Work Requirements: Here's What We Know
As states head toward 2027, Medicaid work requirements — officially called "community engagement requirements" — are becoming real. On September 8, the Centers for Medicare & Medicaid Services (CMS) released guidance for how states can identify who qualifies for a medical frailty exemption. The guidance offers a three-tier system based on existing medical records: some conditions, including end-stage renal disease, could qualify automatically. Others would need more documentation.
Here's the catch: CMS has been clear that this framework is optional, and a diagnosis code alone can't be the only proof required. States still have wide discretion in how they build their systems. Meanwhile, a lawsuit challenging how CMS issued this guidance has oral arguments scheduled for October 20.
What does this mean for patients? States are actively deciding — right now — whether their systems will run on existing medical data or bury people in new paperwork. That's exactly where patient voices matter most.
What We're Focused on This Fall
The Chronic Disease Coalition is running a nonpartisan voter education push through November. We're not telling anyone how to vote — we're making sure the chronic disease community has what it needs to show up informed. A few resources:
- September 15 was National Voter Registration Day — check your status at vote.com
- Our Voter Guide can help you evaluate where candidates stand on health coverage
- See this year's Legislative and Congressional Champions who have made a difference on chronic disease policy
- Watch for patient ambassador videos on why voting matters — and how easy it is
What You Can Do
Two letters need your signature this fall, and you can sign and send them right now!
Protect vote by mail.
The Supreme Court recently kept a block in place on a federal rule that would have changed mail ballot requirements — but that decision was about timing, not a final answer. The door is still open for this to come back.
For many in our community, mail voting isn't a convenience — it's what makes voting possible at all. Flare-ups, treatment schedules, immunocompromised status, and mobility limits can turn a single trip to the polls into a real barrier. Caregivers feel this too, working around medication schedules and care needs. A health condition should never be the reason a vote goes uncast.
Sign and send our letter urging elected officials to protect vote by mail for the long term.
Push for patient-centered work requirements.
As states build out their systems, we're asking for approaches that don't add unnecessary burden to patients or providers, including approaches that:
- Use existing diagnoses and medical records first, instead of requiring people to re-prove what's already documented
- Treat a patient's own statement about their condition as legitimate, not just a placeholder until "real" proof arrives
- Use a broad, workable definition of medical frailty — not one narrowed to exclude people who need the exemption
- Limit how often people have to re-verify, with automatic renewal where appropriate
- Start with the easiest, most accessible data before asking for anything more
- Include real accommodations for people without easy digital or documentation access
- Allow a doctor's certification to serve as a direct path to exemption
Sign and send our letter asking policymakers to build these protections in from the start.
Looking Ahead
As we build our 2027 policy priorities, we are talking with our Patient Advisory Council members, our larger ambassador group, our partners and ally organizations, and more. Chronic disease patients aren't a small slice of the population — more than 75% of adults live with at least one chronic condition. That makes this community's experience the most reliable measure of whether a system actually works. Your voice, and your signature, help make sure policymakers hear it.