Starting January 1, 2027, Illinois plans to impose work requirements on adults enrolled in its Medicaid expansion program. Participants will need to prove 80 hours of work in the previous month, or confirm that they are too sick to work. The state will rely heavily on billing codes to determine eligibility for health-based exemptions. This approach poses challenges, especially during undiagnosed or post-treatment phases of illness.
Congress established the work requirement, and states determine implementation methods. The critical issue is identifying those too sick to work from claims files. A federal judge recently declined to pause this rule despite a multistate legal challenge. Illinois highlights the potential pitfalls of mismanagement in this area.
The law exempts individuals deemed ‘medically frail,’ protecting those with debilitating conditions like cancer. Identifying such patients through billing codes is problematic. These codes are effective during active chemotherapy, but not before diagnosis or post-treatment monitoring. For example, an abnormal mammogram indicates potential cancer, but until diagnosis is confirmed, the patient’s records only reflect initial findings and follow-up tests.
If Medicaid renewal occurs during this diagnostic window, the absence of a formal diagnosis may lead to loss of coverage. The records then misrepresent the patient’s condition, limiting access to necessary care. Additionally, Illinois offers separate Medicaid coverage for breast and cervical cancer, but it excludes those already in the Medicaid expansion from switching, thus they remain subject to the work rule during treatment.
Arkansas experienced similar issues implementing work requirements in 2018, resulting in coverage loss for about 18,000 people. Employment rates did not increase as a result, and many lost coverage due to difficulties with reporting requirements instead of actual unemployment. By 2019, only a small fraction regained coverage.
While federal laws are in place, implementation strategies vary. Some states provide medical frailty screenings at enrollment, install hardship exemptions, or extend compliance timeframes. Illinois could protect patients without altering federal policy by adapting its administrative processes.
Steps include shielding patients upon abnormal screening results, offering grace periods post-diagnosis, and accepting documentation from non-billing clinics. These actions help protect vulnerable individuals from losing coverage despite ongoing health issues. According to the Centers for Medicare and Medicaid Services, an estimated 2.3 million people could lose Medicaid in the policy’s first year.
No legislative changes in Springfield will modify this federal mandate. However, administrative decisions will shape exemption criteria, starting timelines, and necessary proof for demonstrating illness. Illinois must develop procedures that consider medical realities beyond billing codes.
Akshaya Sahasra Ganji is a health policy researcher at Florida International University, focusing on women’s health, neuroscience, and policy.