What Could Medicaid Work Requirements Mean for SSI Applicants?

The 2025 reconciliation law requires 44 states to condition Medicaid eligibility for adults in the Affordable Care Act (ACA) Medicaid expansion group and enrollees in certain waiver programs, on meeting work requirements starting January 1, 2027, or sooner at state option. While the law specifies mandatory exclusions, including for individuals who are “medically frail,” the approach to determining medical frailty specified in the June 2026 interim final rule could make it difficult for some people to qualify for this exclusion. Medicaid expansion provides coverage to many adults with significant health care needs, including some with disabilities who are applying for the Supplemental Security Income Program (SSI). This coverage could be at risk for some because of the planned approach to defining medical frailty.

SSI is a means-tested federal program administered by the Social Security Administration (SSA) that pays monthly cash assistance to people with limited resources who are unable to work because of a disability and generally qualifies people to receive health coverage through Medicaid. Once approved for SSI, Medicaid enrollees would not be subject to work requirements, but the application for SSI can be a lengthy and complicated process, spanning months, if not years, during which time applicants may be at risk of uninsurance because they are unable to work. Medicaid can fill coverage gaps during the SSI application period, particularly in states that have adopted the Medicaid expansion.

This issue brief finds that the percent of new SSI enrollees ages 19 through 64 with Medicaid prior to SSI entitlement is twice as high in ACA expansion states as it is in non-expansion states, and in 2023, over 100,000 new SSI enrollees had ACA Medicaid coverage prior to their SSI entitlement. It also describes the lengthy SSA process for determining SSI eligibility, particularly assessing ability to work, and how the current approach to determining medical frailty could cause some SSI applicants to undergo concurrent assessments of their ability to work using different processes and criteria. The new documentation requirements and processes could cause some people with disabilities to lose Medicaid coverage or be denied Medicaid enrollment while they are waiting on their SSI determination.  

How does Medicaid provide coverage for people during the SSI application process?

Medicaid provides coverage for many people with disabilities, including those who are applying for SSI. One in five Medicaid enrollees have a disability, including 43% of adults ages 50-64, but only one-third of these individuals receive SSI income, generally qualifying for Medicaid for that reason. The remaining people with disabilities are covered through different Medicaid eligibility pathways, including the ACA Medicaid expansion. Because of the lengthy process for obtaining an SSI determination and the fact that people who are applying for SSI are unable to work, many people applying for SSI rely on Medicaid to avoid going uninsured.

In 2023, 223,000 SSI applicants ages 19 through 64 had Medicaid while they were waiting for an SSI determination, including over 106,000 with coverage through the ACA expansion. KFF analyzed detailed Medicaid administrative data to identify people who were ages 19 through 64 and became eligible for Medicaid because of SSI during the calendar year 2023 and whether those enrollees had Medicaid coverage in the months prior to their SSI-based eligibility (see Methods). Among the 337,000 people who started SSI during the calendar year, over 200,000 had prior Medicaid coverage through a different eligibility pathway, with roughly half receiving that coverage through the ACA expansion.

In ACA expansion states, 76% of new SSI enrollees ages 19 through 64 had Medicaid coverage through a different eligibility pathway prior to their disability determination (including 42% who were covered through the Medicaid expansion) compared with only 33% in non-expansion states (Figure 1). In both expansion and non-expansion states, roughly 1 in 3 new SSI enrollees ages 19 through 64 were enrolled in non-ACA Medicaid coverage (such as coverage for parents and caretakers) prior to becoming eligible for SSI. However, in expansion states, an additional 42% of new SSI enrollees were enrolled in Medicaid through the expansion, covering over 100,000 people in 2023. New SSI enrollees who were not covered by Medicaid prior to their SSI approval were likely uninsured because of their low income and inability to work.

How do people demonstrate eligibility for SSI?

To be eligible for SSI, people must have limited income (defined as no more than $2,073 per month in 2026), limited resources (defined as no more than $2,000 for an individual or $3,000 for a couple), and a disability that affects their ability to work for at least a year or result in death or be age 65 and older.

For applicants under age 65, demonstrating a disability is often the most complicated part of the SSI application process, involving a lengthy five-step process that starts by proving one is not gainfully employed (Figure 2). The federal government establishes verification processes that all states must use to determine applicants’ disability status, and funds state Disability Determination Services (DDS) offices to carry out these processes. The same processes are used for SSI and for Social Security Disability Insurance. Illustrating the high costs of this lengthy process, the Social Security Administration provided states with $2.6 billion in Fiscal Year (FY) 2025 to run the DDS offices. The first step requires people to demonstrate that their current earnings are below the threshold of “substantial gainful activity” (SGA, $1,690 per month in 2026).

