Population: Complex Health Needs

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 

1. People under age 19 or 65 and older 

2. American Indians and Alaska Natives 

3. Caregivers for children 13 or younger 

4. Veterans with disabilities 

5. People enrolled in substance use disorder treatment 

6. People deemed medically frail (states must define and operationalize this process).⁸  

7. 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  

8. People living in an area with a Presidential disaster declaration¹⁰ 

9. 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: 

1. Employment: Any paid job counts toward the 80‑hour requirement 

2. Job training/workforce development: Job skills training, workforce preparation, or structured employment programs qualify 

3. Education: Enrollment at half time or more in an approved program, including adult education, community or technical college, GED coursework, or higher education 

4. 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: 

• National Health Law Program, Justice in Aging, and Bazelon Center for Mental Health Law 

• Center on Budget and Policy Priorities 

• National Health Care for the Homeless Council (NHCHC) 

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.  

The projects will serve more than 250 residents through innovative initiatives that tackle complex health, substance use, and aging challenges.

The Challenge: Rising Acuity Among Supportive Housing Residents

Over the last five years, New York City’s supportive housing system has been stretched by a growing number of people experiencing homelessness who need more intensive, coordinated support to stay housed.

More people are experiencing prolonged homelessness due to obstacles in accessing health care, housing, and community-based services. Many individuals entering or living in supportive housing are navigating complex trauma and health conditions, often without consistent access to coordinated and person-centered care.

Supportive housing providers have seen a drastic rise in serious health challenges for their residents. At the same time, the population within supportive housing is aging. Older adults, age 50+, now represent the fastest-growing group of New Yorkers facing housing instability, with many entering homelessness and crisis systems for the first time. Providers are struggling to support aging residents who have lived with substance use disorder for decades, often experiencing cognitive decline and aging issues nearly 20 years earlier than those who have never been homeless.

The COVID-19 pandemic also led to the closure of many nonprofit service providers, and the sector continues to feel the devastating impact of a critical service infrastructure that has been reduced in scale. Further, the sector has received insufficient public and private investments to meet the needs at the required scale.

CSH’s Response: A Multi-Year Initiative

Funded by a three-year grant from The Leona M. and Harry B. Helmsley Charitable Trust, CSH launched a three-phased project to both identify service gaps and surface solutions that better address the needs of supportive housing residents with complex health challenges in New York City (NYC). CSH’s NYC metro team, led by Lauren Velez, launched this project by engaging teams of collaborators and advisors on key phases of the project: starting with establishing partnerships with network leaders at The Supportive Housing Network of New York (the Network) and The Health and Housing Consortium to bring their expertise and membership’s perspectives to the project; followed by convening an advisory committee for input and feedback that includes providers, government leaders, and people with lived expertise.

The first official phase of the project was to complete a full landscape assessment aimed at understanding the local and national challenges, and opportunities to serving this population in the supportive housing field.

Informed by and in response to these findings, Phase Two included the creation and announcement of a competitive RFP to solicit ideas with the most promise to improve the service levels in the sector to better meet these unmet needs. In November 2025, CSH selected four proposals to be the pilot projects for the “High Health Acuity in Supportive Housing Initiative”, awarding a total of $1,000,000 in grants over 2 years. The selected pilot projects will holistically address the high acuity health needs of supportive housing residents through increased capacity and innovative interventions.

Evidence Towards Innovation

Phase Three of this project involves CSH choosing and engaging an evaluation partner, L&G Research and Evaluation Consulting, Inc., to evaluate learnings from the initiative and, together with CSH’s deep expertise in the field, and the input from their expert advisory committee, coordinate the evaluation for the pilots projects with an eye towards opportunities for scaling and sustainability for those that are successful. The evaluation partner will also develop education materials to share with policy makers and other stakeholders.

“I couldn’t be more excited about this initiative as it combines grant funding with CSH’s tailored technical assistance and policy expertise to help providers better support residents living with multiple co-occurring physical and behavioral health conditions,” said CSH NYC Metro Director, Lauren Velez. “Pilot programs test innovations that include hiring additional specialized staff, implementing flexible service models, and strengthening collaboration across homelessness and health systems. We need to reimagine our investment in supportive housing services. Cost effective measures don’t mean that we can fail to provide adequate funding- it means that the return on that investment is greater and more stable than alternatives. “

Private funding is often needed to create the evidence and testing needed to advocate for public adoption. “A project like this with three important ingredients of evidence-based innovation – research, testing, and evaluation – bolstered by the deep bench of expertise from CSH and their partners to find solutions to this growing challenge for New Yorkers living with complex health issues in Supportive Housing, is one of the strongest doses of philanthropic support that we could apply to the problem,” said Tracy Perrizo, NYC Program Officer from the Leona M. and Harry B. Helmsley Charitable Trust. The project’s aim is to show why making the necessary investments to meet these needs at scale is smart and cost-effective policy. Decades of research have proven that supportive housing offsets public costs of crisis systems and creates safe, thriving communities.

