What We Know - And Don’t - About Impending Medicaid Work Requirements in Ohio
Beginning in January 2027, individuals who receive health coverage as part of Medicaid Expansion in Ohio will be subject to certain work or community engagement requirements, unless otherwise exempted, in order to keep their benefits. This change, brought about by the 2025 passage of H.R.1, also known as the “One Big Beautiful Bill” by Congress, represents a significant upheaval in the ways in which Medicaid eligibility is managed for this population. From more frequent eligibility reviews to changing definitions of medical frailty, there is a lot the state, local agencies, and individuals need to prepare for ahead of the new year.
What is changing?
The Medicaid Expansion option came about in 2014 thanks to the Affordable Care Act and allowed states to expand Medicaid coverage to adults with incomes up to 138 percent of the poverty level, with the federal government picking up the majority of the cost share. The program significantly reduced uninsurance rates in the states that participated, reduced uncompensated costs for hospitals, and resulted in net savings for many states. Since 2018, individual states have sought to add certain work or community engagement requirements to eligibility for Medicaid Expansion via the 1115 waiver process. Ohio was in pursuit of its own waiver to add work requirements when the federal government opted in 2025 to implement them across the Medicaid Expansion population nationwide.
Broadly, H.R.1 requires that some individuals enrolled in Group VIII coverage — also known as Medicaid Expansion, MAGI Adult, or Ribicoff coverage — will need to engage in certain qualifying activities such as work, education, job training, or community service in order to maintain their Medicaid eligibility. There will also be more frequent checks of compliance under this new rule, with a 6-month renewal requirement replacing the previous 12-month renewal timeline. Click tabs below to see specific requirements & exemptions.
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Work: Work a minimum of 80 hours during the month, which can include unpaid work like caregiving, work in exchange for goods or housing , or an internship.
People can meet this requirement by having a monthly income that is at least $580 (the federal minimum wage times 80 hours). Seasonal workers can use average monthly income to meet this requirement.
Individuals can verify their work by submitting documentation such as an employer statement or a recent paycheck stub showing income.
Community Service: Complete at least 80 hours of community service with a public or nonprofit organization (including government agencies or religious groups) in the month. The organization must not serve a partisan purpose.
Community service includes activities performed without pay that support or improve the community.
Individuals can verify their community service hours by providing a letter from the organization.
Work Program Participation: Participate in a recognized work program for no less than 80 hours within the month.
Individuals can verify their work program participation by submitting a letter from the organization leading the program.
Education: Maintain enrollment in an educational program at least half-time during the month. This can include high school, a GED course, college, or technical schools, and the definition of “half-time” is determined by the specific school.
Individuals can verify their education by providing enrollment documentation or a class schedule.
Combination of Activities: Engage in any combination of the above activities—employment, community service, work program participation, or education—for a total of at least 80 hours in the month.
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Under the age of 19 or over the age of 64
Entitled to, or enrolled for Medicare Part A or enrolled in Medicare Part B
Eligible for Medicaid under a different coverage category
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Current or former foster child under the age of 26
Native American, Urban Native American, or California Native American or otherwise eligible for the Indian Health Service
Parent, guardian, caretaker relative, or family caregiver of:
A dependent child age 13 years or younger, or
A disabled individual (including someone in another household if the care provided is significant)
Veteran rated as fully disabled due to service-connected conditions
An individual with a health condition that prevents work or other activities, including:
Blindness or disability as defined by the Social Security Administration
A substance use disorder
A disabling mental disorder
A physical, intellectual, or developmental disability that significantly limits activities of daily living
A serious or complex medical condition
An individual who meets the SNAP or TANF program work requirements
A person participating in a drug or alcohol treatment and rehabilitation program
A person who is incarcerated or recently released from incarceration
A person who is pregnant or entitled to postpartum medical assistance
As of June 2026 in Ohio, there are 690,034 individuals in the Medicaid Expansion group. According to the Ohio Department of Health, as of June 2026, 78.3% of individuals in the Group VIII Medicaid Expansion group already meet the statutory requirements, either by already working or participating in a qualifying activity, or because they fit in one of the exclusion categories. A remaining 21.7% — about 155,000 Ohioans — needs deeper assessment by the state to determine whether they are engaged in community or work activities or if they meet some exemption criteria.
