On July 4, 2025, the federal budget reconciliation bill, H.R.1, was signed into law, enacting major structural reforms to Medicaid, the Children’s Health Insurance Program, and the Affordable Care Act Marketplaces. These changes, including a $911 billion reduction in federal Medicaid spending over the next 10 years, significantly reshape the operational and financial landscape of the health coverage system, with far-reaching implications for program enrollment, expenditures, and administration, immediately and in the years ahead.
H.R.1 establishes work reporting requirements as a new condition of Medicaid eligibility. These resources are designed to support state planning and implementation with the goal of preserving coverage for eligible individuals.
On Thursday, February 19, State Health and Value Strategies hosted a webinar on communicating the new work reporting requirements under H.R.1. A robust communications and outreach strategy can help states protect coverage for eligible enrollees and support broader operations as they roll out these new requirements. During the webinar, experts from GMMB provided an overview of key H.R.1 provisions related to communications and walked through a communications workplan to support outreach on the new reporting requirements. Experts from Health Equity Solutions also shared recommendations from the toolkit Engaging Enrollees in Medicaid Work Reporting Requirements Implementation and highlighted ways states can involve people enrolled in Medicaid in communications planning and message development.
Work reporting requirements marks a major shift in how Medicaid operates and how consumers access and maintain their coverage. This workplan is designed for state Medicaid and health and human services communications staff responsible for planning and executing outreach related to new work reporting requirements. States can use it to inform the creation of communications efforts or to cross-reference existing plans, ensuring key tactics are considered, gaps are identified, and strategies are aligned around maintaining coverage for eligible people enrolled in Medicaid.
Under H.R.1, states implementing Medicaid work reporting requirements must exempt individuals who are medically frail. With an effective date less than a year away, time is of the essence. The Medical Frailty Project Workplan lays out a sequenced, implementation-ready approach for operationalizing the exemption.
As states work to operationalize H.R.1’s mandatory work reporting requirements for Medicaid, key implementation decisions must be made in the coming months. Strategically and intentionally engaging Medicaid enrollees early in this process can help states design efficient processes that reduce administrative burden. This toolkit provides practical strategies for engaging Medicaid enrollees in implementation decisions, including general guidelines, suggested opportunities for engagement, and sample questions and activities to support meaningful enrollee participation.
H.R.1 fundamentally restructures Medicaid by conditioning eligibility for expansion adults on compliance with new work reporting requirements. States face the challenge of operationalizing at scale, and in a way that minimizes coverage loss, exemptions from Medicaid work reporting requirements for certain groups of enrollees. This toolkit offers a high-level roadmap for how states can plan to identify and protect three exempt populations.
On December 8, the Centers for Medicare & Medicaid Services issued a Center for Medicaid & CHIP Services Informational Bulletin (CIB) providing initial guidance to states as they implement Medicaid work reporting requirements under H.R.1. Although the guidance generally tracks the requirements of H.R.1 and incorporates several important clarifications, it remains high-level and stops short of addressing the many operational questions states must resolve as they implement these major changes. This expert perspective summarizes the CIB and highlights where open questions remain.
The enactment of H.R.1 introduces mandatory work reporting requirements for Medicaid expansion adults, while explicitly exempting individuals who are medically frail. The toolkit provides a step-by-step guide for how states can tackle the operationalization of medical frailty exemptions, while reducing burden on individuals and state administration and making accurate eligibility determinations.
With the passage of H.R.1, states face the most extensive transformation of eligibility and enrollment policies and operations since the enactment of the Affordable Care Act in 2010. The law’s provisions require fundamental updates to how states administer the Medicaid program. Data and technology will be critical to implementing work reporting requirements, and states are being approached by many vendors offering data and technology solutions ranging from full system platforms to new data sources for verifying compliance. This expert perspective explores key human-centered principles that states should consider when evaluating vendor solutions to implement work reporting requirements, with the goal of mitigating coverage losses and reducing administrative burdens for state staff.
Managed care plans (MCPs) are well-positioned to support state Medicaid agencies as they develop their policy, operational and information technology (IT) system plans to implement federally mandated work reporting requirements. While MCPs cannot make determinations of work reporting compliance or exemptions under H.R.1, they can provide states with data analysis, evidence, and recommendations which states can use to make determinations. This expert perspective describes MCP partnership strategies to support the implementation of work reporting requirements to promote continuity of coverage and minimize procedural disenrollment risks.