“This project gives us the ability to explore the impact of interventions that are truly person-centered, responsive to need, and properly funded on the overall health and well-being of high-need supportive housing tenants,” added Velez.

Meet the Four Pilot Projects

CSH and evaluation partners selected these four organizations from an extremely competitive applicant pool of New York City supportive housing providers.

Alliance for Positive Change

Alliance for Positive Change will integrate a housing-focused social worker to provide comprehensive clinical support services to residents of their Bronx supportive housing building. Residents have complex health needs including HIV and other chronic illnesses, mental health concerns, aging issues, and other challenges. The new full-time staff member will provide frequent, one-to-one counseling to improve residents’ financial skills, apartment-care skills, self-efficacy, and independence.

Lantern

Lantern’s Adapted-Intensive Case Management (A-ICM) pilot project will adapt the most effective elements of the traditional Intensive Case Management (ICM) model to make it more sustainable and scalable for organizations with limited resources. Case managers will receive training to support residents with complex needs through intensive services. Within the A-ICM model, services will include needs assessments, referrals and warm handoffs, health navigation, and accompaniment to health appointments. The pilot also includes hiring new Tenant Peer Navigators who will leverage their lived expertise to help residents navigate complex health systems.

Project Renewal

Project Renewal’s High-Acuity Response Team (HART) project will pilot a care team consisting of a nurse care manager and occupational therapist who will support their highest-need supportive housing residents. The new full-time staff members will manage a shared caseload to serve residents with complex needs including substance use, serious mental illness, aging, generational trauma, and/or chronic health issues. This pilot project will bring coordinated in-house care that specializes in complex needs, while increasing capacity for frontline staff who are strained in supporting 100 of their highest need residents across multiple supportive housing sites.

St. Nicks Alliance

The St. Nicks Alliance project will pilot a new mobile Wellness Outreach Team to support residents of their scattered-site supportive housing program. Tenants living in scattered-site supportive housing can be more difficult to reach, as they live in units rented from private landlords throughout the city. This multidisciplinary team will conduct comprehensive in-home assessments and provide ongoing support services including medication management, behavioral health support, and health education. This new team will coordinate with existing case managers and be integrated with community providers to facilitate warm hand-offs when clients stabilize. The outreach team plans to serve around 60 tenants during the pilot period.

This resource is intended to support health centers in identifying some important components to effective programming for HIV+ individuals leaving carceral settings to ensure smooth linkage to care and housing following discharge.

The verdict this week related to the death of Jordan Neely on a New York City subway train underscores the urgent need for change in how we respond to the unmet mental health and housing crises. When the immediate response to a mental health crisis is excessive force by a member of the public, resulting in death, it is clear that our system is broken.

Data show that Black, Indigenous and People of Color are disproportionately represented among people experiencing homelessness due to unfairness in housing and employment, as well as higher rates of incarceration. Furthermore, these groups are less likely to receive mental health services compared to those identifying as white, a disparity that is even more pronounced among the homeless population. Ensuring that housing is affordable for everyone and that services are available fairly, is crucial to supporting our most vulnerable populations.

We believe that true public safety is achieved not through force, but through compassion and support. Until we prioritize affordable housing and services in our country, more people will be subjected to violence under the guise of public safety. The common-sense and compassionate public safety response recognizes the critical role of stable housing and support services in helping people and communities thrive.

Our elected leaders must invest in data-driven, fiscally responsible solutions that protect the rights and well-being of all human beings. States like Nevada and Michigan have made historic investments of $32 million and $26 million respectively with bi-partisan support in services to address housing and mental health needs.

We call on Governor Hochul and Mayor Adams to take action on their commitments to invest in affordable housing, breaking the cycle of violence in the name of public safety. With this they can take decisive steps to honor Jordan Neely and achieve justice for him and public safety for all people.

For Immediate Release | Media Contact: Jesse Dean, [email protected] or 347-931-0132

The appropriation will provide critical funding for 500 supportive housing units that can end the jail-homelessness cycle for people exiting Rikers. 

The New York City Council passed the fiscal year 2025 budget, allocating $6.4 million to fund 500 Justice Involved Supportive Housing (JISH) units for individuals leaving Rikers. This funding is critical for providing supportive housing units that greatly increases the chances for persons with a history of homelessness and incarceration, to achieve stability, recover from substance abuse disorder, manage mental illness, and finally end the jail-to-street homelessness-jail cycle. 

