NHeLP has launched a new weekly Timely Tips to Safeguard Medicaid series to help advocates navigate Medicaid work requirements and other implementation issues stemming from the One Big Beautiful Bill Act (OBBBA). As federal and state agencies move quickly to implement sweeping policy changes, advocates need timely, practical information to understand what is happening on the ground and how to respond.
This ongoing blog will be updated weekly with each new tip, which are designed to provide a quick snapshot of emerging issues, explain what they mean for Medicaid eligibility and enrollment, and highlight where implementation may put coverage and access to health care at risk.
February 19, 2026: Maximizing the utility of work requirement exemptions
By Shandra Hartly
OBBBA exempts anyone who is “medically frail” or who “otherwise has special medical needs (as defined by the Secretary)” from Medicaid work requirements. Future rulemaking and guidance will clarify the scope of this exemption, but states can still work now to maximize its utility. States should adopt broad and flexible definitions of medical frailty and avoid impermissibly restricting the definition by adding extra requirements about an inability to work. Additionally, states should develop robust, multifaceted strategies for identifying exempt individuals.
Read more about existing trends in the medical frailty designation here, and recommendations for operationalizing the OBBBA exemption here.
February 12, 2026: Eligibility and enrollment changes increase risk of erroneous coverage loss
By Shandra Hartly
OBBBA’s changes to Medicaid eligibility and enrollment will impose considerable administrative burden on applicants and enrollees, which will assuredly increase the risk of erroneous coverage loss. Specific to work requirements imposed by OBBBA, there are important policy options states can adopt to minimize this risk. States can elect to only verify compliance with work requirements once every 6 months, adopt a 1-month lookback period, and accept the statements of applicants and enrollees as proof of exemptions to the maximum extent possible.
Read more about OBBBA’s eligibility and enrollment changes here.
February 5, 2026: Individual repayment of advanced premium tax credits
By Alicia Emanuel
Beginning in tax year 2026, OBBBA eliminates the cap on advanced premium tax credit (APTC) repayments. Individuals whose actual income exceeds their projected income will have to repay all excess APTCs from PY 2026 when filing their 2026 taxes. The one exception is that individuals with income below 100% FPL still do not have to pay back excess APTCs. Prior to OBBBA, a repayment cap applied to individuals under 400% FPL. Advocates should remind individuals to report income changes to the Marketplace to avoid excess APTCs.
Read more about OBBBA’s eligibility and enrollment provisions here.
January 29, 2026: Reviewing accuracy from electronic data sources on work requirement compliance
By Shandra Hartly
In line with existing ex parte requirements for Medicaid eligibility determinations, OBBBA requires states to verify compliance with (or exemption from) work requirements using already available “reliable information,” without requesting information from applicants and enrollees. States have Medicaid Eligibility Verification Plans, which describe the electronic data sources in use for ex parte eligibility determinations. Once work requirements take effect in January 2027, advocates should monitor verification activities for adherence to ex parte requirements and for potential accuracy issues with these or any new data sources.
Read more about common electronic data sources here.
January 22, 2026: State coverage for lawfully present children and pregnant people
By Katy DeBriere and Sarah Grusin
OBBBA changes a lot about immigrant eligibility for Medicaid, but what it does not change is a state’s option to cover lawfully residing children and pregnant people. The term “lawfully residing” is broad and encompasses immigrants who will otherwise become ineligible for Medicaid in October 2026, including asylees, refugees, parolees, survivors of trafficking, and others. Importantly, lawfully residing pregnant people are entitled to 12 months of postpartum coverage if their state has elected that option. Furthermore, all children eligible for Medicaid are entitled to one year of coverage regardless of a change in circumstance.
Read more about upcoming changes to immigrant eligibility under Medicaid and what state advocates can do now to respond here.
January 15, 2026: Increased barriers to care for lawfully present immigrants
By Alicia Emanuel
Effective January 1, 2026, OBBBA eliminates premium tax credits (PTCs) for lawfully present immigrants with incomes below 100% FPL who are ineligible for Medicaid due to immigration status. Although these individuals can still enroll in Marketplace coverage, the lack of financial assistance will likely make coverage prohibitively expensive. Advocates should help connect affected individuals to any available state and local health programs, and work with their Marketplace to monitor implementation of this provision. Read more about OBBBA’s immigration changes here.
