The H.R. 1 (also known as the One Big Beautiful Bill Act) requires states to implement Medicaid work and community engagement requirements by January 1, 2027. Expansion adults ages 19-64 who are applying for or enrolled in Medicaid must document at least 80 hours per month of work, education, job training, volunteering, or qualify for an exemption to maintain coverage. For the millions of Medicaid members who are not exempt, failing to navigate, understand, and comply with these new requirements may result in loss of coverage.

Work and community engagement requirements create an urgent and significant implementation challenge for states. In addition to standing up systems to track member compliance and process exemptions, states are working to ensure that eligible individuals do not lose coverage due to the administrative complexity of these new requirements. Helping people navigate evolving Medicaid requirements, especially those facing significant barriers to gaining or maintaining coverage, will require a dedicated workforce to support eligibility determinations, enrollment, awareness of coverage rules, and connections to community resources. With limited time and resources, building practical and scalable navigation supports will be essential to maintaining coverage for millions of people.

States may consider leveraging existing infrastructure and funding streams to expand and strengthen on-the-ground enrollment supports

Expanding outstationed eligibility and enrollment services: Federal law requires and provides Federal Financial Participation to state Medicaid programs for providing enrollment and eligibility support at locations other than state benefit offices, including at Federally Qualified Health Centers, tribal clinics and Indian Health Services facilities, and disproportionate share hospitals (DSH). States may consider scaling existing outstationed eligibility and enrollment services to support individuals understanding of and ability to meet new requirements.
Leveraging Community Health Workers (CHWs): CHWs are well-positioned to help Medicaid members maintain coverage by assisting with identifying opportunities to support member compliance and navigating reporting systems. States need to determine whether existing CHW benefits, typically approved by CMS through a State Plan Amendment of 1115 waiver, allow reimbursement for these activities. See the National Academy for State Health Policy’s CHW tracker for a high-level summary of state CHW benefits. As one example of state action in this area, California’s Department of Health Care Services recently released policy guidance indicating that “Under health navigation, CHWs may assist Medi-Cal members in enrolling or maintaining enrollment in Medi-Cal and in other government or assistance programs that support better health. Providers can access more information on the CHW webpage.”
Using Rural Health Transformation (RHT) Funding: CMS encourages states to invest RHT funding in implementing workforce models that strengthen navigation and access to care, particularly in underserved rural areas. States can direct RHT resources to expand their workforce through investments in community health workers or other individuals trained to support patient navigation of health care systems.
Engaging Managed Care Organizations (MCOs): States can partner with MCOs to strengthen outreach and enrollment support. Given the risk of increased churn under work requirements, MCOs have a strong interest and incentive to help members maintain coverage and will be key partners in coordinating navigation resources.
Coordinating with Trusted Community Partners: Recent experiences with widespread redeterminations during unwinding and early state adoption of work requirementshighlight the importance of state partnerships with trusted messengers, such as community-based organizations and local providers to amplify outreach and help members understand requirements. States may build or revive systems that allow for close coordination with these community partners, ensuring they have accurate and up-to-date information, and that states understand barriers members face on the ground.

Together, these approaches offer a practical starting point for states seeking to operationalize H.R. 1 while protecting coverage for those most at risk of falling through the cracks.

Aurrera Health remains committed to advancing access to affordable, comprehensive, high-quality health coverage and care. We provide strategic guidance and technical assistance that helps clients navigate complex policy environments offering support in vision setting, policy development, operational planning, stakeholder engagement, and on the ground implementation. States and other stakeholders interested in tailored support related to implementation of new, federally mandated work requirements are encouraged to contact Lauren Block at lauren@aurrerahealth.com for more information.

For more policy insights related to H.R. 1 implementation, see the following Aurrera Health blog posts: