This Civilla report provides evidence-based recommendations for states implementing Medicaid work requirements under H.R. 1, which takes effect January 1, 2026. The requirements will affect nearly 20 million Medicaid recipients and mandate 80 hours per month of qualifying activities (work, community service, or education) or documented exemptions.
The Stakes:
- Millions could lose Medicaid coverage if states underestimate the communication and design challenge
- Even with strong data matching, millions will need to take action to keep coverage
- Poor user experience will result in missed deadlines, overwhelmed call centers, and eroded trust
Key Insight: User experience will be central to whether eligible people keep coverage and whether staff can manage the workload.
Based on 2019 research and user testing in Michigan with Medicaid recipients and staff. Findings show that:
- Technical jargon confuses residents
- Complex notices get ignored
- Poor communication design causes unnecessary coverage loss
- Small design changes have massive impact on outcomes
Problem: Separate processes for work requirements and exemptions create confusion and coverage loss.
Solution: Integrate into single streamlined application
- Add "Work requirement exemptions" section after income/employment questions
- Screen exemptions first with Yes/No questions
- Use work-activity grid for those without exemptions
- Enable data verification through single consent checkbox
Impact: Applicants prove compliance once; states get cleaner data pipeline.
Problem: Government notices are confusing, overwhelming, and often ignored.
Key Failures Identified:
- "Burying the lede" - residents see "approved" but miss action requirements
- Visual overload prevents residents from identifying critical actions
- Legal jargon like "qualifying activity" and "exemption" confuses even careful readers
Solutions:
- Design a top sheet with bold summary of required action
- Make the action the largest text on the page
- Highlight a single action - avoid conflicting instructions
- Make consequences clear - "If you don't act by [date], coverage will end"
- Use plain language - avoid "good cause," "qualifying activity," etc.
- Streamline copy with clear headings, short paragraphs, bullets
Evidence: Redesigned notices saved caseworkers hundreds of thousands of work hours and dramatically reduced user errors.
Problem: Without timely reminders, residents miss deadlines and flood offices with calls.
What Works:
- Short, actionable, urgent messages
- Single call to action per message
- Words like "Action Needed," "Required," "Today"
- Clear consequences of inaction
What Doesn't Work:
- Technical terms ("qualifying activities," "80 hours," "premiums")
- Multiple tasks in one message
- Passive language that feels optional
Example - Effective:
"ACTION NEEDED: Complete your required monthly healthcare report today or you may lose coverage: www.url.com"
Example - Ineffective:
"Your monthly healthcare report is due. Log in to complete your report today or you may lose coverage: www.url.com"
User Testing Result: Minor wording differences had significant impact—first message felt urgent and required, second felt optional and non-urgent.
Problem: "Exemption" is unfamiliar—residents associate it with taxes, not healthcare. Eligible people don't see themselves in broad legal categories.
Key User Quotes:
"What does exemption mean? I need to look that up in the dictionary."
"When would you be exempt? When you are hospitalized? Government agencies don't accept excuses."
Solutions:
- Explain the concept before showing options
- Use human language instead of legal terms
- Instead of: "Caring for an incapacitated individual"
- Use: "You care full-time for someone with a serious illness"
- Reassure no proof needed (if self-attestation accepted): "You do not need to upload any documents. We trust you."
- Pair categories with examples: "This includes conditions like asthma, heart disease, or depression"
- Train caseworkers on what verification is required and what documents are valid
Example Exemption Table:
| Legal Category | Plain Language | Examples |
|---|---|---|
| Work-limiting medical condition | You have a health issue that limits your ability to work | Asthma, diabetes, depression |
| Caring for someone full-time | You care full-time for a person who is sick or disabled | Child with disability, elderly parent |
| Full-time student | You're going to school full-time | GED, community college |
Licensed photographer who became primary caregiver for niece with severe depression. Left job to provide full-time care. Unsure if caregiving qualifies as exemption—afraid of losing healthcare coverage.
"I've given up everything to take care of this child, but I can barely take care of myself. If I lost my healthcare coverage, I couldn't go to my counselor and I don't know what I would do."
Home health aide, mother of two, long driving hours between clients. Schedule completely full, stress unmanageable.
"I feel like I'm going to self-destruct. My plate is so full I need three more plates."
Single mother, GED student, works night shift at Amazon. Received letter about work requirements but didn't understand it. Deep distrust of mail system.
"I don't trust the mail system when it comes to feeding my kid and accessing healthcare for my family. If I had to do something about it, my caseworker would call me."
Parents who alternate work and childcare throughout the week. Live paycheck to paycheck. Had to choose between insulin and food before applying for Medicaid.
"My husband and I already never see each other. How much more time do we have to give up to meet these requirements?"
- Any user research is better than none - States should conduct whatever level of testing is feasible
- User experience is not optional - It determines coverage outcomes and staff capacity
- Plain language is critical - Legal jargon causes confusion, anxiety, and drop-off
- Small design changes have big impacts - Minor wording differences significantly affect resident behavior
- Design with empathy - Work requirements are experienced in the context of caregiving, job insecurity, health challenges, and navigating complex systems
Benefits of Human-Centered Implementation:
- Prevent unnecessary coverage loss
- Lower administrative costs
- Reduce call center volume
- Maintain trust in government
- Protect staff capacity
- Meet federal requirements while protecting eligible residents
Cost of Poor Implementation:
- Millions lose coverage despite being eligible
- Overwhelmed call centers and offices
- Increased administrative burden
- Eroded public trust
- Staff burnout
Civilla will develop open-source templates including:
- Draft application language
- Model online flows
- Notice designs
These will be paired with this guidance to support human-centered implementation across states.
Need help with your state's implementation? [email protected]
Source: Civilla, Fall 2025 Disclaimer: This research can inform state implementation, but each state's policy landscape differs. This is not legal advice and should be adapted with state policy teams.
Work requirements are coming January 1, 2026. States have a choice: implement them in ways that cause unnecessary hardship and administrative chaos, or use human-centered design to meet federal requirements while protecting eligible residents and staff capacity. This report provides a roadmap for the latter, based on real user research and proven results.