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.
June 4, 2026: Disability and language access preparation
By Elizabeth Edwards
Medicaid eligibility can be a complex process, especially if you need a disability-related accommodation, language assistance, or both. OBBBA increases the complexity of eligibility for many adults and is predicted to create significant burdens on state eligibility workers and systems. The demand on frontline staff, like those at call centers, may result in long waits or delayed responses. In previous times of stress on state eligibility systems, people often struggled to access the help they needed to get or keep their health coverage. Non-discrimination provisions require states to ensure language and disability access. Therefore, states should include disability and language access planning in their OBBBA implementation work.
For more on disability access preparation, see our blog on preparing a “landing pad” to mitigate harm from OBBBA’s requirements. NHeLP’s Questions for LEP & Disability Access may also help advocates examine call center access preparedness.
June 2, 2026: Coverage options for people who lose Medicaid
By Jules Lutaba
Individuals who are no longer eligible for Medicaid due to restrictive eligibility provisions in OBBBA will be forced to look for other coverage. Individuals in a limited number of states may be eligible for a state-only funded program. ACA Marketplace plans are another alternative, but there are affordability barriers due to upcoming immigrant restrictions in OBBBA. Finally, some may turn to non-Marketplace insurance plans. Advocates must urge caution with enrollment in non-Marketplace insurance plans, or “junk plans” because they are not well regulated, do not offer comprehensive health coverage, and often have deceptive policies.
Read more about junk insurance and how to spot red flags here.
May 28, 2026: Using public records requests to gather information on Medicaid eligibility systems
By Sarah Grusin
Understanding how Medicaid eligibility systems work is important to protect Medicaid enrollees from erroneous coverage loss. But states do not always publicize how their computer systems work, leaving advocates in the dark. As states are making significant changes due to OBBBA, advocates can effectively deploy public records requests to gather information, including contracts, draft notices, and technical design documents.
Find NHeLP’s guidelines for submitting OBBBA-specific public record requests here.
May 26, 2026: Automating verification using consent-based verification (CBV) tools
By Shandra Hartly
As states continue to explore automating verification of work requirements compliance, consent-based verification (CBV) is gaining traction. CBV works by having users log in to financial accounts (such as banking and gig work accounts) through a CBV app, which uses information from those accounts to produce an income report. CBV tools will be useful for people whose work likely will not be captured by “traditional” wage and income databases, such as gig workers, independent contractors, and self-employed people.
Learn more about CMS’ CBV tool, “Emmy,” here.
May 21, 2026: Using data matching to verify work requirement exemption status
By Shandra Hartly
Much has been made of data matching to verify work requirements compliance through wage and income information, but reliable data matching will also be critical to identify exempt individuals to the maximum extent possible. Although OBBBA does not require states to verify exemption status, we are awaiting further guidance in the upcoming Interim Final Rule. Either way, states electing to require verification must use available information before requesting information from applicants and enrollees. Most exemption factors are verifiable through existing data sources, meaning that states should already be familiar with them.
Read more about common electronic data sources here and review your state’s Medicaid Eligibility Verification Plan here.
May 19, 2026: Exemptions under OBBBA
By Skyler Rosellini
There are two types of exemptions under OBBBA’s work requirement provision: mandatory exemptions and short-term hardship exemptions. Unlike the mandatory exemptions, states are not required to provide short-term hardship exemptions and must opt into doing so. An individual may be temporarily exempt from work requirements only when they: 1) have an inpatient stay for part or all of the month; 2) reside in a county where there is a natural disaster or where the unemployment rate is greater than 8% or greater than 150% of the national average.; or 3) they (or their dependent) have a serious or complex medical condition and must travel outside their community for an extended period to receive care not available in their area. Advocates can push their states to opt into making short-term hardship exemptions available for individuals who may be unable to demonstrate compliance with work requirements.
Learn more about work requirements implementation here.
May 14, 2026: Automating processes can also automate errors that cause harm to Medicaid applicants and enrollees
By Elizabeth Edwards
Many states are turning to automation, including AI, to help with the administrative burdens imposed by OBBBA. However, automating processes can also automate errors that cause harm to Medicaid applicants and enrollees. Errors are more likely when system changes occur on a quick timeline with limited opportunities for testing. Advocates can work with their state to establish automation guardrails such as testing protocols, a “sandbox” or other mechanism for stakeholders to test implemented technology, and ongoing monitoring through multiple avenues after initial implementation (e.g., complaints, appeals, systems reporting, testing). States should also increase transparency of known problems through a public list of system issues, so people can self-identify they experienced the problem and receive help.
Read more about potential system errors and prevention tips here.
May 14, 2026: Automating processes can also automate errors that cause harm to Medicaid applicants and enrollees
By Elizabeth Edwards
Many states are turning to automation, including AI, to help with the administrative burdens imposed by OBBBA. However, automating processes can also automate errors that cause harm to Medicaid applicants and enrollees. Errors are more likely when system changes occur on a quick timeline with limited opportunities for testing. Advocates can work with their state to establish automation guardrails such as testing protocols, a “sandbox” or other mechanism for stakeholders to test implemented technology, and ongoing monitoring through multiple avenues after initial implementation (e.g., complaints, appeals, systems reporting, testing). States should also increase transparency of known problems through a public list of system issues, so people can self-identify they experienced the problem and receive help.
