MEDICAID CHANGES
What’s changing in Medicaid under H.R. 1, and who each change applies to.
FIRST: WHICH RULES APPLY TO YOUR CLIENT?
It depends on how the person qualifies for Medicaid, not just which state they live in. Every rule on this page is tagged so you can tell at a glance:
ADULTS IN STATES THAT EXPANDED MEDICAID
Applies only to adults 19–64 in states that expanded Medicaid who qualified based on income alone. These are the people facing the biggest changes.
EVERYONE ON MEDICAID
Applies to all Medicaid enrollees, including people who qualify through a disability, SSI, pregnancy, as a parent, or as an older adult.
Not sure which group a client is in? Their Medicaid approval or renewal letter usually names the eligibility category. See Who the changes affect for how disability fits in.
KEY DATES
OCTOBER 1, 2026
Narrower immigrant eligibility. Everyone on Medicaid.
JANUARY 1, 2027
Work requirements, renewals every 6 months, and 1-month retroactive coverage. Adults in states that expanded Medicaid only. Address checks and 2-month retroactive coverage for everyone else.
OCTOBER 1, 2028
Copays of up to $35. Only adults in states that expanded Medicaid earning over 100% of poverty.
January 1, 2027 is the deadline for work requirements; states can start earlier. Nebraska already began on May 1, 2026, phasing people in at their renewals. In practice, each person runs into the new rules at their own renewal date, so some state materials cite later dates (for example, California cites March 2027). HHS can give some states extra time on work requirements, up to December 31, 2028.
AT A GLANCE: WHO EACH RULE APPLIES TO
Shaded red cells are where the rules differ. Some states have passed laws that go further than H.R. 1; see the State Directory.
WHO IS IN THE EXPANSION GROUP
The "expansion group" is adults ages 19–64 who qualify for Medicaid based on income alone (up to 138% of the federal poverty level) in the 40 states plus D.C. that expanded Medicaid. States may call this group "applicable individuals." About 20 million people nationwide are in it. Georgia and Wisconsin cover similar adults through special waivers, and they are also subject to work requirements.
HAVING A DISABILITY DOES NOT AUTOMATICALLY EXEMPT SOMEONE
Many people with real disabilities, including many people living with HIV, are in the expansion group because they qualified on income and were never formally found disabled, or are still waiting on an SSI/SSDI decision or for Medicare to start. They must claim an exemption, usually medical frailty (see below). People who get Medicaid because of a disability or SSI are not in the expansion group and don't face work requirements.
Worth knowing: research cited by KFF suggests 92% of people subject to these requirements are already working or would qualify for an exemption (caregiving, illness, or school). Most coverage losses are expected to come from people getting tripped up by paperwork and reporting systems, not from actually being ineligible.
THE WORK REQUIREMENT
ADULTS IN STATES THAT EXPANDED MEDICAIDEach month, a person must show either at least $580 in income or 80 hours of qualifying activity. The $580 figure is based on the federal minimum wage and is the same in every state, even states with a higher minimum wage. People who show $580 a month in income don't need to track hours.
Activities that count toward 80 hours:
- Work, paid or unpaid, or organized volunteering
- School, including GED programs
- Certain state-approved job training programs
Watch for this: under CMS guidance, job services paid for by Medicaid through a managed care plan do not count as a "work program" on their own. Check how your state treats a client's existing job support.
Students: being enrolled in school at least half-time meets the requirement on its own. Seasonal workers: H.R. 1 lets them meet the income test using their average monthly income over the past six months.
LOOK-BACK PERIODS & HOW OFTEN STATES CHECK
ADULTS IN STATES THAT EXPANDED MEDICAIDThe "look-back period" is how far back a state checks whether someone met the work requirement. Most states check only the past month. Some go further:
- Three months at application: Arkansas, Idaho, Indiana, North Carolina
- Checks every three months (not just at renewal), each looking back three months: Indiana and New Hampshire
Rules vary by state and are still changing. Check your State Directory entry for local details.
EXEMPTIONS FROM THE WORK REQUIREMENT
ADULTS IN STATES THAT EXPANDED MEDICAIDStates must first check their own data to see if someone is already exempt or meets the requirement. If they can't confirm it, they contact the person to prove it.
Required exemptions (most must be re-proven at each 6-month renewal; medical frailty lasts 12 months; American Indian/Alaska Native status is documented once):
- People who are medically frail, which includes people who are blind or disabled (see below)
- People who are pregnant or postpartum
- Parents or caregivers of children 13 and under or of a person with a disability
- People already meeting SNAP or TANF work requirements
- People in treatment for a substance use disorder
- Veterans with a 100% disability rating
- People enrolled in Medicare
- American Indian or Alaska Native individuals
- Former foster youth under age 26
- People in jail or prison, or released within the past 3 months
Optional short-term hardship exemptions (a state may choose to offer these):
- Hospitalization
- Living in a federally declared disaster area or an area with high unemployment
- Traveling out of state for needed medical care
GOOD TO KNOW: APPEALS
A person keeps full Medicaid benefits while their appeal is pending. If a client is denied or cut off and believes it's a mistake, filing an appeal right away can protect their coverage during the review.
