LWVUS submitted comments opposing the Centers for Medicare & Medicaid Services’ (CMS) Interim Final Rule (IFR) related to the implementation of HR 1’s new mandatory Medicaid work requirements.
Centers for Medicare & Medicaid Services
Department of Health and Human Services
Attention: CMS-2454-IFC
P.O. Box 8016
Baltimore, MD 21244-8016
Re: Medicaid Program; Community Engagement Requirement for Certain Individuals, 2026-11094
Dear Administrator Oz,
The League of Women Voters of the United States (LWVUS) strongly opposes the Centers for Medicare & Medicaid Services’ (CMS) Interim Final Rule (IFR) related to the implementation of HR 1’s new mandatory Medicaid work requirements. The IFR adds administrative barriers that eligible people may be unable to navigate and makes it more difficult for states to implement the new policies by January 11, 2027.
The League is a grassroots organization comprised of over 1 million members and supporters in all fifty states and the District of Columbia across more than 800 local and state Leagues. The League focuses on advocacy, education, litigation, and organizing to advance our mission of empowering voters and defending democracy. Our work is grounded in policy positions shaped by multi-year studies and member consensus, ensuring our advocacy reflects best practices and a national perspective.
In addition to our advocacy in support of Making Democracy Work®, the League focuses on issues that will impact people’s ability to participate in democracy. Access to health care is fundamental to such participation. Voters consistently identify health care as one of the top issues on their minds when they choose who and what they support at the polls, and Medicaid remains broadly popular, with 77% of Americans holding a favorable view of the program. Research shows that Medicaid coverage is associated with improved health, lower rates of disability in adulthood, less medical debt, and long-term financial benefits for society. Polling also shows that cutting federal Medicaid funding is deeply unpopular across political affiliations.
While the CMS rule makes numerous changes affecting Medicaid eligibility, the League is especially concerned about provisions that will make it substantially harder for vulnerable people to qualify for and maintain Medicaid coverage. These policies create new administrative barriers that are likely to cause eligible individuals to lose coverage simply because they cannot navigate additional documentation requirements. The League opposes Medicaid policies that threaten coverage for eligible enrollees, including requirements that certain enrollees work, volunteer, or be enrolled in an educational program for at least 80 hours a month. Most Medicaid enrollees are already working, and those who are not would largely be exempt. This requirement risks denying coverage to eligible recipients due to administrative burdens.
The IFR’s new mandatory work requirements differ significantly from what is outlined in the HR 1 statute and from CMS’s informal guidance to states in two ways. First, the proposed definition of medical frailty narrows who can qualify for an exemption. Second, the requirement that states regularly reverify patients’ medical frailty without allowing self-reporting will create additional barriers for patients and state agencies.
Redefining "Medical Frailty"
The IFR’s definition makes it harder for health care workers and state-level bureaucracies to implement frameworks to identify and verify individuals as “medically frail.” Congress explicitly exempted individuals who are medically frail from Medicaid work reporting requirements in HR 1. CMS' implementation narrows that exemption by requiring individuals not only to demonstrate that they meet their state's medical frailty criteria, but also to prove that their medical condition prevents them from working.
Additionally, the policy as a whole will make it harder for states to exempt people with complex health needs from the work requirement. This interpretation forces states to make complex determinations about an individual's work capacity through a convoluted assessment. By excluding such individuals through this strict work requirement, even fewer people will qualify for medical frailty, and individuals in the middle of their treatment will need to prove their frailty or risk loss of coverage. The result is a costly and burdensome administrative process that includes more paperwork for applicants, higher administrative costs for states, and longer delays and larger backlogs.
Beyond the administrative burden, this policy forces people with serious illnesses into an impossible choice. Many individuals can work intermittently or part-time to pay their bills while managing significant medical conditions, yet that decision to work intermittently could disqualify them from the medical frailty exemption and, ultimately, from their Medicaid coverage. Individuals with serious medical conditions are effectively penalized whether they work or prioritize their health.
As a result of the reporting requirements associated with the work requirement, significant coverage losses loom large. The Urban Institute estimates that 3 to 7 million people will lose Medicaid coverage by 2028 directly because of the work reporting requirement.
Restrictions on Self-Attestation
Second, the IFR further departs from the HR 1 statute by requiring states to reverify a person’s medical frailty every 12 months and by prohibiting self-reporting by Medicaid enrollees beginning in 2028. This will create additional red tape in the form of paperwork and bureaucracy and is particularly detrimental to people with serious health conditions.
Many people who should qualify for the medical frailty exemption or other exemptions from the work reporting requirement will struggle to provide the documentation CMS now requires. Yet, beginning after 2027, CMS largely eliminates states' ability to accept self-attestation, requiring applicants instead to produce documentation verifying their health condition or qualifying circumstance.
This policy adds unnecessary bureaucracy for people who are already facing significant health and financial challenges. Instead of helping eligible individuals access care, the rule increases the likelihood that people will lose coverage due to paperwork barriers rather than failing to meet the law's eligibility requirements.
Taken together, these changes would transform an exemption intended to protect people with serious health conditions into another source of coverage instability. The added documentation and reverification requirements would fall hardest on people least able to navigate complex paperwork while managing illness, work, caregiving, or financial insecurity.
The evidence is clear: the overwhelming majority of Medicaid beneficiaries who are able to work are already working or qualify for another exemption. Expanding work reporting requirements will not meaningfully increase employment or improve health outcomes. Instead, these policies will increase administrative costs, divert limited state resources away from patient care, and cause eligible low-income individuals to lose coverage because of procedural hurdles rather than actual ineligibility.
The new restrictions on self-attestation and the narrowed interpretation of medical frailty illustrate how HR 1's implementation risks undermining access to health coverage for millions of Americans. Rather than strengthening Medicaid, these policies make it harder for eligible people with serious health conditions to obtain and keep the care they need.
The League respectfully asks that CMS withdraw this IFR and rescind these new rules that exceed what is statutorily required by HR 1. It is critical that the Medicaid program continues to provide and protect health coverage for millions of vulnerable people across the country.
With a nationwide membership and longstanding expertise in democracy and public policy, the League of Women Voters is a trusted, nonpartisan resource. For additional engagement, please contact Jessica Jones Capparell, Director of Government Affairs, at [email protected], or Kristen Kern, Federal Policy and Advocacy Manager, at [email protected].