Medicaid's work requirements start January 1. For a care management team, the big question isn't whether your members work. It's whether the state can see what you already know about them.
The members you spend the most time with are often the ones the rule exempts. Whether they're actually let off, or get a letter asking them to prove it, depends on what the state finds in its own records.
What the rule requires
CMS spelled out the details in an interim final rule that took effect in July. It covers adults ages 19 to 64 who got Medicaid through their state's expansion, aren't pregnant and aren't on Medicare. To keep coverage, they need 80 hours a month of work, volunteering, job training or some mix of the three. Going to school at least half-time also counts, and so does earning at least what 80 hours at the federal minimum wage would pay.
According to KFF's survey of states:
The timing is less sudden than it sounds. Members who are already enrolled get checked at their first renewal after their state's start date, so the checks will roll in month by month through 2027. States that are making a good-faith effort can also get permission to start later, as late as the end of 2028, and a few planned to start early. It's worth finding out where yours stands.
Who counts as medically frail
The rule calls it an exclusion, but most people call it the medically frail exemption. A member qualifies when a health condition makes it hard to meet the requirement and they fall into one of these groups.
A few other groups don't have to meet the requirement at all. They include members in drug or alcohol treatment, pregnant women and new mothers, and parents or caregivers of a child 13 or under or of someone with a disability.
Each state keeps its own list of the diagnoses that qualify, and it has to give members whose condition isn't on the list a way to ask.
Why last year's claims decide it
Before a state asks a member for anything, it has to look at what it already has. For medical frailty, that includes every claim from the past 12 months, whether it was paid, denied or still pending, plus the records plans send in for each visit. If those show a qualifying condition, the member is exempt and never hears a word about it.
If they don't, the member gets a notice and has 30 days to show they qualify. Through 2027, states can take a signed statement from the member. After that, a signed statement only works once while the member stays enrolled, and the state checks it against records or documents at the next renewal.
States are planning around this. In KFF's survey, done early in 2026, most states said they'd use claims to spot frail members, and ten had already picked the diagnosis and billing codes they'd look for. State officials also pointed out the weak spot: new applicants don't have any claims yet, and new members probably won't have many by their first renewal six months in.
How care teams protect the medically frail exemption
Here's what we'd do before each member's first renewal.
One caution: addiction treatment records have extra federal privacy protections, and the rule says they still apply. Talk to your compliance team before sharing any of that information.
What health plans can and can't do
If your team works inside a Medicaid health plan, the rule spells out your role. States can ask plans to send reminders by text, phone or online, and to share what they know about members' health conditions and treatment. Plans can also point members to job training programs.
Plans can't decide whether a member meets the requirement, send the official notice, or keep track of members' work, volunteer or school hours. And the cost of the extra outreach can't come out of what the state pays the plan for care, so it needs its own budget.
Where coaching fits
In our experience, members tell their coaches things they don't mention at the doctor's office, and a coach who checks in every few weeks usually knows when a member's phone number changed. Next year, both of those could decide whether a member keeps coverage.
Avidon doesn't decide anyone's status or track work hours. It handles the work around that: automated check-ins and reminders between sessions, notes and assessments kept on the member's record, and connections to a plan's eligibility and claims systems. If you run coaching or care management for Medicaid health plans, the months before each member's renewal are when that work counts most.