MEDICAL FRAILTY & DISABILITY: WHAT TO KNOW
Under the law, "medically frail" includes people who are blind or disabled (using the Social Security definition), and people with a disabling mental disorder, a substance use disorder, a serious or complex medical condition, or a disability that limits daily activities.
But a diagnosis alone isn't enough. CMS's June 2026 rule added a second test: the condition must also significantly limit the person's ability to meet the work requirement. Each state keeps a list of qualifying conditions, decides what proof counts, and decides who can sign off (often a medical provider). CMS lists HIV among example conditions states may treat as "serious or complex," but the condition must still be shown to limit the person's ability to work, so a diagnosis alone usually isn't enough. See the state code lists.
Self-attestation: through 2027, people can generally state on their own that they are medically frail when the state can't confirm it from its records. Starting in 2028, that's limited to once per enrollment period. North Carolina and New Hampshire have banned self-attestation, so clients there need documentation from the start.
Privacy: claiming medical frailty can mean sharing an HIV diagnosis with new state systems. Help clients understand this before they apply, and connect them with staff who can explain what will and won't be shared in your state.
Legal challenge underway: on June 29, 2026, 25 states and D.C. sued over the CMS rule, specifically the burden it puts on states to assess medical frailty. We'll update this page as the case develops.
RENEWALS EVERY 6 MONTHS
ADULTS IN STATES THAT EXPANDED MEDICAIDStarting in early 2027, adults in the expansion group must renew their Medicaid every six months instead of once a year. Everyone else on Medicaid, including people who qualify through a disability or SSI, still renews once a year.
Most states let people renew online, by phone, by mail, or in person. Clients should watch for renewal notices by mail, text, and email, and respond by the deadline.
RETROACTIVE COVERAGE
DIFFERENT FOR EACH GROUPMedicaid can pay medical bills from before someone applies. Starting January 2027, that window shrinks from 3 months to 1 month for adults in states that expanded Medicaid and 2 months for everyone else. Encourage clients to apply right away after a hospital stay or new diagnosis.
COPAYS
ADULTS IN STATES THAT EXPANDED MEDICAIDStarting October 1, 2028, states must charge copays of up to $35 per service to adults in the expansion group earning more than 100% of the poverty level, capped at 5% of family income. Primary care, mental health, substance use, pregnancy, emergency, and family planning care, and visits to community health centers, are exempt. Kentucky has passed a law charging adults in the expansion group more than H.R. 1 requires, and North Carolina has passed one adding copays for traditional Medicaid too.
MAILING ADDRESS & CONTACT INFORMATION
EVERYONE ON MEDICAIDStarting January 2027, states must regularly update enrollees' addresses using returned mail, the Postal Service change-of-address list, and health plan records. By late 2029, a national system will flag anyone enrolled in Medicaid in more than one state. States reach out by text, email, and mail, so every client should update their address and phone number now, before a notice is sent.
IMPORTANT
P.O. Boxes may not be accepted as a valid address. Clients without a stable address may need a different solution, such as a CBO's physical address where allowed. Confirm current policy with your state before relying on either option.
IMMIGRANT ELIGIBILITY
EVERYONE ON MEDICAIDSince October 1, 2026, Medicaid is limited to citizens, green card holders, and a few other groups. Refugees and asylees without a green card lose eligibility. Louisiana and Wyoming now give applicants only one chance to submit citizenship or immigration documents.
WHAT THIS MEANS FOR YOUR ORGANIZATION
- Find out how each client qualifies for Medicaid (expansion vs. disability, SSI, or another category). That decides which rules apply.
- For clients with a disability who are in the expansion group, start on a medical frailty exemption now, and consider helping them apply for SSI or SSDI, which moves them out of the expansion rules.
- Identify which health partners can sign off on medical frailty forms, and make sure HIV, mental health, and substance use diagnoses show up in clients' recent care
- Help every client confirm or update their mailing address and phone number now
- Designate a staff person to track your state's timeline, announcements, and system changes
- Build an internal process for when a renewal or compliance notice arrives
- Track, for every client: Medicaid category, coverage type (Medicaid, Medicare, VA, private), managed care plan and contact, and when their renewal is due
- Use the Resources page glossary and documents checklist, and see your State Directory entry for state-specific contacts and rules
Sources: H.R. 1 (Sections 71107, 71109, 71112, 71103, 71119, 71120) as summarized by Families USA and the AMA; CMS Medicaid Community Engagement Interim Final Rule; Georgetown Center for Children & Families, "How H.R. 1 Cuts and Changes to Medicaid Played Out in 2026 State Legislative Sessions (Part 2)" (July 2026); National Alliance to End Homelessness (2026); National Center for Housing + Health (CSH) (2026); Stay Covered Coalition; KFF; National Health Care for the Homeless Council. Rules vary by state and may change. Verify current requirements with your state Medicaid agency before advising clients.
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