Understanding the Impacts of H.R.1 – Community Engagement Requirements and Six-Month Redeterminations

H.R.1 requires states to implement community engagement requirements for Medicaid recipients by January 1, 2027. States may choose to implement earlier through 1115 demonstration waivers. States that demonstrate a good faith effort may request an extension, no later than December 31, 2028. Additionally, states must conduct Medicaid eligibility redeterminations every six months for Medicaid expansion populations.

Reduction in Medicaid Enrollment – Urban Institute Analysis

According to a study published by the Urban Health Institute using their Health Insurance Policy Simulation Model, these two policies could result in 4.9 to 10.1 million fewer people enrolled in Medicaid expansion in an average month in 2028. From work requirements alone, this is about 3 to 7 million, or 27 to 55 percent, loss of enrollees. In addition, they project a loss of between 2 to 3.1 million enrollees from six-month redeterminations.

Even with robust efforts from states and other outreach efforts, the Urban Institute predicts Medicaid expansion enrollment to fall by 19 to 37 percent, despite many enrollees meeting work requirements or qualifying for an exemption. Exempt populations include:

• Foster care youth: Current and former foster youth under age 26.
• Indian Health Service members: Individuals recognized as American Indians or Alaska Natives eligible for services through the Indian Health Service.
• Caregivers: “Parent, guardian, caretaker relative, or family caregiver of a dependent child 13 years of age and under or a disabled individual.”
• Disabled veterans: A veteran “with a disability rated as total under section 1155 of Title 38, United States Code” (section of law that establishes the schedule for rating veterans’ disabilities and governs how compensation is determined).
• Medically frail individuals: People who are blind or disable, have a substance use disorder, a disabling mental disorder, a physical, intellectual, or developmental disability, or who have a serious or complex medical condition.
• Individuals already meeting work requirements: Individuals who meet work requirements for other programs including Temporary Assistance for Needy Families (TANF or the Supplemental Nutrition Assistance Program (SNAP).
• Individuals participating in a qualifying substance use disorder (SUD) treatment program: SUD programs that meet SNAP-related federal requirements, run by nonprofit organizations or public community mental health centers.
• Incarcerated or recently incarcerated individuals: Individuals who are currently incarcerated or have left incarceration within the prior three months.
• Pregnant and postpartum individuals: “Pregnant or entitled to postpartum medical assistance under paragraph (5) or (16) of subsection (e)” (the 12-month Medicaid continuous postpartum extension).
• Short-term hardship: States may allow exemptions for certain extenuating circumstances, including individuals receiving care in hospitals, nursing facilities, psychiatric facilities, or other intensive care settings, individuals in a federally declared disaster area, individuals living in counties with unemployment rates higher than eight percent, or 1.5 times the national unemployment rate (pending permission from HHS secretary), and individuals or their dependents who are required to travel outside their home for medical care for an extended time.

Recommendation to Prepare for Changes and Maintain Enrollment

States

In December 2025, the Center for Medicare & Medicaid Services (CMS) . Additional guidance and clarifications are expected later in 2026.

States are also working through their budget processes to determine what programmatic changes need to happen. These include eligibility system changes, redetermination volume, and community engagement implementation. To do so states must understand how the changes to federal Medicaid, Medicare, and ACA Marketplace interact. In addition, rural health transformation funding may provide additional outreach, retention, and infrastructure opportunities.

Providers and community-based organizations (CBOs)

Providers and CBOs will continue to play a key role in supporting patients in maintaining coverage and navigating new requirements. In addition to preparing for greater uncompensated care needs and costs, they should focus on supporting their patients through policy changes.

Additional Resources:

Policy Center for Maternal Mental Health: Medicaid Work Requirements and Access to Perinatal Care – examines the upcoming federal Medicaid work requirements and eligibility redetermination policies may intersect with coverage and care during pregnancy and the postpartum period.

Medicaid Work Requirements and Caregiver Exemptions Flowchart - helps Title V CYSHCN programs and family leadership organizations understand who the new Medicaid work requirements apply to and who may be eligible for a caregiver exemption. This resource is designed for Title V CYSHCN programs and family leadership organizations who are providing benefits counseling or working closely with state Medicaid programs as they navigate and respond to these upcoming changes.