Read more about potential system errors and prevention tips here.
May 12, 2026: Work Requirements – What Is A Qualifying Activity/How to Demonstrate Compliance
By Skyler Rosellini
As states scramble to implement OBBBA’s regressive work requirements provision by January 2027, CMS must provide clarifying guidance to states by June 2026.. Qualifying activities must include one or a combination of the following: employment, community service, or participation in a work or educational program. Individuals must demonstrate their activities for at least 80 hours per month (or at least 40 hours for educational programs). States electing to create pathways to connect individuals to qualifying activities, use digital employment verification programs, and maximize self-attestation will ease work requirements compliance for Medicaid enrollees, including such activities that may not have a digital footprint.
Learn more about ways to lessen the burden to comply with and verify work requirement activities here.
May 7, 2026: Using MACs/BACs to Monitor State OBBBA Implementation
By Miriam Delaney-Heard
States are required to form Medicaid Advisory Committees (MACs) and Beneficiary Advisory Councils (BACs) so that beneficiaries can share their lived experiences with Medicaid policymakers. During OBBBA implementation MACs/BACs can be a vital tool to monitor how states will implement work requirements and how eligibility changes are impacting communities.
MAC/BACs must comply with certain CMS requirements regarding composition. And MAC/BACs must hold accessible, inclusive quarterly meetings. Learn more about MAC/BAC requirements here.
May 5, 2026: Medicaid work requirements 3 month advance notice
By Shandra Hartly
OBBBA requires that states notify enrollees potentially subject to work requirements at least 3 months in advance of the work requirements’ effective date. States must notify enrollees through at least 2 modalities, including email or regular mail. States should provide information in plain language and avoid confusing jargon. All communications must also be accessible to people with disabilities and people with limited English proficiency. Allocating sufficient time and resources to outreach, as well as working with partners, will be critical in ensuring maximum reach.
Read more about effective outreach here.
April 28, 2026: OBBBA Medicaid Changes for Immigrant Eligibility
By Katy DeBriere and Sarah Grusin
OBBBA changed a lot about immigrant eligibility for Medicaid but recent CMS guidance confirms that the exemptions from the 5-year bar for Lawful Permanent Residents (LPRs) are unchanged. States generally cannot provide full-scope Medicaid coverage to LPRs until 5 years after their date of entry into the U.S. with a qualified immigration status. However, there are exemptions from this 5-year waiting period, including for refugees and asylees. When those who are exempt adjust to LPR status, they are immediately eligible. Individuals may also be able to meet the 5-year bar through a combination of qualified statuses.
Read more about the five-year bar and exemptions here and about what state advocates can do to respond here.
April 23, 2026: Medicaid Changes for Immigrant Eligibility
By Sarah Grusin
Changes to immigrant eligibility for Medicaid are imminent. Recent CMS guidance creates a cliff: starting October 1, 2026 only citizens, LPRs, Cuban or Haitian entrants, or Compact of Free Association (COFA) migrants will be eligible for most types of Medicaid. States cannot wait until an individual’s next renewal, even for children or pregnant individuals who would otherwise be entitled to a year of continuous coverage. But states must still provide advance notice, preserve hearing rights, and maintain coverage for those who attest to remaining eligible. Advocates should work with their states now to ensure that state notices clearly communicate what is changing and who is still eligible.
Read CMS’s guidance here and learn more about what advocates can do to respond here.
April 21, 2026: Work Requirements – Technology Solutions May Automate Help & Harm
By Elizabeth Edwards
Automation is often heralded as the fix for the administrative burdens OBBBA places on applicants, enrollees, and state Medicaid agencies. CMS has touted pledges from technology companies and developed eligibility technology. However, eligibility technology sometimes promises to help agencies without fully assessing their impact on Medicaid applicants and enrollees. The promised help can also automate harm, often in hidden ways. The harms are usually avoidable with meaningful transparency, testing, monitoring, and accountability throughout the technology’s lifecycle.
Read more about mitigating risks from automation here.
April 16, 2026: OBBBA requires marketplace applicants to submit proof of eligibility before subsidies
By Shandra Hartly
Beginning in plan year 2028, OBBBA requires Marketplace applicants to submit proof of eligibility before subsidies can take effect. Applicants must verify their household income, immigration status, eligibility for other coverage, place of residence, and family size. Additional requirements are potentially forthcoming. Marketplaces can only waive these requirements for people enrolling during a special enrollment period (SEP) due to a change in household size. Advocates should educate stakeholders on this new requirement now, emphasizing the importance of maintaining necessary documentation.
Read more about OBBBA’s eligibility and enrollment changes here.
April 14, 2026: OBBBA’s sweeping Medicaid changes make due process more important than ever.