H.R.1 provides that certain individuals, including those who are medically frail or otherwise have special medical needs, should be exempt from new Medicaid work reporting requirements. To support states in developing medical frailty definitions for work reporting requirements, the SHVS and Manatt teams developed a medical frailty toolkit that is based on a review of publicly-available policy guidance, information from states’ existing definitions of medical frailty, and research on clinical conditions. This toolkit provides a description of the factors that states may want to consider as they define the term for purposes of each of the key sub populations identified in H.R.1.
States are working towards establishing a robust data verification process to meet H.R.1’s ex parte verification requirements and determine individuals’ compliance with or exemption from Medicaid work reporting requirements. As states evaluate their data sources and systems, a new IT systems’ enhancement states can consider is a verification hierarchy that enables states to efficiently identify individuals who can be exempted from or deemed compliant with work reporting requirements. This toolkit lays out a potential step-by-step strategic verification hierarchy for identifying compliance with or exemption from work reporting requirements at application. States should use this toolkit as a jumping off point as they assess their own state-specific eligibility systems’ capabilities and available data sources.
H.R.1 provides for certain mandatory exemptions from Medicaid work reporting requirements, including for some people enrolled in the Supplemental Nutrition Assistance Program (SNAP). As states implement Medicaid work reporting requirements, this tool can be used to identify where exemptions from Medicaid’s new work reporting requirements may overlap or relate to exemptions in SNAP to help states identify people who should not be subject to work reporting requirements in Medicaid.
While H.R.1’s mandatory work reporting requirements are prescriptive, states must still make a number of policy and operational decisions that will heavily influence whether eligible individuals are able to enroll in and retain coverage. This toolkit details the federal requirements for various features of the mandatory work reporting requirements, outlines state policy and operational options, and provides key considerations related to maximizing efficiencies and mitigating coverage losses.
H.R.1’s mandatory work reporting requirements expressly direct states to use an ex parte process, relying on reliable information to verify compliance and mandatory exemptions, and avoiding requests for additional information from individuals whenever possible. To meet the aggressive timeline required by federal law to implement mandatory work reporting requirements, states can use this toolkit to support their assessment of which data sources are currently available and which data sources require new state builds and/or data matching processes.
The enactment of H.R.1 establishes mandatory work reporting requirements for certain Medicaid enrollees, marking the first federal mandate making Medicaid eligibility conditional on work or other qualifying activities in the program’s history. This expert perspective provides state Medicaid officials with essential implementation details, identifies affected populations, outlines compliance pathways, and provides information on state choices for implementing work requirements.
H.R.1, signed into law by President Trump on July 4, 2025, requires that states implement work reporting requirements for adults ages 19 through 64 who are enrolled through Medicaid expansion or expansion-like coverage under a section 1115 demonstration. The effective date of work reporting requirements is January 1, 2027 and states will need to proactively prepare for implementation by developing comprehensive policy and operational plans that align with federal guidelines while addressing state-specific needs. The toolkit outlines the key implementation milestones that it is anticipated states will need to meet to launch work reporting requirements and a timeline for doing so.
This Excel tool provides an integrated view of implementation dates for Medicaid, the Children’s Health Insurance Program, Marketplace, and Medicare provisions in the budget reconciliation law, H.R.1. Because of interdependencies with the budget reconciliation provisions, policies in the Marketplace Integrity and Affordability final rule of June 25, 2025, are also included in this timeline. This tool is intended to support states in (1) planning for timely implementation of reconciliation-driven health policy changes, and (2) effectively communicating potential impacts to communities and key stakeholders.
On Thursday, July 24, State Health and Value Strategies hosted a webinar on the budget reconciliation legislation (H.R.1) and the sweeping changes to Medicaid that it will make to state Medicaid program expenditures, enrollment, and operations now (with many provisions having already taken effect upon enactment) and in the years to come. It concentrates cuts to the Affordable Care Act’s Medicaid expansion population, limits use of provider taxes and state directed payments, constraining the ways states can raise revenue to finance their share of Medicaid program costs, and adds major restrictions on access to affordable health coverage for noncitizens.