Protecting Medicaid Coverage

An NCSA family action checklist for the federal Medicaid work requirements taking effect in 2027.

First: does the requirement apply to your family member?

The work requirement applies only to non-pregnant adults ages 19 to 64 who receive Medicaid through the ACA expansion adult group (or similar Section 1115 coverage) and are not enrolled in Medicare.

Adults who qualify for Medicaid through a disability pathway are not subject to the requirement. That includes SSI-linked eligibility and the eligibility categories used by HCBS waiver programs. Adults enrolled in Medicare, including Disabled Adult Child (DAC) beneficiaries, are also excluded. The twice-yearly eligibility redeterminations described below likewise apply to the expansion group, not to disability-pathway enrollees.

If you are not certain which category your family member is in, ask your case manager or state Medicaid office. The answer determines how the rest of this page applies. Even when the requirement does not apply, the documentation in this checklist protects your family member at every renewal, error, and appeal. Keep it current.

The exemption, and the real risk

The evidence on this point is stark. When Arkansas piloted Medicaid work requirements in 2018, more than 18,000 adults lost coverage before a court halted the program, driven largely by confusion and reporting problems rather than ineligibility (Sommers et al., 2019). Paperwork, not eligibility, is where coverage is lost.

Do not ignore state outreach. States are required to contact enrollees who may be subject to the requirement before implementation. If any notice arrives from your state Medicaid agency, respond and submit documentation even if you are confident your family member is exempt. If the state cannot verify compliance or exemption, it must provide 30 days to respond before denying or disenrolling. If coverage is terminated in error, request a fair hearing immediately; coverage can often be reinstated retroactively during appeal.

Key dates

Date	What happens
July 4, 2025	The One Big Beautiful Bill Act is signed; the work requirement becomes law.
June 1, 2026	The CMS interim final rule takes effect and defines the medically frail exemption nationally.
Summer and fall 2026	States conduct required outreach to enrollees who may be subject to the requirement. Respond to every notice.
July 29, 2026	A federal court declines to pause the rule; the multistate challenge continues, with a ruling on the merits expected by January 1, 2027.
January 1, 2027	Deadline for states to implement; some may implement earlier. Non-exempt adults who do not meet or verify the requirement can be denied or disenrolled after a 30-day notice.
Every 6 months	Expansion-group adults face eligibility redeterminations twice a year instead of annually. Documentation must stay current.
January 1, 2028	Self-attestation of medical frailty largely ends. Documentation becomes mandatory, re-verified against the prior 12 months. A current physician letter matters most from this point forward.

Part 1: Current documents to keep updated

Review and update at least annually. Keep both physical and digital copies. You do not need every document on this list; the goal is current records, organized and ready if requested.

A. Benefits and eligibility

• ☐  Current Medicaid eligibility notice
• ☐  Current Medicaid waiver eligibility notice
• ☐  Current waiver service plan or person-centered plan (PCP)
• ☐  Current SSI benefit letter (if applicable)
• ☐  Current SSDI benefit letter (if applicable)
• ☐  Current Disabled Adult Child (DAC) documentation (if applicable; an often overlooked benefit category)
• ☐  Most recent Medicaid renewal or redetermination notice

B. Legal and authorized representative

• ☐  Guardianship order (confirm it is on file with Medicaid, all providers, SSA, and the physician's practice)
• ☐  Representative Payee documentation (if applicable)
• ☐  Authorized Representative documentation on file with Medicaid (if not full guardian)
• ☐  Special Needs Trust documents (if applicable)

C. Medical documentation

• ☐  Completed Physician Verification of Lifelong Disability and Functional Impairment (download the form below; update annually)
• ☐  Current medication list
• ☐  Most recent specialist documentation (psychiatry, neurology, developmental medicine, physical medicine and rehabilitation)

D. Service and support documentation

• ☐  Current support plan / person-centered plan
• ☐  Current level-of-care determination or support intensity assessment (for example, the Support Intensity Scale)
• ☐  Most recent case management or support coordination summary
• ☐  Most recent day program summary (if applicable)
• ☐  Most recent residential services summary (if applicable)
• ☐  Current Behavior Support Plan from a BCBA (if applicable; supports behavioral complexity)
• ☐  Current Functional Behavior Assessment (if applicable)

E. High support approvals: state-issued documents

Step 1: identify what has been approved. Common examples:

• ☐  1:1 staffing authorization (a state determination that your family member cannot be supported safely at a lower staffing ratio; one of the most powerful documents in this file)
• ☐  2:1 staffing authorization (if applicable; indicates even higher support intensity)
• ☐  Enhanced behavioral support hours authorization (for example, BCBA hours above the standard waiver allocation)
• ☐  Extended day program authorization
• ☐  Specialized residential staffing ratio approval (if applicable)
• ☐  Adaptive equipment or environmental modification approvals (for example, sensory equipment or safety modifications to the home)
• ☐  Crisis or emergency respite authorizations (if ever approved; documents that the state has recognized behavioral crisis risk)

Step 2: for each approval that applies, confirm the following:

• ☐  Get a copy of the current authorization document from your service coordinator (the state-issued letter or form, not just a reference in the support plan)
• ☐  Note the date the authorization was first approved and every renewal date since
• ☐  Ask your service coordinator: “Is this authorization reflected in the state Medicaid system, not just in the paper file?”
• ☐  Ask your day program or residential provider for a letter confirming the approved staffing ratio and how long it has been in place (program director signature; one or two paragraphs is sufficient)
• ☐  Ask your service coordinator: “If the state contacts you to verify my family member's eligibility or support needs, do you know what to say, and to call me?” (prep them; do not assume they will handle it correctly without a heads-up)

Part 2: Documents to keep as backup

These generally do not need updating but should be retained. Older evaluations, even from 10, 20, or 30 years ago, remain valuable documentation of lifelong disability. New neuropsychological testing is generally unnecessary unless the state specifically requests it or an appeal requires it.

