Medicaid Work Requirement Exemptions
Many people in the Medicaid adult group never have to report hours. Here is the full federal list, what each one means, and how it is usually shown.
Your state checks first. Federal rules say your state must use the records it already has, such as medical claims, SNAP files, and tribal status, before asking you for proof. Many people will be exempted automatically.
People the rule doesn't cover at all
- Anyone under 19 or 65 and older
- People with Medicare Part A or Part B
- People who get Medicaid through another group, such as disability or SSI, low-income parents and caretakers, or pregnancy coverage
- People in a state that did not expand Medicaid (except Georgia Pathways and Wisconsin BadgerCare Plus childless adults)
Exemptions in federal law
If any of these describes you for all or part of a month, you are treated as meeting the requirement. Federal law calls most of these "specified excluded individuals."
| Exemption | Who qualifies | How it is usually shown |
|---|---|---|
| Pregnant or postpartum | Pregnant, or still in Medicaid postpartum coverage | State records or your own report of pregnancy |
| Parents and caregivers | Parent, guardian, or caretaker relative of a child 13 or younger, or family caregiver of a person with a disability | Household information on your case; for caregivers, a description of the care you give |
| American Indian and Alaska Native | Members of federally recognized tribes and others eligible for Indian Health Service, tribal, or urban Indian health care | Tribal status already on file, a tribal document, or IHS eligibility |
| Veterans | VA disability rated 100% (total), temporary or permanent | VA rating letter or data match |
| Former foster youth | In foster care at age 18 and now under 26 | State child welfare records |
| Medically frail | Blind or disabled, a substance use disorder, a disabling mental disorder, a disability that limits daily activities, or a serious or complex condition (details) | Medical claims from the past 12 months; otherwise a statement or doctor's records |
| Drug or alcohol treatment | Taking part in a treatment and rehabilitation program | Treatment records or claims (kept private under federal law) |
| SNAP work rules | You get SNAP and are subject to (not exempt from) SNAP work rules | SNAP case records |
| TANF work rules | Meeting your state's TANF cash assistance work requirements | TANF case records |
| Jail or prison | In jail or prison now, or released within the past 3 months | Corrections data or release papers |
Parents and caregivers in detail
The CMS rule defines a dependent child as a child 13 or younger who relies on someone for care. A disabled individual is anyone who meets the Americans with Disabilities Act definition. They do not need to be on disability benefits. You qualify as a family caregiver if you:
- Live with the child or person with a disability and help them regularly, or
- Are a relative who helps them regularly (more than now and then), even if you live apart, or
- Are not a relative and do not live with them, but give at least 80 hours of care a month.
More than one adult in the same home can qualify for the same child.
Medically frail: the five categories
Court ruling, October 29, 2026. In Massachusetts v. Oz, a federal judge in Massachusetts struck down the CMS rule's extra test that a health condition must "significantly impair" your ability to meet the requirement. That language is vacated. If you are in any one of the five categories below, you count as medically frail. You do not also have to prove your condition keeps you from working.
The court kept the rest of the verification rules, including the 12-month claims look-back and the 2028 limit on signed statements. It gave the states that sued a six-month grace period from federal enforcement of their medically frail decisions while they update their systems. The January 1, 2027 start date did not change. CMS had not said whether it will appeal as of October 30, 2026, so this could change.
Federal law says you are medically frail, and excluded from the requirement, if you are in any one of these groups:
- Blind or disabled (Social Security definition)
- A substance use disorder. The CMS rule leaves out people who have been in stable recovery for 5 years or more.
- A disabling mental disorder
- A physical, intellectual, or developmental disability that significantly limits one or more activities of daily living (this limit comes from the law itself)
- A serious or complex medical condition
The CMS rule describes a serious or complex condition as one that, for example, is life-threatening or seriously disabling, causes significant pain that disrupts daily life, needs frequent monitoring or several specialists, or carries a risk of serious complications. CMS named examples such as cancer, end-stage kidney disease, viral hepatitis, sickle cell disease, COPD, HIV/AIDS, heart disease, ALS, Parkinson's, Huntington's, cystic fibrosis, multiple sclerosis, muscular dystrophy, and hemophilia. The list is not complete.
