Key facts
- New guidance from the Trump administration redefines medical frailty exemptions for Medicaid work requirements.
- Patients may need to prove their condition significantly impairs their ability to work, volunteer, or attend school.
- This could jeopardize health coverage for individuals with chronic illnesses or treatment side effects.
- Experts warn the rule may lead to more people needlessly losing coverage.
- States are reportedly confused about how to implement the new definition and verify patient conditions.
A new interim final rule from the Trump administration's Centers for Medicare and Medicaid Services (CMS) is raising concerns among patients and health experts regarding Medicaid work requirements. The guidance, effective next year, redefines medical frailty exemptions, potentially jeopardizing health coverage for individuals with serious illnesses or treatment side effects.
Previously, conditions like substance use disorders, disabilities, or serious medical conditions qualified individuals for exemptions. However, the new rule requires that a person's condition must "significantly impair" their ability to work, volunteer, or attend school for at least 80 hours a month to be exempt. Patients will be able to attest to meeting this definition in 2027, but will need to provide proof for renewal in 2028.
DeAnna Brandon, a 48-year-old blood cancer survivor in North Carolina, fears this change could lead to her losing coverage for essential chemotherapy. She described the difficulty of proving her inability to work, even during active treatment, and worries about the bureaucratic burden on sick individuals.
Health analysts and state officials have expressed confusion and alarm. Experts like Adrianna McIntyre, a professor at Harvard University's school of public health, believe the rule will lead to more people unnecessarily losing coverage. State Medicaid officials and consultants are unsure how to verify a patient's condition using existing data, as claims data does not typically prove significant impairment from working.
CMS Administrator Dr. Mehmet Oz suggested that most people would be helped without direct interaction, but the agency stated it would not allow categorical exclusions based solely on diagnosis. This approach leaves states uncertain about how to implement the rule, with some, like Nebraska, needing to rework their systems. The task of preparing for these changes is described as immense and expensive, with an estimated $200 million cost for states.