This article was written by Sheila Cooper, a consulting partner with Strategic Partnerships, Inc who specializes in Medicaid. To learn more about Sheila, and our other consulting partners, please visit the SPI website.
New federal rules under H.R. 1, also known as One Big Beautiful Bill Act (OBBA), are set to significantly alter Medicaid administration, with major changes including new work/community engagement requirements for many adults, more frequent six-month redeterminations for the expansion population, and stricter verification and disenrollment safeguards.
These changes, which must be implemented by December 31, 2026, will require state Medicaid agencies to update systems, increase administrative and outreach efforts, and prepare for a rise in disenrollment appeals due to administrative errors.
Key provisions include:
Work and community engagement requirements
- Mandatory participation: Adults aged 19–64 in Medicaid expansion or certain demonstration programs must participate in 80 hours per month of qualifying activities, such as employment, education, or volunteering, unless they qualify for an exemption.
- System updates needed: Agencies must update systems to track hours, verify compliance, manage exemptions, and handle a new notices and appeals process for non-compliance.
- Member outreach is crucial: Extensive education is needed to help members understand the new rules, their rights, and how to report their activities.
More frequent redeterminations
- Six-month cycles: Medicaid expansion enrollees will now have their eligibility redetermined every six months, a change from the previous annual process.
- Increased administrative burden: This will lead to more frequent renewals, potentially causing more enrollees to drop off due to missed paperwork and increasing administrative churn.
- System and staffing adjustments: Agencies will need to adapt their eligibility and renewal systems, staffing levels, workflows, and error-handling processes to manage the increased workload.
Stricter verification and disenrollment
- New verification rules: There are new requirements for verifying enrollee addresses and preventing duplicate enrollment across states through processes like mortality/death matches.
- Data and system changes: Agencies will have to rework data exchanges and system matches to meet these stricter verification rules.
- Higher audit and appeal risk: These stricter rules increase the risk of audits and appeals related to disenrollments resulting from procedural or administrative mistakes.
What this means for technology vendors
The short implementation timeframes for these complex requirements mean that state agencies should rely on AI driven technology tools rather than custom building add-ons to existing systems. Technology solutions that offer workflow engines and AI enabled requirement engines are an ideal solution for ensuring these mandated requirements are implemented efficiently and effectively and on time.
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