The work requirements outlined in H.R. 1 represent a fundamental shift in how Medicaid operates for able-bodied adults aged 18-65 without dependent children. Under this legislation, these individuals must work, participate in education or job training programs, or engage in community service for at least 80 hours per month to maintain their Medicaid benefits – and, after a three-month grace period within any 36-month cycle, non-compliant beneficiaries will lose coverage.
Early analyses from the Congressional Budget Office suggest this could affect between 10 and 15 million current Medicaid beneficiaries nationwide, creating an administrative and operational challenge that parallels — and in some ways exceeds — the complexity of the recent Medicaid unwinding process.
“This administrative complexity presents a clinical risk factor,” said Sanjay Basu, Waymark’s co-founder and Head of Clinical. “We’ve seen in several states that Medicaid unwinding caused so many people to lose coverage because of state-level administrative issues, and it’s not unreasonable to expect the same thing here. Patients are feeling this anticipatory stress already.”
In both instances, the stakes extend beyond administrative complexity. Gaps in Medicaid coverage are associated with increased risk of unmet health needs, delayed care, lower vaccination coverage, unfilled prescriptions, and increased asthma-related emergency department visits. During Medicaid unwinding, health plans saw increased per-enrollee costs, and similar impacts are likely as these work requirements are enforced. For health plans managing value-based care arrangements, these coverage disruptions translate directly into higher acute care utilization and deteriorating health outcomes for the populations they serve.
The Arkansas cautionary tale
Arkansas's experience with work requirement implementation from 2018-2019 offers a preview of what can go wrong. The state required beneficiaries to report their work hours through an online portal each month, but the system was plagued with technical problems and accessibility issues. Many beneficiaries didn't have reliable internet access, didn't receive adequate notification about the new requirements, or couldn't navigate the reporting portal even when they were complying with work requirements.
The result was devastating: over 18,000 people lost coverage, with the vast majority of losses stemming from procedural barriers rather than actual failure to work. People who were employed, participating in job training, or exempt from requirements lost coverage simply because they couldn't figure out how to prove their compliance through a broken reporting system. It was a demonstration of how operational shortcomings can undermine policy intent and harm the very people a program is designed to serve.
The vital nature of effective, comprehensive communication
States and health plans will have to prepare for work requirements in the absence of any concrete federal guidance. A good place to start, said Jeremy Schifberg, Waymark’s VP of Northwest Operations, is with an intentional approach to patient redetermination.
“The process of patient communications, and then being sure patients can act on those communications, is really hard, even for states that are actively trying not to make it hard,” he added.
The infrastructure required goes beyond traditional Medicaid communication systems. States will need platforms that can send automated reminders about work reporting deadlines, provide real-time updates about compliance status, and offer multiple pathways for members to report work hours and request exemptions. Most states don't currently have these capabilities, demanding investment in both technology platforms and the human support systems that help members navigate these new requirements.
“This mirrors the challenges community-based care teams encounter daily, because we serve people without consistent contact information,” said Jeremy. “A lot of communication is sent out via mailers, which are often dead on arrival, or via phone, which isn’t always reliable. When you couple that with outdated systems, there are even more variables and vulnerabilities in those communications.”
Data suggests that states with more robust technology infrastructure and automated renewal capabilities had significantly lower procedural denial rates during unwinding. States with outdated systems experienced higher rates of procedural denials, longer processing times, and greater member confusion about renewal requirements and status. When members lost coverage due to system failures and later had coverage restored, it created complex reconciliation issues for claims processing, provider payments, and care coordination — operational challenges that rippled through the entire system.
Work requirements implementation will demand technology capabilities that exceed those needed for traditional Medicaid eligibility determinations or renewal processes. States face unprecedented integration challenges between systems that historically operated independently, compounded by the need to accommodate multiple types of qualifying activities, each requiring different verification methods and data sources.