Each state must keep a list of qualifying diagnoses and must let you ask to be considered if your condition is not on it.
Proof: the state checks your medical claims from the past 12 months first, and it cannot treat missing claims as proof that you don't qualify. Until January 1, 2028, if claims don't show it, the state may accept your signed statement. From 2028, a signed statement can be used only once while you stay enrolled, and the state must confirm it with records at your next renewal. Medically frail status is rechecked at least every 12 months. The court upheld these proof rules. A separate lawsuit in Maryland federal court (Taylor v. Kennedy) challenges the limit on signed statements.
Short-term hardship exceptions (state choice)
States may also excuse a month for these hardships. Each state decides whether to offer them, so ask yours:
- Inpatient care: a stay in a hospital, nursing facility, psychiatric hospital, or similar care. Usually you or someone for you must ask.
- Disaster area: your county has a presidential disaster or emergency declaration. Applied automatically if the state offers it.
- High unemployment: your county's unemployment rate is at least 8%, or 1.5 times the national rate, and CMS approves the state's request. Applied automatically.
- Medical travel: you or your dependent must travel away from your community for a long time for treatment of a serious condition. Usually by request.
Wisconsin says it plans to offer all of them, and Washington applies the disaster and unemployment exceptions automatically. Check your state page.
What does not count as an exemption
- Caring for a child who is 14 or older (unless the child has a disability)
- Having a health condition that is not in one of the five medically frail categories (for example, one that is mild and not serious or complex)
- Being homeless, by itself
- Being Native Hawaiian, by itself (only American Indian and Alaska Native status is in the law)
Frequently asked questions
Do I have to apply for an exemption?
Usually not at first. Your state must check its own records before asking you. If it cannot confirm your exemption, it will send a notice explaining how to show it. Tell your state whenever your situation changes.
My youngest child just turned 14. What happens?
The parent exemption ends when no child in your care is 13 or younger, unless you care for a person with a disability. After that, the rule can apply to you at your next check. Report the change and start tracking hours.
Does caring for my disabled parent count?
Yes. If you are a relative who helps them regularly, you can qualify as a family caregiver even if you do not live together. Your parent does not need to be on disability benefits. They only need to meet the ADA definition of disability.
Does getting SNAP make me exempt?
Only if you are in a household that gets SNAP and you are subject to SNAP's work rules. If you are exempt from SNAP work rules for another reason, check the other exemptions on this page.
I was just released from jail. Do I need to report hours?
Not right away. You are treated as meeting the requirement for any month in which you were in jail or prison at some point during the 3 months before it.
What did the October 2026 court ruling change?
In Massachusetts v. Oz (October 29, 2026), a federal court vacated the CMS rule's added test that a condition must significantly impair your ability to comply. Being in any of the five medically frail categories is now enough. The court upheld the 12-month claims look-back and the 2028 limit on signed statements. It also gave the states that sued six months of relief from federal enforcement of their medically frail decisions. CMS had not said whether it would appeal as of October 30, 2026.
What if I am in recovery from addiction?
A substance use disorder counts toward the medically frail exemption unless you have been in stable recovery for 5 years or more. Taking part in a treatment and rehabilitation program is a separate exemption.
Can my state add more exemptions?
States cannot waive the requirement or add new permanent exemption groups, and the CMS rule says states cannot add categories beyond the five medically frail groups in the law. They can choose to offer the short-term hardship exceptions.
Sources
- Public Law 119-21 (H.R. 1), sec. 71119: community engagement requirement (GovInfo)
- CMS interim final rule, Medicaid community engagement requirement, 91 FR 33348 (June 3, 2026)
- CMS-2454-IFC, official PDF (GovInfo)
- CMS fact sheet: community engagement interim final rule (June 1, 2026)
- Massachusetts v. Oz, No. 1:26-cv-12962-RGS (D. Mass.), memorandum and order (Oct. 29, 2026)
- HFMA: court rules on medical frailty in Medicaid work requirement (Oct. 29, 2026)
- GIH: federal court strikes medical frailty limits from CMS rule (Oct. 30, 2026)
- KFF: states sue CMS over the work requirements rule (medical frailty)