The Real Risk of Medicaid Work Requirements Isn’t Eligibility. It’s Response.

On June 1, 2026, CMS issued the interim final rule implementing mandatory Medicaid community engagement requirements under H.R. 1. States must comply by January 1, 2027. And right now, millions of people are at risk of losing coverage for a reason that has nothing to do with whether they actually qualify.

We’ve been here before. During the COVID-19 unwinding, more than 25 million people were disenrolled from Medicaid. Nearly 70% of them lost coverage for procedural reasons—not because they were ineligible, but because a notice went unanswered, a deadline passed, or a form never got completed. (KFF.org) The systems designed to keep them covered couldn’t reach them in time.

Work requirements create the same risk, at scale, on a tighter clock. For plans and states, the challenge isn't new. The scale is.

What the Rule Actually Requires

The new rule requires non-pregnant adults ages 19–64 in Medicaid expansion to document 80 hours per month of qualifying community engagement—employment, education, volunteer work, or a combination of these activities—as a condition of eligibility. States must implement the requirement by January 1, 2027.

The outreach mandate is explicit. States must notify affected members through regular mail plus at least one additional method: telephone, text message, website, or “other commonly available electronic means.” And that outreach must begin no later than July, August, or September 2026, depending on how many reporting months the state requires before implementation.

The timeline isn’t optional. It isn’t aspirational. It’s a federal requirement, and implementation is already underway.

The Mandate is Multi-Modal for a Reason

Most Medicaid adults are already working. The coverage risk isn’t non-compliance. It’s that millions of eligible, qualifying members won’t respond to a mailer in time, won’t see a notice, and won’t understand what they’re supposed to do. Under the rule, members whose compliance or exemption status cannot be automatically verified may need to respond to notices or provide information to maintain coverage. For many members, the challenge won’t be meeting the requirement. It will be successfully navigating the process.

CBO estimates 4.8 million people could lose Medicaid coverage specifically due to work requirements. The Urban Institute puts the range between 4.9 and 10.1 million by 2028 across both work requirements and six-month redeterminations. Every one of those projected coverage losses starts with a member who failed to respond.

The COVID-19 unwinding showed us what that gap looks like when states lean on mail and passive communication. It also showed us what closes it: multi-modal, direct member outreach that meets people where they are—in their texts, not their mailboxes.

What Good Outreach Looks Like

The rule names it directly: mail plus one or more of phone, text, website, or electronic means. But the lesson isn’t just that you need multiple channels. It’s that you need channels that create a response.

A letter sent once rarely moves someone to action. A two-way SMS conversation that starts with a question creates a moment of engagement. It invites a response. It starts a conversation that can walk a member through what they need to do, answer their questions, and connect them to support before their coverage is at risk.

That’s the model Drips is built around—conversations that start with a question, guide members to action, and end with an outcome.

The compliance reporting requirement creates a structured, ongoing member communication need: initial notification, exemption guidance, compliance confirmation, renewal-cycle check-ins every six months. That’s not a campaign. It’s a member engagement program. And it requires infrastructure that can run at the scale of state Medicaid populations—hundreds of thousands of members, across multiple touch points, on a legally mandated timeline.

What Plans and States Should Be Doing Right Now

Outreach must begin by summer 2026. That window is open now. A few practical questions for any state agency or MCO working through implementation:

•      Is our current member contact data accurate and complete? Returned mail is often a primary failure mode.

•      What is the second-channel outreach strategy beyond mail? The rule requires it.

•      Can the outreach infrastructure operate at state-population scale on a compliance-mandated timeline?

•      Do you have a workflow for members who don’t respond to the first touch?

•      Who is managing the compliance around how those outreach messages are structured and sent?

The last question is where a lot of plans and states underestimate the complexity. The member population here is vulnerable and coverage loss can be devastating. Outreach content and methodology need to meet federal standards and, critically, need to be able to demonstrate that they did.

The Bottom Line

The work requirement itself will move millions of members through a new compliance process. Whether they stay covered on the other side depends largely on whether someone reached them in time, in a way they understood, and gave them a path forward.

Drips exists for exactly that moment. Conversational outreach, built for compliance, designed to convert outbound effort into real member action and outcomes.

The rule doesn’t create a new problem. It creates a deadline for solving the one we’ve always had: how do you reach a Medicaid member, get a response, and move them to action—before the clock runs out?