By Katy DeBriere
OBBBA’s new restrictions on Medicaid eligibility criteria and its restructuring of enrollment processes puts the importance of due process front and center. Advocates will need to act as critical watchdogs. In taking on this role, a good first step is to submit a public records request and include a request for draft notices the state plans to use in OBBBA implementation. Using due process guidelines for issues like work requirements, and changes to immigrant eligibility, evaluate the sufficiency of those notices and if they don’t stack up, advocate with your state to fix the problems.
You can learn more about how OBBBA implicates due process protections here.
April 9, 2026: Assess Eligibility and Enrollment Notices in Your State Prior to Implementation
By Katy DeBriere
OBBBA’s new restrictions on Medicaid eligibility criteria and its restructuring of enrollment processes puts the importance of due process front and center. Advocates will need to act as critical watchdogs. In taking on this role, a good first step is to submit a public records request and include a request for draft notices the state plans to use in OBBBA implementation. Using due process guidelines for issues like work requirements and changes to immigrant eligibility, evaluate the sufficiency of those notices and if they don’t stack up, advocate with your state to fix the problems.
You can learn more about how OBBBA implicates due process protections here.
April 7, 2026: Advocates should monitor verification activities for data-related accuracy issues
By Shandra Hartly
Wage and employment databases will help minimize reporting burden for people subject to work requirements, but they are not perfect. Employment databases do not contain comprehensive information, are prone to error, and can contain outdated information. Advocates should review their state’s Medicaid Eligibility Verification Plans and monitor state procurement efforts for awareness of current data sources and potential future ones. Once work requirements take effect, advocates should monitor verification activities for data-related accuracy issues.
Read more about wage and employment databases here.
April 2, 2026: Medicaid enrollees should check for duplicate enrollments
By Shandra Hartly
Starting January 1, 2027, OBBBA requires “regular” address checks to identify individuals who are enrolled in Medicaid in multiple states. By October 1, 2029, states must submit certain information at least monthly and at every redetermination to a forthcoming HHS system to check for duplicate enrollment. Advocates should advise enrollees to check for duplicate Medicaid enrollment now and to immediately cancel their enrollment in any state where they do not live to avoid coverage loss later.
Read more about the burden of increased data matching here.
March 26, 2026: Complicated Medicaid eligibility requirements
By Sarah Grusin
OBBBA creates a host of complicated Medicaid eligibility requirements that require states to make substantial changes to their eligibility systems–and on timelines much faster than states and vendors are used to. Errors can occur any time states modify their eligibility systems but are especially likely in this context. Advocates should work with their states to develop robust testing protocols before changes “go live”–including providing detailed test case scenarios and direct testing by Medicaid enrollees and advocates. Otherwise, errors may not be discovered until real Medicaid enrollees’ cases are processed.
Read more about how to reduce testing errors here.
March 19, 2026: Six month renewals starting in 2027
By Sarah Grusin
Six-month renewals start January 2027. For people who renew in the second half of 2026, states have 2 options: (1) reschedule or move the date earlier in 2027 or (2) maintain enrollees’ next-scheduled annual renewal date, waiting to switch to a 6-month schedule until then. For example, if Sam renews coverage in October 2026, states can move the renewal date earlier in 2027 (but not before April) or wait until October 2027 to renew again. Six-month redeterminations are bad policy and moving renewal dates adds burdens to states. Advocates should push for Option 2.
Read CMS’s recent guidance on the 6-month redeterminations here.
March 12, 2026: States to re-evaluate eligibility every 6 months for certain groups
By Sarah Grusin
Beginning January 2027, OBBBA requires states to re-evaluate eligibility every 6 months for certain groups. This is bad policy: it burdens Medicaid enrollees and state staff, increases procedural terminations, and creates costly churn. Fortunately, many populations are excluded from this change: children, individuals enrolled in pregnancy or parent/caretaker groups, and adults enrolled in a waiver that covers less than the entire expansion population.
Read CMS’s recent guidance on the 6-month redeterminations here.
March 3, 2026: Elimination of PTCs for income-based SEP applicants
By Jules Lutaba
Beginning in PY 2026, OBBBA does not allow individuals who newly apply for Marketplace coverage through an income-based special enrollment period (SEP) to receive premium tax credits (PTCs). This is a continuation of the Marketplace Final Rule that eliminated the 150% FPL SEP until the end of PY 2026, effectively eliminating the 150% FPL SEP permanently. Advocates should explain to Marketplace applicants that they must enroll through an open enrollment period or other SEP to be eligible for PTCs.
Read more about OBBBA’s eligibility and enrollment changes here.
February 26, 2026: Effective application of exemptions will help reduce the burden of OBBBA’s work requirements
By Shandra Hartly
The burden of OBBBA’s Medicaid work requirements will be reduced by effective application of exemptions. Advocates should work with states to proactively identify exempt individuals, to focus on longer-term exemptions, and to avoid overly-restrictive interpretations of exemption definitions. Developing straightforward screening language will also empower applicants and enrollees to identify themselves as potentially exempt during application or redetermination, reducing the risk that they will erroneously be subjected to work requirements.
Read more about effectively applying exemptions to mitigate OBBBA-related coverage loss here.
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.
