11/13/2025

Ohio Department of Medicaid Outlines New Work and Community Engagement Requirements

The Ohio Department of Medicaid (ODM) presented an overview last week of upcoming federal requirements related to Medicaid eligibility for certain adults. The presentation focused on changes introduced through the federal H.R. 1, which establishes work and community engagement requirements for some Medicaid enrollees.

Under the federal provision, states must implement these requirements by December 31, 2026, although extensions may be available until 2029. The rule applies only to nonexempt adults ages 19 to 64 who are eligible for coverage under Medicaid’s expansion group—often referred to as Group VIII, MAGI Adult, or “expansion” coverage—and whose income falls below 138 percent of the federal poverty level. ODM emphasized that this provision affects only this specific eligibility group, not all Medicaid recipients.

To maintain coverage, individuals in this group will need to document participation in qualifying activities—such as employment, education, job training, or community service—for at least 80 hours per month, unless they meet an exemption. Examples of exempt individuals include those who are pregnant, medically frail or living with a disability, caregivers for children under 13, participants in substance use treatment programs, or veterans with a total disability rating. The federal policy also allows exemptions for temporary hardships, such as hospitalization, short-term institutional stays, or living in areas affected by a federally declared emergency or high unemployment.

ODM compared the new federal requirements with Ohio’s earlier proposal under its Section 1115 demonstration waiver, submitted in alignment with Ohio House Bill 33. While both approaches set similar activity thresholds, H.R. 1 includes broader age applicability and more defined exemptions. ODM noted that it is working with the Centers for Medicare & Medicaid Services (CMS) to determine final parameters and the most appropriate start date.

According to ODM’s analysis, a significant share of Ohioans currently enrolled in the expansion group already meet exemption criteria or are participating in qualifying activities. The department estimates that roughly 43 percent are known to be working, and an additional 18 percent meet the definition of medical frailty or disability. Once all known exemptions are accounted for, about 22 percent of enrollees may require further documentation or data review to verify eligibility.

ODM outlined expectations for how compliance will be verified. The state will rely primarily on existing data sources—such as wage information and program participation records—before requesting documentation directly from individuals. Eligibility will be reviewed every six months rather than annually, with members receiving advance notice and 30 days to provide information if verification cannot be completed automatically.

The department also previewed its member outreach and education plan, which will begin several months before implementation. Communication will include mailed notices, website updates, text and phone outreach, and collaboration with stakeholder organizations to ensure accurate information reaches affected individuals. ODM expects to release draft materials and a partner packet for feedback in 2026 as CMS guidance becomes available.