly if they are filling out paper applications.

Do not impose additional restrictions on exemptions not required by the statute.

The state should determine eligibility for the medically frail and family caregiver exemptions based on an individual’s reported medical conditions, diagnoses, functional impairments, or caregiving responsibilities, and not require proof of unemployment or inability to work. Evidence of recent or current employment should not be considered in determining exemption eligibility, as many people who qualify as medically frail or family caregivers may also be employed. Ensuring they have the exemption in place will help protect them from coverage loss should their employment status change, which is particularly common for people with disabilities, serious health conditions, and caregiving responsibilities.

Under the medically frail exemption, the statute requires the state to exempt many categories of individuals well beyond Social Security disability standards, including people with a physical, intellectual or developmental disability that significantly impairs one or more activities of daily living, a substance use disorder, a disabling mental disorder, or a serious or complex medical condition. Therefore, the state must not limit the medically frail exemption to Social Security disability or similarly strict standards and ensure its eligibility criteria are inclusive of people described in the statute.

H.R. 1 uses the RAISE Family Caregivers Act definition to define caregivers as “an adult family member or other individual who has a significant relationship with, and who provides a broad range of assistance to, an individual with a chronic or other health condition, disability, or functional limitation.” All such family caregivers, including caregivers for older adults and others who may not identify as disabled, must be exempted. The state must not impose restrictions like requiring the person being cared for to have a diagnosed disability, or be a dependent of or related to the caregiver. Nor should the state require caregivers to be providing a minimum number of weekly or monthly caregiving hours.

Real world application [insert your own example or customize this one]: Robin, age 49, is a caregiver for her father who has several health conditions and lives by himself in the house Robin grew up in. Robin lives about 20 miles away and visits her father several days a week to help him with groceries, meal preparation, and to take him to doctors’ appointments. Recently, after her father fell and broke his leg, Robin made the difficult decision to transition to part time at the retail store where she works so that she can spend more time helping her father. Robin lost her health coverage and is applying for Medicaid.

Here, Robin meets the RAISE Act definition for the caregiver exemption and the state should approve her Medicaid application based on her self-attestation that she is a caregiver. The state should not require her to submit any documentation of her caregiving duties when she applies for or renews Medicaid coverage.

Utilize self-attestation and ex parte verification to minimize administrative burden and procedural churn.

To reduce administrative barriers for both Medicaid enrollees and the state, self‑attestation should be accepted as verification for medically frail and caregiver exemptions. The statute permits self-attestation and [name of your Medicaid program] already uses self-attestation without additional verification for caretaker relative eligibility [add other eligibility categories that your state accepts self-attestation for].²

Real world application [insert your own example or customize this one]: Marsha, 56, is applying for Medicaid. She has diabetes and arthritis which significantly limit her mobility and have forced her to go weeks without working. Marsha qualifies for a medically frail exemption since one of her activities of daily living are limited. She does not own a car or have access to public transportation, and, being uninsured, she does not have a primary care provider. Last time she ran out of insulin, she ended up in the emergency room.

In Marsha’s case, self-attestation would be the most accessible and efficient method for verifying she is eligible for the medically frail exemption. If the state required medical or other documentation of her condition, then Marsha would be in an impossible position where she cannot access Medicaid without first getting health care from a provider to verify she is medically frail. Marsha would have to either pay out-of-pocket to get documentation or potentially go to the emergency room. This creates expensive and burdensome delays for both Marsha and the state.

We also urge the state to reduce administrative burden by automatically renewing exemptions, including those based on disability, functional impairment, or a chronic condition that is unlikely to change over time. Similarly, the caregiver exemption should be automatically renewed for as long as the caregiving relationship lasts.

H.R. 1 requires states to use an ex parte process to verify exemption eligibility and avoid requesting individuals to provide for additional information whenever possible. The state should maximize such data‑driven verification by linking and cross‑checking existing state sources to identify people who qualify for the medically frail exemption, such as [Medicaid claims, Managed Care Organization (MCO) records, long-term services and supports and other disability and aging services data, and behavioral health records]. Similarly, the state may be able to use existing data to exempt some caregivers, such as those being paid under Medicaid Home- and Community- Based Services (HCBS) programs. Ex parte data that confirms an individual meets a statutory exemption should be applied automatically without requiring the applicant or enrollee to provide additional documentation confirming their exemption status. Importantly, even when maximizing these data sources, the state must accept self‑attestation since most family caregivers are not identified in existing data sources and many people who qualify for the medically frail exemption, like Marsha, cannot easily document their condition, especially without Medicaid.

Ensure accessibility, due process, and operational safeguards.

Given the extensive and confusing nature of these work requirements, it is essential for the state to provide clear and accessible information to applicants and enrollees. This includes plain‑language, accessible notices in multiple formats and languages explaining the reporting requirements, exemptions, and information about requesting accommodations. It is especially important that the state test applications and any technology and include older adults among the testers.

Medicaid enrollees should also have accessible options, such as a well-staffed hotline, to reach trained and knowledgeable staff to ask questions or get additional information. The state should also be explicit about enrollees’ right to appeal adverse decisions, including an opportunity to temporarily continue coverage pending appeal and an opportunity for a hearing. This includes providing clear deadlines for requesting appeals and for agency decisions, and ensure beneficiaries receive timely notice of those deadlines. Beneficiaries should also be offered assistance, including help completing forms, requesting continuations, and obtaining representation or advocacy support.

[Additional topics to raise if relevant to the state (e.g., utilizing Beneficiary Advisory Committees and other stakeholder engagement opportunities; data sharing responsibilities, role of MCOs and third-party contractors, privacy concerns and proper use of data, etc.)]

Conclusion

We appreciate your careful consideration of these recommendations and urge the state to adopt these policies and practices to protect access to care while implementing work requirements. Establishing clear exemption rules and processes consistent with Congress’s intent to exempt people with serious and complex health conditions and family caregivers for older adults, prioritizing self‑attestation and ex parte renewals, and providing robust due process rights will reduce wrongful terminations and help preserve health and independence for older adults, people with disabilities, and their caregivers.

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1. Tavares, J. and Cohen, M., What are Socio-Demographic Characteristics of Medicaid Expansion Population compared to Non-Expansion Medicaid Population age 50 to 64? Analytic Brief, LeadingAge LTSS Center @UMass Boston (April 2025), https://www.ltsscenter.org/wp-content/uploads/2025/04/Differences-between-Expansion-and-Non-Expansion-Medicaid-Beneficiaries-April-2025.pdf.
2. See Medicaid eligibility verification plans by state: https://www.medicaid.gov/medicaid/eligibility/medicaidchip-eligibility-verification-plans.