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The One Big Beautiful Bill Act (OBBBA, or H.R. 1) became law in July 2025 and included provisions that affected how certain Medicaid beneficiaries can become eligible for and retain Medicaid coverage. States that expanded coverage to adults under the Affordable Care Act (ACA) are required to condition eligibility upon enrollees meeting “community engagement” requirements, otherwise referred to as “work requirements.” Under these standards, eligible individuals must engage in 80 hours per month of work, community service, education, or equivalent activity. These restrictions apply to eligible individuals in 41 expansion states, including the District of Columbia (DC), as well as to those enrolled in certain Medicaid waiver programs, meaning the work requirements apply in a total of 44 states (with DC).1 Importantly, the law exempts certain individuals from these requirements, including those who are “medically frail.” A recent regulation has narrowed the range of individuals who can qualify for this exception.2
New Requirements Affecting Eligibility
On June 1, 2026 (the statutory deadline), the Centers for Medicare & Medicaid Services (CMS) issued an interim final rule (IFR) implementing the community engagement requirements.3 The law authorized the agency to issue the rule as an IFR, thereby permitting it to forego the regularly required notice and comment period and allowing the rule to take effect on July 31, 2026, without issuing a final rule. The agency received public comments through July 31, 2026.1 Notably, the IFR added requirements for individuals to qualify for the medical frailty exemption.
The OBBBA included five categories of individuals within its definition of medical frailty. This included those who have a “serious or complex” medical condition. Importantly, the law did not add any conditions to this exemption, such as it did for those with a physical, intellectual, or developmental disability, for whom it required that the condition limit their ability to perform one or more activities of daily living.4 Under the IFR, the individual’s condition must also “significantly impair” their ability to comply with the community engagement requirements.5 Hence, individuals must fall within one of the five specified categories and demonstrate that the condition means they cannot comply with the work requirements.
While the IFR does not include an exhaustive list of conditions that would meet the definition of “serious and complex” for the purposes of the medical frailty exemption, it does note that it would be reasonable to consider cancer (and other specified conditions) as “serious and complex” when they significantly impair a person’s ability to comply with the community engagement requirements.5
Added Burden on Beneficiaries and Key Stakeholders
In addition to limiting the number of eligible individuals through this added requirement, the new standards for meeting the exemptions impose additional burdens upon states, potential and existing enrollees, and healthcare providers. States must verify eligibility at the time of application and renewal. Self-attestation to verify work or health exceptions can be accepted during the first year if documentation is not reasonably available; after that, it is accepted, but individuals must show documentation within 30 days or face denial or disenrollment.1 Experts indicate that state Medicaid agencies are not equipped to determine if someone can work or participate in community engagement activities. For example, they do not employ occupational medicine experts who could determine readiness to work.4
Furthermore, the new standard changes what CMS had been telling states for several months about the definition of medical frailty. Therefore, states will have to alter systems and implementation plans developed based on their earlier understanding of the requirements and may not be able to automatically identify those who qualify as medically frail when their systems go into effect. The changes also mean that states’ determinations regarding medical frailty exemptions will involve more manual work. Since fewer individuals will be automatically identified, individuals will have to obtain and submit documentation, which eligibility workers will have to review, leading to more paperwork burden for beneficiaries and state agencies.6
Additionally, certain clinical providers serving poor and underserved patients have indicated that they do not have the expertise in occupational medicine needed to assess whether someone is capable of meeting the community engagement or work requirements.4 Therefore, patients with cancer may need to ask their providers to document the severity of their condition and its impact on their ability to work, adding an additional burden to providers and patients.
Impact of Community Engagement Requirements on Medicaid Coverage Levels
Significant reductions in the number of people with health insurance are foreseen as a consequence of H.R. 1’s community engagement and work requirements, although estimates of the scope of this impact vary. CMS projects Medicaid enrollment would be reduced by 2.3 million individuals in FY 2027 and by 3.1 million to 3.3 million individuals in the subsequent years through FY 2036.7 Other sources have estimated larger impacts. For example, the Urban Institute estimates that between 3 million and 7 million people could lose Medicaid coverage by 2028 as a consequence of the work requirements.8 The Congressional Budget Office (CBO) estimated that the imposition of these restrictions would result in 5.3 million fewer people with health insurance in 2034.9
Opportunity for Public Comment
The public comment period for the IFR closed on July 31, 2026. The Association of Cancer Care Centers submitted comments to CMS and will continue to provide updates.
Nicole Tapay, JD, is the Director of Cancer Care Delivery and Health Policy for the Association of Cancer Care Centers in Rockville, Maryland.
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