Millions of Medicaid adults will face a new federal 80-hour-per-month work rule starting in 2027. The rule comes from the 2025 budget reconciliation law, and it links Medicaid eligibility for expansion adults to steady work or other approved activities. States can even move faster if they use federal 1115 waivers.
Federal law says some people are automatically exempt. This includes pregnant adults, postpartum adults, parents or caretakers of young children, and adults the state marks as “medically frail.” But how states decide who is medically frail is already causing big confusion.
The Medicaid rules from HHS, CMS, and state agencies say “medically frail” includes adults who are blind or disabled. It also includes people with major physical limits, developmental disabilities, serious mental health conditions, substance use disorders, and other complex medical conditions that make daily life hard. This group is larger than people on SSI or SSDI, and federal guidance is clear about that.
But the rules work very differently in real life. Many states use narrow screens or old disability-style checklists. Some states only tag about 8% of expansion adults as medically frail, even though far more meet the federal definition. Plans and doctors must often send extra forms, and some states expect adults to prove their frailty on their own.
This creates a major risk for people with chronic pain, long COVID, anxiety, depression, or substance use disorders who struggle to work full time but do not have complete medical records in the Medicaid system. These adults may not be listed as medically frail in time. Under the new rule, that can cause fast coverage loss.
Many states use online portals with monthly deadlines. If someone misses the window or thinks they are exempt when the state has not coded them as exempt, the system may suspend or end their coverage. Medicaid experts warn that these rules can hit people with unstable work or poor internet access the hardest.
Officials from federal agencies like CMS say states can use claims data, past diagnoses, and plan referrals to identify medically frail adults automatically. But not all states do that. Some rely on long forms or clinic notes that take time to collect. This leads to what experts call a “gray zone” where people are sick enough to qualify but not labeled correctly in the system.
Advocates worry that millions of Medicaid adults could be touched by the rule. About 10 to 15 million adults fall into the core expansion group that will face work checks first. For them, the medically frail label may decide who keeps health care and who loses it.
People at highest risk are adults with health limits that do not show up clearly in the data. This includes those with chronic conditions that flare up, like migraines or back pain, and those with behavioral health needs who change jobs often. Many already struggle with paperwork. The new rule adds more steps, more deadlines, and more stress.
State Medicaid offices are now deciding how to handle screenings, reporting, and appeals. Some states may expand automatic detection. Others may keep strict rules. Experts from national research groups say the difference between states could be huge, and it may influence who gets care in 2027.
The federal government urges adults with serious or complex conditions to contact their Medicaid plan or state agency early to understand how to document their medical needs. Plans may be able to help send forms or update records before renewals begin.
For now, the message from state officials is simple but urgent: the “medically frail” label may decide your Medicaid future. Make sure your records are updated before the 2027 work rules start.