• ☐  Original autism diagnosis
• ☐  Intellectual disability determination
• ☐  Neuropsychological evaluation (retain even if decades old)
• ☐  Adaptive functioning assessment (Vineland, ABAS, or similar)
• ☐  School records and IEP history (especially transition-age records)
• ☐  Historical waiver documentation
• ☐  Historical behavior support plans
• ☐  Vocational assessments (if any; relevant to employment capacity documentation)
• ☐  Any other historical evaluations or determinations

Part 3: Annual review checklist

Conduct this review each year, ideally 60 days before your family member's Medicaid renewal date.

Eligibility and enrollment

• ☐  Medicaid remains active; confirm via state portal or enrollment line
• ☐  Waiver eligibility remains active
• ☐  Contact information is current: mailing address, phone, email
• ☐  Authorized representative information is current in the Medicaid system

Documentation currency

• ☐  Physician Verification letter is dated within the last 12 months
• ☐  Medication list is current
• ☐  Support plan / PCP has been updated
• ☐  Behavior Support Plan is current (if applicable)
• ☐  Electronic copies of all key documents saved and backed up
• ☐  Emergency contacts are current across all provider records

Contact information audit

Confirm your family member's address and contact information is correctly on file with each of the following:

• ☐  State Medicaid office
• ☐  Medicaid waiver / state IDD agency case manager
• ☐  All healthcare providers: primary care, specialists, dental, psychiatric
• ☐  Day program and/or residential provider
• ☐  Social Security Administration

Part 4: If you receive a request for documentation

Submit documentation in the following order. Lead with the strongest, most current evidence.

#	Document	Why it matters
1	Physician Verification of Lifelong Disability and Functional Impairment	Primary clinical attestation of disability, ADL dependence, and inability to work. Addresses the medically frail criteria directly.
2	Current Medicaid waiver documentation	The state's own record of IDD status and waiver enrollment; difficult for the state to dispute.
3	Current support plan and level-of-care assessment	Documents daily support needs and staffing requirements in granular detail.
4	SSI, SSDI, or DAC award letter	Federal disability determination. Some states treat SSI as strong evidence of medically frail status; note that SSI-pathway enrollees are generally not subject to the requirement at all.
5	Additional historical records	Submit only if specifically requested. Older neuropsychological and adaptive functioning evaluations document lifelong disability; do not discard them.

The physician form

The Physician Verification of Lifelong Disability and Functional Impairment form documents clinical status for the medically frail exemption under the One Big Beautiful Bill Act and the CMS rule. Bring it to your family member's physician, ask that a copy be kept in the patient record, and keep a signed copy in your file. Update it annually; from January 2028, current documentation is mandatory.

Glossary of key terms

ADL (Activity of Daily Living)

Basic self-care tasks: bathing, dressing, toileting, eating, personal hygiene, and mobility. Dependence in even one ADL can establish the medically frail exemption under federal law.

IADL (Instrumental Activity of Daily Living)

More complex daily tasks that support independent living: managing medications, finances, transportation, appointments, and communication with healthcare providers or government agencies.

BCBA (Board Certified Behavior Analyst)

A credentialed specialist who assesses behavioral challenges, designs behavior support plans, and supervises behavioral intervention. Their documentation is often the most detailed record of an individual's functional limitations and safety risks.

DAC (Disabled Adult Child)

A Social Security benefit for adults who became disabled before age 22 and whose parent receives Social Security retirement, disability, or survivor benefits. Often overlooked; may provide additional income and Medicare eligibility on top of SSI.

HCBS Waiver (Home and Community Based Services)

A Medicaid program that funds supports and services, such as day habilitation, residential support, respite, and behavioral services, that allow individuals with disabilities to live in the community rather than in institutional settings. Each state administers its own waiver program under a different name.

Medically frail

The federal category that exempts individuals from the Medicaid work requirement. It includes individuals with a physical, intellectual, or developmental disability that significantly impairs one or more ADLs; under the CMS rule the condition must also significantly impair the ability to comply with the 80-hour requirement. Most individuals with profound autism qualify. States must verify this status; it is not applied automatically.

Person-Centered Plan (PCP)

The individualized plan developed with the person and their guardian that documents goals, support needs, and the services authorized through the Medicaid waiver. Updated annually and maintained by the case manager or support coordinator. Also called a support plan or Individual Support Plan (ISP) in some states.

State IDD agency

The state agency that administers Medicaid waiver services for individuals with intellectual and developmental disabilities. The name varies by state (DDA, DDSN, OPWDD, DDS). Your case manager or support coordinator works within this agency or under contract with it.

Support Intensity Scale (SIS)

A standardized assessment used by many states to measure the support an individual with IDD needs across daily living, medical, and behavioral domains. Often used to determine waiver funding levels. Results can serve as strong evidence of ADL dependence.

Sources

• Medicaid Community Engagement Requirement Interim Final Rule fact sheet (CMS-2454-IFC) · Centers for Medicare & Medicaid Services · June 2026
• Explainer of the Interim Final Rule · Georgetown University Center for Children and Families · July 2026
• Commonwealth of Massachusetts v. Oz, No. 1:26-cv-12962 (D. Mass.) · Civil Rights Litigation Clearinghouse · filed June 2026
• Medicaid Work Requirements: Results from the First Year in Arkansas · Sommers et al., New England Journal of Medicine · 2019

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