The second step assesses whether applicants have a severe impairment, where impairment is defined based on which body system is affected. For adults, impairments are classified into the following categories with associated medical criteria: musculoskeletal disorders, special senses and speech, respiratory disorders, cardiovascular system, digestive disorders, genitourinary disorders, hematological disorders, skin disorders, endocrine disorders, congenital disorders that affect multiple body systems, neurological disorders, mental disorders, cancer, and immune system disorders.

The third step assesses whether the impairment qualifies as a disability that wouldn’t require further demonstration of an inability to work using established criteria for disabilities. Some impairments allow applicants to qualify for SSI without further demonstrating an inability to work, including blindness and several hundred specific disorders or conditions included in the “compassionate allowance program,” which quickly identifies diseases and other conditions that meet SSA’s standards for disability benefits. Examples of such conditions include Amyotrophic Lateral Sclerosis (ALS), certain cancers, and Duchenne Muscular Dystrophy. SSA reports that between 2008 and 2025, the agency approved more than 1 million people (for SSI and Social Security Disability Insurance combined) through the compassionate allowance program.

The final two steps respectively assess peoples’ ability to engage in “past relevant work” or any job in the national economy that is feasible considering the applicant’s residual functional capacity, age, education, and work experience. The SSA makes this assessment based on information provided in Form 3368 which requires people to provide personal information including their English language proficiency, current work activity, job history over the last 15 years, the claimed disability onset date, list of medical conditions, prescription list, and medical treatment history. Medical records from providers can be submitted with the application. Along with this form, the SSA will request any missing medical records and may request that the person have a consultative medical examination by an SSA medical consult. SSA also compares information about people’s jobs from the past 5 years (such as job title and pay; tasks performed; tools, machinery, and equipment used; knowledge, skills, and ability required; physical demands; and environmental conditions) with tables of rules about the requirements for jobs in the national economy.

Assessing ability to engage in any job requires information about all jobs in the economy, which can be difficult to implement in practice, and SSA is currently relying on outdated job information. SSA’s current jobs listing comes from the Department of Labor’s Dictionary of Occupational Titles which was last updated in 1991 and is not currently used by the Department of Labor. Since FY 2021, SSA has partnered with the Department of Labor to develop a survey that will be the main source of updated occupational information, but that new system has not yet been implemented. Congressional Research Services reports that between FYs 2012 and 2024, SSA spent $300 million on this project.

The application for disability benefits can be a lengthy and complicated process, spanning months, if not years, meaning hundreds of thousands of people are currently waiting for determinations. As of May 2026, the initial processing time for all disability applications was 184 days—over 6 months—and roughly 862,000 people were waiting for their initial determinations. (This number includes applications for SSI and applications for Social Security Disability Insurance, a related program that uses the same disability determination process.) Many people receive initially unfavorable decisions and choose to appeal, which can considerably lengthen the process. Having a lawyer increases the likelihood of being approved at the initial stage and, on average, can reduce the time it takes to reach a final decision by nearly one year.

How might work requirements affect Medicaid coverage for people during the SSI application process?

Starting in January 2027, individuals applying for or enrolled in coverage through the ACA expansion and in certain waiver programs will be required to work or engage in qualifying activities, such as volunteer community service, for 80 or more hours per month, attend school half-time, unless they qualify for an exemption or exclusion from the requirements. SSI applicants enrolled in the ACA expansion will be subject to these new requirements. Applicants who meet the SSI criteria do not have to meet the community engagement requirements, but there may be challenges for them in proving their eligibility for the medical frailty exclusion while they are applying for SSI.

People applying for SSI are generally unable to work, but current rules could make it challenging for them to qualify for a medical frailty exclusion. Because individuals must have earnings below the SGA level to be eligible for SSI, they are unlikely to be able to work 80 or more hours in a month. Additionally, most people with new impairments significant enough to qualify for SSI will likely also face challenges meeting the Medicaid community engagement requirements through education or volunteering. Instead, to obtain or retain Medicaid, individuals applying for SSI who are subject to the work requirements will need to qualify for an exclusion from the requirements, most likely through the medical frailty exclusion. The interim final rule implementing Medicaid work requirements issued on June 1, 2026, adopts a restrictive definition of medical frailty that requires individuals to have a physical or mental health condition that impairs their ability to meet community engagement requirements. This two-part test for medical frailty will require navigating a verification process that may lead to people losing coverage because they cannot provide the required documentation, even though they qualify for the exclusion.