AOF opposes work requirements on principle — they introduce unnecessary barriers to healthcare coverage that has, in states where these programs were attempted prior to the 2025 bill, resulted in coverage losses for otherwise qualified individuals, leading to delays in care or increased medical debt. They also have not been shown to improve workforce participation — already, most folks who receive these benefits are working or are otherwise exempt, meaning that much of the administrative burden created by these requirements just introduces more opportunities for individuals to slip through the cracks. We believe that access to health care enables meaningful employment, not the other way around. When people have their health needs met, they are able to engage in their communities and participate in the economy.
However, because these work and community engagement rules are coming to Ohio, we have a vested interest in ensuring that they are implemented with the utmost care and consideration in order to mitigate losses and help people maintain their benefits.
The rule-making process
After H.R.1 passed in 2025, state and federal officials set about planning what implementation would look like. In June 2026, the Centers for Medicare and Medicaid Services (CMS) introduced an Interim Final Rule, which set the language for the official, federal rule containing the bill’s changes. During the public comment period on the IFR, AOF submitted comments to CMS detailing our concerns with deviations between the IFR and the original bill language. We were chiefly concerned that the IFR introduced a two-pronged set of criteria for an individual to meet the medical frailty exemption: they would have to have a serious or complex medical diagnosis AND that condition would have to impact their ability to work. While serious medical conditions are able to be determined by state health officials thanks to various diagnostic codes, there is not a similarly simple way to tell the extent to which a condition impacts an individual’s ability to work. Our concern is that this standard could require health providers to attest to the effect that conditions have on ability to work, which physicians have said they are not adequately trained or resourced to do.
Just six days after the CMS comment window closed, the Ohio Department of Medicaid put out their own proposed language for how the federal requirements would appear in the state code. AOF once again submitted feedback. In this case, we were surprised and disappointed that the state had decided not to allow individuals to self-attest to their medical frailty status for the first year of the program, as was allowed by the federal rules. By opting out of self-attestation, we fear that state and local officials, as well as patients and providers, will not have adequate time or capacity to assess the status of individuals in the 155,000 estimated Ohioans that need further investigation for their potential medical frailty or other exemptions.
The comment period for ODM is now closed. They may opt to make changes to their draft based on comments and then must formally file the proposed rule with the Register of Ohio. They must then announce a public hearing date, which must be at least 30 days after the rule filing. Following the public hearing, the rule must be prepared and reviewed by the Joint Committee on Agency Rule Review (JCARR) and approved for final adoption. All of this must be done ahead of the January 1, 2027 implementation date for the Medicaid changes.
The Ohio Department of Medicaid is hosting two webinars on August 25th & 26th regarding the changes coming to Medicaid Expansion. Sign up online.
What we know so far
In a recent meeting facilitated by the Center for Community Solutions and Advocates for Ohio’s Future, a representative of ODM shared further details about how these new engagement requirements would take shape in Ohio. Here’s what we’ve learned so far:
Medical frailty will be based on a set of ICD-10 codes that ODM has determined are associated with a medically frail classification. Individuals who are blind or disabled based on Social Security Administration definitions will also likely be deemed medically frail, but will be identified through other data, not the ICD-10 codes. AOF and others were assured that ODM has been in communication with CMS and that Ohio’s operationalization of the medically frail definition is compliant with the federal standards. ODM expects to make their list of 1,935 codes and subcodes public in the coming months.
For ex parte renewals each month — meaning the automated ODM redetermination process ODM that doesn’t require individuals to provide additional information — ODM will look at the last year of claims data for the diagnosis codes and merge that list with the Group VIII enrolled population to identify individuals who mee the exemption.
