Implementing Medicaid Work Requirements: Key Considerations for States

With the passage of the One Big Beautiful Bill Act (OBBBA) Medicaid work and community engagement requirements are becoming a federal requirement for Medicaid eligibility among certain adult enrollees. While the policy is set at the federal level, implementation will be the responsibility of states. As we discussed in our previous blog post, Federal Medicaid Work Requirements: What States Should Know, past efforts in Arkansas and Georgia demonstrate how administrative complexity and communication challenges can result in high disenrollment and limited program participation. Lessons from the recent Medicaid public health emergency unwinding further underscore the importance of system readiness and member-focused design.

Below, we outline six strategies states can consider to support implementation of Medicaid work and community engagement requirements.

Design Member-Friendly, Accessible Compliance Systems

Data from Arkansas’s 2018 work requirement rollout shows that over 18,000 enrollees lost coverage within the first seven months, many likely still eligible, largely due to confusing online reporting and insufficient member support. This highlights the need for person centric, mobile-responsive systems that don’t penalize members with limited digital access. Many Medicaid enrollees rely on mobile phones as their primary method for accessing the internet, and some lack reliable broadband altogether. States should ensure that compliance systems are mobile-responsive, easy to navigate, and available in multiple languages. Portals should avoid unnecessary steps, technical barriers, or multiple logins that can deter or delay members.

Equally important is providing alternatives to digital reporting. States should offer phone, paper, and in-person options to ensure members with limited digital access can still meet requirements.

Strengthen Member Support and Navigation Services

To avoid preventable disenrollments, states should invest in customer support infrastructure such as call centers, live assistance, and in-person navigation. Arkansas’s experience, including lengthy call wait times and limited in-person assistance, led to administrative disenrollments and confusion for members. Clear guidance and adequate staffing will be essential during the ramp-up and implementation phases.

In addition, states should consider establishing or expanding an ombudsman function to help resolve individual cases and identify systemic issues that may be creating barriers to compliance.

Communicate Early, Often, and Through Trusted Partners

Previous work requirement implementations showed that confusion, not noncompliance, was often the reason for administrative disenrollments. States should develop clear, plain-language materials explaining what’s required, who is exempt, and how to report compliance. Outreach should be multi-channel, including mail, text, phone, and email.

Partnering with trusted messengers such as community-based organizations, managed care organizations, and local providers can help amplify messaging and support member understanding. There is a lot of fraudulent activity happening, particularly targeting vulnerable populations, so having trusted partners with accurate and up-to-date information is essential.

Coordinate Across Agencies and Programs

Many Medicaid enrollees are already engaged with other public programs such as Supplemental Nutrition Assistance Program (SNAP), Temporary Assistance for Needy Families (TANF), or unemployment services. States should coordinate with these agencies to streamline verification and minimize duplication. States like Michigan prioritized readiness through cross-agency coordination and data integration across programs including SNAP and TANF. Shared data systems can reduce member burden and administrative workload.

Build in Continuous Monitoring and Improvement

During the Medicaid unwinding, states were required to submit monthly performance data to the Centers for Medicare & Medicaid Services. These monthly reports covered eligibility renewals, call center operations, and transitions to Marketplace coverage. Call center metrics served as an important early warning signals. Rising wait times and call abandonment rates often preceded spikes in disenrollments, suggesting that members were unable to access the support needed to complete their renewals and maintain coverage.

States that closely tracked renewal outcomes, member inquiries, and disenrollment patterns were better equipped to identify systemic failures and adjust outreach or processing strategies in real time, helping preserve coverage continuity during this critical period.

States should plan for real-time monitoring of key performance indicators, including disenrollment rates, exemption processing, call center traffic, and member feedback. Early identification of system bottlenecks or communication breakdowns can help states adapt before issues escalate.

Apply Lessons from the Unwinding

Nationwide more than 80 million people went through a Medicaid eligibility review during the unwinding. The experience offers insights into how policy design and administrative systems impact coverage continuity. Many of the strategies used during the unwinding can be applied to the implementation of Medicaid work requirements. These include maximizing the use of ex parte renewals, investing in robust outreach and communications, and engaging trusted stakeholders throughout the process.

Aurrera Health’s recently authored a publication on behalf of the California Health Care Foundation; Lessons from the Medi-Cal Unwinding: How California Protected Coverage and Policy Options to Improve Renewals highlights actionable best practices in outreach and system coordination that can inform future work requirement implementation efforts and support states in protecting coverage as policies evolve.

Looking Ahead

As states move forward with implementing federally mandated Medicaid work requirements, there is an opportunity to apply the lessons from past efforts and the unwinding. Success will depend on thoughtful design, operational readiness, and strong stakeholder engagement to help eligible members maintain coverage.

At Aurrera Health, we remain focused on advancing high-quality health coverage and care. States and other stakeholders interested in tailored support related to implementation of federally mandated work requirements are encouraged to contact Lauren Block for more information.

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Authors

Catherine Gekas Steeby [Deputy Director]