Different requirements for Medicaid eligibility determinations mean SSI applicants covered through the Medicaid expansion could face two concurrent assessments of their ability to work: one for SSI and one for Medicaid. Medicaid eligibility determinations of whether an individual meets the medical frailty exclusion will need to be done on a faster timeline than SSI determinations. States are required to process Medicaid applications for individuals who qualify based on income within 45 days, and starting January 1, 2027, they must conduct renewals for individuals enrolled through the Medicaid expansion every six months instead of annually. That makes it likely that many SSI applicants will not have a disability determination before they have an assessment of their ability to work to meet the medical frailty exclusion from Medicaid work requirements. These new requirements could place additional administrative burdens on individuals who are experiencing significant physical or mental health challenges and could cause people to lose health insurance while they wait for an SSA disability determination.

In contrast to the SSI determination process, the Medicaid interim final rule is not clear on how states should determine ability to work in the context of Medicaid work requirements, which will lead states to adopt different approaches that could put coverage at risk for some SSI applicants. The rule requires states to automate, to the extent possible, verification of the Medicaid medical frailty exclusion using claims and encounter data before requesting information from the individual. However, claims data alone will often be insufficient to assess whether a condition impairs the ability to work or engage in community service, and claims data do not include information about people’s ability to engage in the activities of daily living (one measure of disability) or their overall functional status and frailty. Given the broader Medicaid definition of community engagement activities, states will need to assess people’s ability to participate in education or volunteer activities in addition to doing any work in the national economy. The lack of information about minimum acceptable practices raises questions about what standards states will use to assess ability to work, and what types of documentation will be sufficient to prove the inability to comply with the requirements. As they develop processes for verifying medical frailty, states will rely more heavily on provider determinations or other documentation and self-attestation, to the extent permitted by the rule, for individuals who cannot be automatically verified. Self-attestation will be permitted in 2027 and once for each individual in 2028. Absent clearer guidance, the approaches states develop will differ. This variability coupled with enhanced documentation requirements could cause some people with disabilities to lose Medicaid coverage or be denied Medicaid while they are waiting on their SSI determination.

Methods

Data: Data are from the 2023 Transformed Medicaid Statistical Information System (T-MSIS) Analytic Files (TAF) Research Identifiable Files (RIF) files.

State inclusion criteria: National estimates include enrollees living in 49 states and DC and exclude residents in the U.S. territories. Non-expansion states include AL, FL, GA, KS, MS, NC (Medicaid expansion started 12/1/23), SC, TN, TX, and WY. WI is excluded from this analysis because it has an 1115 waiver that offers coverage similar to the ACA expansion. The pre-SSI Medicaid coverage rates look much more similar to those of an ACA expansion state, but the T-MSIS data do not clearly identify people enrolled in the 1115 coverage.

Identifying new SSI enrollees using Medicaid administrative data: Enrollees are classified as new SSI enrollees if their latest eligibility group in the year is SSI (having ELGBLTY_GRP_CD_LTST with value of 11-22, 37, 38, 40, or 41) but in January, they are either not enrolled in Medicaid or they are enrolled through some other pathway (ELGBLTY_GRP_CD_01 not having value of 11-22, 37, 38, 40, or 41). The analysis is limited to enrollees ages 19 through 64 who are in Medicaid only (and not CHIP) during the year.

Assessing prior Medicaid coverage in the year for new SSI enrollees: Monthly eligibility group codes (ELGBLTY_GRP_CD_01-ELGBLTY_GRP_CD_12) are used to determine the first month of SSI enrollment (first monthly eligibility group code with value of 11-22, 37, 38, 40, or 41). Then, all monthly eligibility group codes prior to the first month of SSI enrollment are used to assess prior Medicaid enrollment during the year as follows:

• Prior Medicaid coverage through the expansion pathway: having at least one monthly eligibility group code indicating enrollment through the ACA expansion group (value of 72, 73, 74, or 75) before the first month of SSI enrollment.
• Prior Medicaid coverage through non-expansion pathway: having at least one non-missing monthly eligibility group code and no monthly eligibility group codes indicating enrollment through the ACA expansion group (value of 72, 73, 74, or 75) before the first month of SSI enrollment.
• No prior Medicaid coverage: eligibility group codes for all months before the first month of SSI enrollment are missing.