Medicaid Work Requirements and Substance Use Treatment
There are two separate exemptions that can cover you: being in a treatment program, and having a substance use disorder.
Short answer: Yes, you are likely exempt. Anyone taking part in a drug or alcohol treatment and rehabilitation program is excluded. Separately, anyone with a substance use disorder counts as medically frail, unless they have been in stable recovery for 5 years or more. These rules apply from January 1, 2027, or earlier in a few states.
Exemption 1: taking part in treatment
Federal law excludes a person "participating in a drug addiction or alcoholic treatment and rehabilitation program" as defined in the Food and Nutrition Act (sec. 1902(xx)(9)(A)(ii)(VII)). That definition covers programs run by a private nonprofit or by a public community mental health center that provide treatment that can lead to recovery.
CMS did not set a minimum number of hours or days. States may set their own minimum, based on clinical guidelines, and decide which programs qualify (42 CFR 435.554(c)(8)). Ask your state what it requires.
Exemption 2: having a substance use disorder (medically frail)
A substance use disorder is one of the five medically frail categories in the law. The CMS rule leaves out people "in stable recovery," which it defines as 5 or more years in recovery. After the October 29, 2026 ruling in Massachusetts v. Oz, you do not also have to show the disorder keeps you from meeting the requirement. Reports on the ruling do not say it changed the 5-year recovery rule. See medically frail.
Your privacy
Substance use treatment records have extra federal privacy protection (42 CFR part 2). CMS told states that any data sharing for these exemptions must follow those rules. Your treatment program may need your written consent to share records with Medicaid.
What proof is usually needed
- Your state first checks Medicaid claims from the past 12 months, which often show treatment or a diagnosis.
- Until January 1, 2028, the state may accept your signed statement if records don't settle it.
- A letter from your treatment program confirming you take part, if you agree to share it.
What to do next
- Ask your treatment program whether it can confirm your participation to Medicaid, and what consent form it needs.
- Use the free checker to see if the rule applies to you and which exemptions may fit.
- Read the full list of exemptions.
- Find your state guide for start dates, how to report, and who to call.
- Got a notice? You have at least 30 days to answer, and you can ask for a fair hearing. See what to do about a notice.
Frequently asked questions
Do people in rehab have to meet Medicaid work requirements?
No. People taking part in a qualifying drug or alcohol treatment and rehabilitation program are excluded. States can set a minimum level of participation.
I take medication for opioid use disorder. Am I exempt?
Likely yes. Even if your state does not treat your care as a "treatment and rehabilitation program," a substance use disorder makes you medically frail unless you have been in stable recovery for 5 years or more.
I have been in recovery for 6 years. Am I exempt?
Not under the substance use disorder category, because the CMS rule leaves out people in recovery 5 years or more. Other exemptions, such as a disabling mental disorder or a serious condition, may still fit.
Will my employer or others see my treatment records?
No. Medicaid uses this information only to decide eligibility, and substance use treatment records have extra federal privacy rules.
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)
- 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)
- 42 CFR part 2: confidentiality of substance use disorder patient records (eCFR)