The essential components of proactive community partnerships
The Medicaid unwinding process revealed both the essential role of community-based organizations in supporting vulnerable populations and their significant capacity limitations. Community health centers, legal aid organizations, faith-based groups, and social service agencies became lifelines for members trying to navigate renewal processes — but many were overwhelmed by the sheer volume of requests for help.
Federally qualified health centers reported 200-300% increases in requests for Medicaid enrollment assistance during peak unwinding periods. Work requirements will likely generate similar demand, with a crucial difference: the support needed extends directly to social determinants of health. Members won't just need help understanding paperwork — they'll need assistance finding employment, arranging childcare, accessing transportation, and navigating workforce development systems. This represents a fundamentally different and more resource-intensive type of support.
“With these work requirements, access to work becomes a patient’s assurance that they’re going to be able to stay covered by Medicaid,” said Liz Cagianesa, Waymark’s VP of Mid-Atlantic Operations. “That requires so many more resources and, while community-based care teams already have access to those resources, the important piece now is going to be ensuring this is integrated into patient care.”
The most effective community partnerships during unwinding were those built on long-term relationships with sustainable funding mechanisms rather than crisis-response partnerships created during the process itself. Organizations that had existing contracts or formal agreements with state Medicaid agencies were better positioned to provide consistent support throughout the renewal process. For work requirements, where the ongoing nature of compliance monitoring means that episodic support will be insufficient, this lesson becomes even more critical.
“This is something states and MCOs need to start with soon if they haven’t already,” said Liz. “In the states we’re in, we’re actively asking MCOs how they’re going to be supporting members in reference to these work requirements to ensure that we’re actively doing the same, and connecting with community development teams to be sure we’re all aware of the same resources. We want to be sure that everyone is aware of what’s expected of them to maintain eligibility, because if they’re not aware, that’s when it feels like the rug is pulled out from under them.”
Important investments for health plans and providers
States, health plans, and providers preparing for work requirements must begin proactively developing innovative approaches that create direct pathways between Medicaid members and the resources they need to maintain both coverage and health stability. This requires rethinking how organizations identify risk, deploy resources, and coordinate across traditional boundaries. Three categories of investment stand out as particularly critical.
Predictive analytics and risk stratification
Health plans need predictive tools to identify which of the 10 to 15 million potentially affected individuals are most likely to lose coverage and who will require proactive intervention. By analyzing patterns in employment history, healthcare utilization, social risk factors, and past engagement with the healthcare system, predictive analytics platforms enable proactive outreach to members who are most likely to need support navigating work requirements. This shifts the approach from reactive problem-solving to anticipatory intervention — identifying members at risk before procedural issues arise.
These tools become particularly valuable when integrated with care delivery operations. Rather than generating reports that sit unused, effective predictive platforms should trigger workflows, alert care teams, and create actionable outreach lists. The goal is to move from broad population-level insights to individualized member engagement strategies that address specific barriers before they result in coverage loss.
Waymark's community-based care teams leverage Waymark Signal™, our proprietary risk prediction platform, to reach members proactively by analyzing utilization patterns, social risk factors, and engagement trends. This ensures that care team members are able to meet patients where they are – which is often during moments when targeted support can prevent a cascade of complications that might otherwise lead to both health deterioration and coverage loss.
“Signal and our next best action models, which help care team members understand which actions are most likely to benefit which patients, are proactive support tools that care teams can use to make sure patients don’t lose coverage,” said Sanjay. “We couple this with real-world outreach, like getting on the phone with a patient and a provider to make sure everything’s lined up to continue coverage or meeting with a patient to walk them through the website and forms they need. It informs where we need to focus our efforts so we’re as efficient as possible.”
Integrated care delivery models
The complexity of work requirements demands care delivery models that can address multiple, interconnected needs simultaneously. Members who struggle to maintain stable employment often face the same social and health barriers that made Medicaid unwinding so challenging: transportation limitations, unstable housing, chronic health conditions that require careful management, limited experience navigating complex administrative systems. These challenges compound each other, and addressing them requires a coordinated approach.