The allocation fulfills a 2019 commitment from city officials to expand access to the program and was championed by CSH with City Council Speaker Adrienne Adams, Council Members Sandy Nurse and Carlina Rivera, Freedom Agenda, Vera Institute of Justice, The Fortune Society, and other partners.  

Approximately 51% of the population at Rikers, more than 2,500 people each year, struggle with untreated or complex behavioral health conditions. Incarcerating them costs approximately $1.4 billion annually. Without additional housing or support to address their health, many of these individuals upon leaving Rikers, will become homeless or will be re-arrested and return to jail. 

In contrast, supportive housing costs $108 million annually, saving the city significant money while also stopping the homelessness-to-jail cycle and assisting in decarcerating Rikers. The JISH program provides individuals exiting Rikers with the higher-level of support they need to re-enter society and thrive in their communities. Several studies show that supportive housing promotes stability, improves connections to health and behavioral health services, and reduces recidivism.  

“The city fulfilling its commitment is a major victory for our residents with highly complex barriers to housing and for advocates who have long championed the JISH program,” said Lauren Velez, NYC Associate Director at CSH. “With these additional resources, the program can finally reach its full potential and offer crucial support to New Yorkers while saving taxpayer dollars that would otherwise flow to costly emergency response services.” 

“Justice-Involved Supportive Housing is key to increasing public safety and advancing successful re-entry for those returning to our communities from the justice system,” said Speaker Adrienne Adams. “It was one of the many commitments of the plan to close Rikers that remained unfulfilled, because of a shortfall in funding for the vital services that accompany the housing. It has been a Council priority to invest in proven safety solutions and secure the necessary funding for JISH over several budgets, and the Council is proud to invest $6.4 million of its own funding to close the gap for these housing units to be realized. Moving forward, it will require the Administration to baseline these funds and fulfill its obligation.” 

“Supportive housing is a lifeline for justice-involved individuals, offering them stability and a chance to rebuild their lives. We are deeply gratified by the Council’s commitment to fully fund the JISH program, ensuring both the maintenance of current units and the creation of new ones. This crucial investment underscores our dedication to providing real opportunities for successful reintegration and lasting positive change in our communities,” said Council Member Sandy Nurse (D-37). 

“Too often New Yorkers exit incarceration into the shelter system, making it more difficult to successfully reintegrate into the community and achieve stability. Access to supportive housing is an important intervention for individuals involved with the criminal legal system that centers compassion and dignity with access to programming and support. I am proud to have helped secure $6.4 million for JISH and look forward to continued work in coalition to support the most vulnerable residents of our city,” said Council Member Carlina Rivera (D-02).  

Darren Mack, Co-Director of Freedom Agenda said, “We are grateful that City Council responded to the tireless advocacy of formerly incarcerated people and allies to add funding for the JISH program in this year’s budget. Because of their commitment to funding true solutions for community safety and well-being, New York City will finally be able to create 380 more JISH units to break the jail to shelter cycle. We hope the administration will work with providers to get these units up and running immediately.“ 

Jullian Harris-Calvin, director of the Vera Institute of Justice’s Greater Justice New York initiative, said: “We applaud the City Council for securing $6.4 million for Justice-Involved Supportive Housing (JISH). Enabling justice-involved New Yorkers to access housing and supportive services helps interrupt cycles of instability, addressing the root causes of crime and keeping communities safe—all without relying on incarceration, which is costly, deadly, and increases the likelihood of rearrest. In addition, judges are often hesitant to release individuals who are unhoused back to their communities to await trial; greater access to JISH will enable some of the decarceration needed to close Rikers Island once and for all. This investment shows that the City Council is serious about safety, and we commend their focus on preventing crime before it happens rather than just reacting in its aftermath.”

The $6.4 million allocation will enhance the services funding for the 500 JISH units to keep up with today’s services costs, staff wages, and the higher service needs of the JISH population. 

Formerly incarcerated people, housing providers, and advocates from across the city came together to support the JISH request, including 43 organizations and nearly 80 individuals urging their support. 

“CSH is grateful for the leadership of the New York City Council, especially Speaker Adams and Council Members Rivera and Nurse, and an outstanding number of advocates. After last week’s Supreme Court ruling in the Grants Pass v Johnson case, which overturned constitutional protections for people experiencing homelessness and exposes them to fines, arrests, and incarceration, their leadership proves that policymakers have a choice in responding to homelessness with data-driven solutions. We thank them for recognizing that supportive housing is a cost-effective, proven solution for breaking the homeless to jail cycle,” said Deborah De Santis, CSH President and CEO.