As new Medicaid work requirements roll out across the country, physicians whose patients seek medical exemptions face an uncertain patchwork of federal and state rules.

Across Nebraska, Montana, and other early-adopter states, clinicians said they don’t understand whether they’ll be asked to document their patients’ functional limitations, how Medicaid program officers will evaluate those, and what the changes will mean both for their clinical practice and for patient care.

“It’s been equal parts confusion, uncertainty, and concern,” said William Ostdiek, a family medicine physician and chief medical officer at OneWorld Community Health Center in Omaha, Nebraska.

‘Medically Frail’ Exemptions Will Draw Scrutiny

On July 1, the state of Montana rolled out new work requirements for certain individuals on Medicaid in advance of the federal requirements passed as part of President Trump’s “Big Beautiful Bill” in July 2025. The bill stipulates that all those with Medicaid insurance as part of state expansions of the low-income insurance program work a minimum of 80 hours each month unless they receive an exemption. Nebraska implemented similar requirements on May 1 of this year.

The law includes several potential exemptions, including caring for young children and those with disabilities, or having a condition that makes them too medically frail to work.

But the “medically frail” category will likely to draw physicians into the eligibility process. While the Centers for Medicare & Medicaid Services (CMS) provided interim guidance around what constitutes medical frailty on June 1, 2026, questions continue to swirl about what that definition actually means and how doctors will implement that guidance.

In July 2025, Congress passed the One Big Beautiful Bill Act, a sweeping budget reconciliation law that extended the 2017 tax cuts and made significant changes to Medicaid, including new work requirements for certain adults enrolled through the program’s expansion.

‘Send Them Back to Work’

During a February 2025 CNN interview about the bill that he later quoted in a press release, Speaker Mike Johnson (R-LA) defended the work requirements. “You don’t want able-bodied workers on a program that is intended, for example, for single mothers with two small children who’s just trying to make it. That’s what Medicaid is for, not for 29-year-old males sitting on their couches playing video games. We’re going to find those guys and we’re going to send them back to work.”

It’s why the work requirements contain several exemptions, including the medical frailty category. Those dual-eligible individuals who are also receiving Social Security Disability through Medicare will automatically be exempt.

Far more challenging will be Medicaid recipients who don’t qualify for disability but still have significant medical issues that may preclude them from working enough hours to satisfy the new requirements.

Disability ‘Gray Zone’

The health policy think tank KFF reported that, in 2023, nearly two thirds of adults aged 19-64 years covered by Medicaid already were working. Nearly, 3 in 10 did not work because of caregiving responsibilities, illness or disability, or school attendance.

Work published earlier this year by Darshali Vyas, MD, a pulmonary and critical care medicine fellow at Massachusetts General Hospital in Boston, showed that half of adults on Medicaid — approximately 8 million adults — who work less than 20 hours per week (or 80 hours each month) are healthy enough to work. It’s a population that’s far more limited functionally due to medical conditions, living “in a gray zone between full health and formal disability,” she said.

Her study in the Annals of Internal Medicine found that adults at risk for disenrollment due to the work requirements were three times more likely to report poor physical health than Medicaid recipients who already met work requirements. These individuals were also more likely to report problems with neuropsychiatric functioning and with independent living activities. The results, she said, indicate that a physician’s judgement on who is able to work and who isn’t will likely prove crucial.

“Looking at just diseases or just diagnoses is not enough to capture how limited someone is,” Vyas said. “We need to be really clear about how these exemptions are being defined and making sure that we’re asking all of our patients not just ‘How is your heart failure or COPD [chronic obstructive pulmonary disease]?’ but how limited they are in their activities.”

CMS published its official guidance on medical frailty less than 24 hours before Montana initiated its own work requirements.

The CMS definition — someone “whose physical, mental, or other behavioral health condition significantly impairs the individual’s ability to comply with the community engagement requirement” — centers on a person’s functional ability rather than their specific diagnosis.

Both Montana and Nebraska, however, have provided specific medical diagnoses that would potentially qualify a person as medically frail, including cancer, fatigue, HIV, and schizophrenia.

The conflict between the CMS functional definition and the states’ diagnostic category-based guidance has created confusion for physicians, said Aaron Wernham, MD, MS, CEO of the Montana Healthcare Foundation in Bozeman, Montana.

“Providers don’t really understand what they’re going to be asked to sign off on,” Wernham said. “CMS hasn’t really provided guidance on how providers are to assess this.”

Physicians are well aware, Wernham said, that Social Security disability evaluations are complicated, painstaking, and take a long time.

But Medicaid work requirements aren’t disability evaluations.

“Providers are really worried about what’s coming their way. What legal risk are [physicians] putting themselves at if they sign something that says the person can’t work?” Wernham asked. “All the providers and systems we talk to are scratching their heads.”

Both patients and physicians are uncertain about the process, said Andrea Skolkin, CEO of OneWorld Community Health Center. “Patients are already coming to physicians asking for letters saying they can’t work — even though that’s not currently how Nebraska’s system operates,” Skolkin said.

That what happens now remains unclear. Nebraska officials said they will at first base their question on medical frailty based on insurance claims data rather than requiring separate physician documentation, but no one yet knows whether that will change, Skolkin’s colleague Ostdiek said. Many of the physicians Ostdiek has talked to worry the requirements will mean more paperwork and more headaches.

“Nobody wants to fill out extra forms,” said Ostdiek.

Jack Hensold, an oncologist from Bozeman, Montana, and president of the Montana State Oncology Society, agreed.

“We already have tremendous administrative load with preapprovals,” he said. “Trying to put additional administrative load on busy practices is problematic.”

However, Hensold’s main concerns center less on definitions than on the ripple effects as patients encounter more barriers to accessing care.

Rather than jump through the hoops of documenting their medical frailty or need for an exemption, Hensold said many individuals could simply drop their coverage. Given how essential early detection is to cancer survival, Hensold worried that this will result in more cancer deaths and more illnesses detected late, when they are harder and more expensive to treat.

“We’re doing this because we have to do this, and we’re trying to make sure we don’t harm people who shouldn’t be harmed,” Hensold said.

The experts cited in this article had no relevant disclosures.