Community-based care teams that integrate clinical expertise with social support can address these interconnected challenges effectively. When care teams include community health workers who understand local employment landscapes, pharmacy professionals who can ensure medication access remains uninterrupted during job transitions, and care coordinators who can connect providers and patients with workforce development resources, they create a comprehensive support system that addresses both health and administrative needs simultaneously.
This integrated approach recognizes that work requirements don't exist in isolation from members' health needs and social circumstances. Someone managing diabetes while searching for employment needs support that addresses both medication adherence and job placement. A member with transportation barriers needs assistance that connects them simultaneously with both workforce resources and the rides that make employment sustainable.
Infrastructure built for continuous outreach and compliance
Beyond predictive analytics, health plans and state agencies need operational technology infrastructure designed specifically for the continuous monitoring that work requirements demand. This includes member portals that make work hour reporting straightforward and accessible, automated reminder systems that reach members through their preferred communication channels, and real-time compliance dashboards that help both members and care teams understand status at a glance.
But it shouldn’t stop there. States must also anticipate the needs of populations without regular access to the internet, without technology literacy, and without proficiency in these types of portals and dashboards. During the Medicaid unwinding and subsequent determination process, states often saw significant challenges getting in touch with Medicaid beneficiaries, and it’s likely those challenges will continue to compound as work requirements take effect.
“States often have a lot of outdated or old contact information, and many patients don’t even know they’re enrolled in Medicaid because each state calls it something different,” said Sara Greenbaum, Waymark’s Head of Operations. “There are a lot of barriers to timely communication and that alone is a significant hurdle to getting patients in touch with what they need and what the changes are that impact them.”
Part of overcoming this hurdle is implementing a “no wrong door approach,” whereby patients can access the information and assistance they need complying with work requirements and reporting at any touchpoint they may have with their system of care. Multidisciplinary care teams are uniquely positioned to address this need, Sara said, because care team members like community health workers – who interact with patients outside a traditional clinical setting – can help patients understand how and when they need to comply with these requirements.
“Every organization, every care team member who touches patients has the opportunity to help here,” she added. “Thinking about how we integrate them into standard workflows is incredibly important to preparing for the work requirements mandate.”
This also extends to Medicaid beneficiaries who need to prove that they are exempt from work requirements. As a physician and Waymark’s VP of Clinical, one of John Morgan’s chief concerns is how the nationwide provider shortage will play a role in patients losing coverage while waiting to get those exemptions.
“For patients who are exempt from these work requirements, and who need a functional capacity evaluation or something similar to get that exemption, they’re looking at long wait times to get in to see a provider – especially because, frankly, many providers aren’t accustomed to facilitating functional capacity evaluations with the frequency that they’ll be requested.” he said. “In the meantime, their eligibility may expire just because of how much time has passed.”
Building infrastructure before the crisis
The key is ensuring these support systems are in place and operational well before work requirements take effect. Health plans and state agencies that wait until implementation to build infrastructure and partnerships will find themselves responding to crises rather than preventing them. The lessons from Medicaid unwinding are clear: administrative complexity creates predictable patterns of coverage loss, and those patterns are most severe for populations already facing the greatest barriers to care.
“Even if you develop a perfect system that allows for automated reporting and could accommodate a wide range of document types, and even if you truly minimized the technical friction, expecting a high-need population to navigate some reporting structure on a highly regular basis, when there are severe consequences if it goes poorly, almost guarantees that people who are eligible are going to lose eligibility,” said John. “It’s our responsibility – everyone who works in this space and serves these patients – to do what we can to make sure we’re not wasting resources, we’re not wasting time, and we have the people and infrastructure we need to support patients in retaining their coverage.”
By investing now in predictive analytics, integrated care delivery models, and robust patient-facing reporting tools, health plans and state agencies can mitigate the most harmful potential impacts of work requirements while supporting members in achieving both health stability and economic opportunity. The challenge ahead is significant, but the roadmap exists – and if the healthcare system chooses to apply these hard-won lessons to work requirements reporting and implementation, we can ensure the patients who need healthcare the most retain their coverage.
