Practical steps for states, advocates, and housing providers to prevent coverage loss
By Marcella Maguire, Ph.D., Director, Health Systems Integration at CSH
As we outlined in our previous post, H.R.1 (the “One Big Beautiful Bill Act”) makes significant changes to Medicaid that will require states to adapt their programs to stay in compliance. The bill’s nearly $1 trillion reduction in federal support over 10 years will force states to cut costs, while new eligibility rules and administrative requirements are expected to push many people off Medicaid entirely.
This article focuses on work requirements, which the federal government refers to as “community engagement.” This change will impact many affordable and supportive housing residents, people actively experiencing homelessness, people who have formerly experienced homelessness, and anyone facing any type of housing instability.
What “Community Engagement” Means
The Centers for Medicaid and Medicare Services (CMS), which administers Medicaid, uses “community engagement” to describe activities that will be required to keep a person’s Medicaid coverage active after 12/31/2026. A subset of Medicaid recipients will have to report 80 hours of work or other qualifying community engagement activities in the previous month to maintain coverage.
States are already designing these systems, and those in the field participating in those discussions now can help reduce barriers that might otherwise disrupt coverage and access to supportive services. We encourage supportive housing, homelessness, and affordable housing advocates to ask their state and health care partners how they are prioritizing continuous coverage for the people they serve.
What Research and Early State Experience Show
Current research indicates 92% of people targeted by work requirements are already working.1 Two states —Arkansas and Georgia —have implemented versions of these policies. Arkansas work requirements program was halted by court order in 2018-19.2 Studies found 18,000 Arkansans lost coverage, primarily because they could not navigate administrative requirements.3 Researchers found that work requirements had no positive impact on employment or health outcomes. Georgia’s program remains active and, similar to Arkansas, shows no measurable impact on work or health outcomes.4
Georgia has not expanded Medicaid under the Accordable Care Act. Because there was no prior coverage pathway for many affected individuals, the state does not report comparable loss of coverage statistics.
Despite these findings, all states must set up systems to track and ensure “community engagement” (commonly known as work requirements) by December 31, 2026.
What This Post Covers and How Your Agency Can Prepare
Below, we outline the critical choices states face in the coming months, who must report, who is exempt, what counts as community engagement, when requirements begin, how states will implement tracking, and concrete steps agencies can take now to help people keep coverage.
Who Must Report Work?
States must implement tracking systems for people whose Medicaid eligibility is based solely on low income—often called the expansion population—in states that expanded Medicaid. Non-expansion states are not required to create these systems, although some, such as Georgia, are experimenting with the impact of these programs.56
This same group will also face more frequent eligibility redeterminations. Proof of work or community engagement will be required at application and at each redetermination. States are required to look back at least one month and up to three months before application within each six-month eligibility period to verify compliance.
Whose Exempt from Work Requirements?
States have some flexibility to set exemptions, and federal law requests several. As defined by the law, exemptions must include:7
- People under age 19 or 65 and older
- American Indians and Alaska Natives
- Caregivers for children 13 or younger
- Veterans with disabilities
- People enrolled in substance use disorder treatment
- People deemed medically frail (states must define and operationalize this process).8
- People facing a short‑term hardship (for example, some states are considering homelessness as a short‑term hardship; Montana has requested this, and as of February 25, 2026, no public decision has been posted).9
- People living in an area with a Presidential disaster declaration10
- People in an area with unemployment at or above 1.5 times the national rate
What Constitutes Work or Community Engagement Under H.R.1?
H.R.1 (Public Law 119-21) ties continued Medicaid eligibility to completing least 80 hours per month of qualifying work and community engagement activities. States have some discretion to refine categories and set tracking methods. Allowable categories include:
- Employment: Any paid job counts toward the 80‑hour requirement
- Job training/workforce development: Job skills training, workforce preparation, or structured employment programs qualify
- Education: Enrollment at half time or more in an approved program, including adult education, community or technical college, GED coursework, or higher education
- Community service: Unpaid service with nonprofits, civic, or community organizations that add up to 80 hours
CSH launched a new partnership to pilot Clubhouse participation to enhance recovery and advocates for other supported employment opportunities to count as work. In states that fund these services through Medicaid, agencies should be able to track attendance via Medicaid claims, so individuals don’t need to submit extra paperwork.
States are also modernizing data systems. If eligibility systems for Medicaid and SNAP communicate, compliance documented in one program could automatically satisfy requirements in the other, reducing the burden on individuals. The simpler and more automated the system, the fewer eligible people will lose coverage due to paperwork barriers.
When Do the Requirements Start?
States must have systems operational by December 31, 2026, to comply with H.R.1 and we expect states to roll out requirements in fall 2026.
To meet federal minimums, states must verify at least 80 hours of work or community engagement in the month before a person applies or redetermines coverage. “Redetermination” means the state confirms the person still qualifies for Medicaid, typically every six months for this population. States may choose to check more often, but federal rules don’t require it.
How Will States Track and Verify?
States must quickly develop ways to track compliance and exemptions and should prioritize verification that doesn’t burden people. Examples include:
- Data matching with state wage or tax systems to verify work without extra paperwork.
- Claims‑based verification for participation in Medicaid‑funded services (e.g., supported employment).
- Interoperability with SNAP or other programs to reduce duplicate reporting.
Today, many state databases operate in silos—even within Medicaid (eligibility vs. claims) and across agencies (e.g., tax, workforce). States that already link systems to comply with SNAP work reporting can apply those lessons to Medicaid.
States must check compliance at least every six months, including at application and each redetermination. Communication channels vary widely: most states accept documents online; a few still require in‑person interviews. Some allow trained assisters or navigators to support people directly in their online accounts. Clear, proactive communication will be essential, so case managers, service coordinators, peer supports, and housing staff can help people maintain coverage.
What a state will count as proving compliance remains to be determined, and advocates are encouraged to push states to make these systems as easy to navigate as possible.
How to Maintain Coverage Under the New Rules
Confirm expansion status. Determine whether you—or your tenant/resident—are in the expansion group (income‑only eligibility). Check state eligibility criteria, contact your Medicaid office, or review enrollment notices and codes that indicate expansion coverage.
Assess eligibility for traditional Medicaid. If someone may qualify through disability (via the Social Security Administration), consider starting that process now. It can be lengthy, and disability advocacy is often critical to success.
Check for exemptions. Review the exemption list above. If one applies, gather documentation early and note how the state wants it submitted.
Plan for compliance if needed. If a person is in the expansion group, does not qualify for traditional Medicaid, and does not meet an exemption, help them identify qualifying activities and straightforward ways to document 80 hours per month.
Helpful Resources
CSH’s partner agencies also have released helpful material regarding this issue, including:
Bottom Line
Our shared goal is to help people maintain continuous health insurance coverage, so they can access the services necessary to manage health conditions and thrive in their communities. Agencies, staff and advocates should be engaging with state officials now to make the systems as easy to navigate as possible. Providing support as people adjust to these requirements will help them stay connected to essential services and strengthen their ability to remain stably housed.
