Missouri rejects optional hardship exceptions to Medicaid work requirements

Missouri will not use optional federal exemptions designed to help low-income people keep Medicaid coverage when they are hospitalized, travel for medical care or live in areas affected by disasters or high unemployment.

The exceptions are optional in the One Big Beautiful Bill Act, which starting Jan. 1, 2027 will require states to verify that adults ages 19 to 64 covered through Medicaid expansion work, attend school or volunteer 80 hours a month to get or maintain coverage.

The Missouri Department of Social Services says it aims to reduce paperwork and accommodate Missourians in some of these “short-term hardship” categories using other, mandatory exemptions in the federal law for caregivers and people who are “medically frail.” But advocates say the mandatory exemptions are likely to exclude some Missourians who would fall within the “short-term hardship” categories — and that where there is overlap, the mandatory exemptions require more verification.

In an email to The Independent, Baylee Watts, media director for the department, said that while the department will not use “separate, standalone” short-term hardship categories, “situations such as acute medical events and travel for specialized medical care will be accommodated under the department’s broader ‘medically frail’ and caregiver exemption pathways.”

Watts told The Independent the department wants to “limit the number of separate processes participants must navigate” and avoid “an additional, burdensome bureaucratic layer for participants” by forgoing short-term hardship exemptions.

The department also plans to verify compliance with work requirements based on one month within each six-month reporting period, Watts wrote, so that “a temporary disruption would not necessarily prevent someone from meeting the requirement.”

As reported by KFF earlier this year, the department initially planned to make exceptions for three of the four “short-term hardship events” in the federal law: extended travel to obtain medical treatment for oneself or a dependent, residence in an area with a federally declared disaster or emergency and inpatient or acute outpatient care in a hospital, nursing facility or intermediate care facility for people with intellectual disabilities. The department did not plan to make exceptions for residents of areas with high unemployment rates.

Watts said that after consulting with the U.S. Centers for Medicare & Medicaid, the department concluded that “circumstances outside of disasters can be effectively addressed through our existing plans for an exemption structure.”

According to a department webpage on Medicaid work requirements, the caregiver exemption will apply to parents or people caring for a child age 13 or younger and people who “regularly care for” someone with a disability and live with that person, are related to that person or provide 80 hours of care in a month.

Joel Ferber, director of advocacy at Legal Services of Eastern Missouri, said it’s unclear whether the “medically frail” exemption will accommodate people hospitalized for short-term acute medical events.

“It is speculative that the department’s definition of medical frailty will solve these problems since we haven’t seen their definition,” he said.

In a Sept. 22 email, Watts told The Independent the department “is continuing to finalize” its “process for identifying and verifying individuals who may qualify for the medically frail exclusion.”

Emily Kalmer, Missouri government relations director at the American Cancer Society Cancer Action Network, told The Independent she is concerned the department’s decision not to grant short-term hardship exemptions will deprive low-income Missourians of options to keep the health insurance they need to detect and undergo treatment for cancer.

“We know people will lose coverage under this federal law,” Kalmer said. “It’s unclear right now how the state is going to be applying the medically frail exemption, and so we would like them to keep the options the federal law allows them as far as short-term hardship so that can be a tool if it’s needed.”

In the federal law, the “medical frailty” exemption includes people who are blind or disabled, have a substance use disorder, a “disabling mental disorder” or a “serious or complex medical condition.”

A federal rule issued by the Centers for Medicare & Medicaid in June declined to include specific conditions like cancer in its definition of “serious or complex medical conditions,” saying the severity of a patient’s condition can vary over time.

Bureaucratic barriers

Even if the department’s definition of “medically frail” encompasses acute medical events and medical travel, the federal rule instructing states how to implement the “medically frail” exemption is the target of multiple lawsuits arguing it creates an unlawfully high bar for people to qualify.

The rule, issued by the Centers for Medicare & Medicaid in June, requires states to verify not only that they have a qualifying condition, but also that their condition impedes their ability to fulfill work requirements.

It’s unclear how much of the burden of proving eligibility will fall on applicants and enrollees. States are required to attempt to process Medicaid applications using information already available to them before requesting information from enrollees — a process known as ex parte verification. But Missouri only conducted 52.3% of Medicaid renewals that way in the first quarter of 2026, according to the Center for Children and Families at Georgetown University. That’s slightly below the national median of 54.8%.

The department also recently added new verification requirements for Missourians applying for or recertifying their eligibility for federal food assistance through the Supplemental Nutrition Assistance Program, or SNAP. Applicants and participants must provide documentation of shelter, utility and dependent care costs, as well as their financial resources, instead of being able to self-attest.

Ferber said it “does not ring true” for the department to say it wants to streamline processes for accessing public benefits “when the agency just added multiple new bureaucratic layers for SNAP applicants and participants.”