Group VIII enrollees will keep their current renewal date for the first evaluation in 2027. The federal law now requires renewals to take place every six months, rather than once per year. ODM has opted to implement this change in batches: for 2027, initial renewal due dates will be one year from their 2026 dates. After that initial renewal, the case will then be scheduled for renewal every six months.
The renewal process will include three verification checkpoints.
Ex Parte Review - 60 days before renewal, eligibility systems will review existing data sources to identify members who are exempt or are already meeting the work and commmunity engagement requirement
Renewal Packets Mailed & Reviewed - for those who are not renewed ex parte, renewal packets will be mailed to members to sign and return, and to add any additional new information if needed.
Notice of Noncompliance - if compliance still cannot be verified with the packet return, two checklists will be sent to individuals on types of documentation they can submit for review
The renewal due date is also the deadline to demonstrate compliance, at which point coverage will be renewed or discontinued.
The first disenrollments for noncompliance with the new requirements will happen April 1, 2027. The renewal process for individuals with March 2027 renewal dates will begin in January to verify whether individuals are compliant, through the process listed above. Based on the timing of this process, if a person does not provide information verifying their exclusion or compliance, they will be disenrolled by April 1.
ODM will send outreach notices to potentially impacted individuals in September. This is required three months before the first look-back month for January applications. This outreach will only go to Group VIII enrollees, as they are the only ones impacted by this change.
What we’re still wondering
Our biggest questions center on how individuals, providers, eligibility caseworkers, nonprofits, county agencies, and more can prepare for these rapidly approaching changes. In their release of the proposed rule, ODM’s fiscal analysis concluded that the addition of the rule does not impose any new requirements on county agencies and implementation should result in no fiscal impact. We are curious how they came to that conclusion. Members of AOF have expressed concerns that the six-month renewal cycle alone will increase the volume of work for county agencies, as will having to verify more stringent compliance rules. As this process moves forward, AOF will continue to question what level of support counties are receiving to enable them to complete this work in a timely manner.
We are also waiting to see what the state will require for documentation of hours for engagement options like volunteering. Individuals who participate in 80 hours of volunteering, or in a combination with other qualified activities, are eligible for Group VIII Medicaid coverage. Many deeply important organizations across our state rely on volunteers to deliver services, but the ways in which they track volunteer hours may look very different. By releasing more guidance on this aspect of the law, ODM can give nonprofits and other community service groups time to implement new systems that will help them offer volunteer opportunities to folks who want to maintain their Medicaid eligibility.
We are unsure what gaps exist in the data that ODM needs to redetermine cases. While checking the records of Medicaid Expansion applicants or renewals falls on the Ohio Department of Medicaid, we want to advocate for and ensure that they have the data and tools they need across various branches of the state to make the verification and compliance efforts smooth. Our hope, as AOF, is to be able to champion policies that improve transparency and communication in government so that individuals are not lost in the shuffle.
Opportunities to engage
As this process moves forward, AOF will continually engage with our stakeholders and with those in charge of these major state decisions to ensure that the voice of everyday Ohioans is not lost. In the meantime, as we wait for the next steps of implementation at the state level, there are some actions members can take now to help their communities get ready:
Remind folks to keep their contact information up to date. ODM will be communicating important changes in the very near future and giving impacted groups more details about what to expect. UHCAN Ohio has produced an info sheet for distribution.
Begin conversations in your organization about compliance. If you are a nonprofit that offers volunteer opportunities, job training, part-time work, etc., it’s important to consider how you can help make sure your people maintain or qualify for Medicaid coverage. Many of the people impacted by these changes already work and volunteer in the community. Working with them to make the process of verifying their hours of engagement smoother is a net benefit for all.
Stay connected to coalitions. In times like these, coming together is critical to keeping each other informed about issues on the ground and aware of opportunities for creativity. As these changes rollout, our goal as Advocates for Ohio’s Future is to ensure that all eligible Ohioans keep their coverage, and therefore their access to healthcare. In the coming months, there will be more ways to engage and provide feedback on the process. Join our mailing list, and connect with our members and partners in this work.