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NEW YORK — <\/span>On hot afternoons, DeAnna Brandon\u2019s three dogs zag around while she splashes in a backyard kiddie pool with her grandkids. These are the moments the 48-year-old blood cancer survivor cherishes \u2014 and wonders if she\u2019ll get to have in the years to come. <\/p>\n Brandon, who lives in Rockwell, North Carolina, is worried that new Medicaid work requirements<\/a> starting next year could jeopardize her health coverage. She had expected to qualify for a medical frailty exemption, but new guidance<\/a> introduced by President Donald Trump’s administration<\/a> last week has thrown that into question. <\/p>\n The interim final rule released by the Centers for Medicare and Medicaid Services<\/a> means being sick with extreme exhaustion and memory challenges related to her treatments may not be enough for Brandon to evade the new work requirements. She\u2019ll have to attest and later prove that those symptoms \u201csignificantly impair\u201d her ability to fulfill the new mandates. <\/p>\n If the government doesn\u2019t accept her case, she could lose her coverage \u2014 and the twice-monthly maintenance chemotherapy that keeps her multiple myeloma in remission. Working is \u201coutside of the realm of possibility for me,\u201d she said in an interview.<\/p>\n \u201cI was always a push-through-it person \u2014 you know, \u2018Oh, you\u2019re tired. Push through,\u2019\u201d Brandon said. \u201cIt\u2019s hard to explain to people you can\u2019t push through it.\u201d <\/p>\n Health analysts have sounded the alarm about the Republican Trump administration\u2019s newest guidance, which differs from what states had been expecting<\/a>. Experts said it will put more Americans at risk of losing their health insurance and force states to scramble in their already harried efforts to implement the changes on time.<\/p>\n \u201cThis will mean more paperwork for Medicaid patients \u2014 specifically for the sickest Medicaid patients,\u201d said Adrianna McIntyre, a professor at Harvard University\u2019s school of public health. That, she said, “is going to push in the direction of more people needlessly losing coverage.\u201d<\/p>\n The new Medicaid restrictions<\/a> were part of Trump\u2019s big tax and policy law<\/a> in 2025. The change affects those covered through an expansion, which most states chose to make, that gave more lower-income people access to the government\u2019s safety net healthcare program.<\/p>\n Expansion enrollees aged 19 to 64 will have to show that they work or do community service at least 80 hours a month or are in school at least half the time. There are exceptions for those considered medically frail or in addiction treatment programs, among others.<\/p>\n Last week\u2019s announcement from CMS caught states off guard with a new definition of medical frailty. The law had said medically frail people include those who have substance use disorders, disabilities or serious medical conditions. But the CMS rule last week went further, saying someone\u2019s condition must \u201csignificantly impair\u201d their ability to work, volunteer or attend school at the rates required in the law for them to be granted an exemption. <\/p>\n In 2027 and once in 2028, the patient can attest that they meet this definition. But when they try to renew coverage in 2028, they\u2019ll need to prove it. <\/p>\n Advocates said it\u2019s unclear what kind of documentation could prove that point. They said doctor notes may be required \u2014 something some providers don\u2019t feel comfortable writing. Medicaid enrollees fighting disease may carry the bureaucratic burden.<\/p>\n Brandon, who tried to prove she couldn\u2019t work to access disability benefits during her active cancer treatment and failed, said she\u2019s worried about the hoops she and other patients may need to jump through.<\/p>\n \u201cIt\u2019s not that easy \u2014 you may have to go through four doctors,\u201d Brandon said. \u201cIf you\u2019re already battling an illness like this, you don\u2019t have the physical or the mental or the emotional energy to do that all the time.\u201d<\/p>\n States have been planning to use Medicaid claims data and other data sources to automatically exempt eligible enrollees whenever possible.<\/p>\n CMS Administrator Dr. Mehmet Oz<\/a> on a call with reporters last week endorsed that approach, saying he hoped most people would be helped “without ever having to talk to anybody.\u201d <\/p>\n Asked to clarify how the rule should be implemented, CMS told The Associated Press in an emailed statement that the agency \u201cchose not to allow states to categorically exclude individuals from work requirements based solely on a diagnosis or condition type.\u201d For renewal in 2028, it said, \u201cverification through claims data or other documentation will generally be required.\u201d <\/p>\n But state Medicaid officials and consultants said Medicaid claims data doesn\u2019t prove someone is significantly impaired from working, and they don\u2019t know of any existing data that does. That has left them confused about how to honor the government’s rule.<\/p>\n \u201cStates are going to be asked to make a determination using information that doesn\u2019t exist in their systems,\u201d said Kinda Serafi, a partner at the consulting firm Manatt Health who is working with states to make the changes.<\/p>\n One state, Nebraska, started the new Medicaid work requirements<\/a> ahead of schedule. But it used diagnostic codes to identify people who are medically frail, and it therefore will likely have to rework its system, said Sarah Maresh, healthcare access program director at the advocacy group Nebraska Appleseed.<\/p>\n Maresh said she was concerned doctors in the rural state who are already reluctant to take Medicaid patients may decide to stop.<\/p>\n \u201cThey\u2019re already drowning in paperwork, so to require them to do an additional step of certifying whether someone is able to work, I think is concerning,\u201d she said.<\/p>\n Preparing for the Jan. 1 kickoff of the new policies is an immense and expensive task. A $200 million federal allotment is flowing to states to help, and CMS has partnered with technology companies to provide free and discounted services, but the tab for the additional technology requirements and more staff is likely to exceed $1 billion, according to an AP analysis. That extra cost will be borne by a mix of federal and state tax dollars.<\/p>\n