Series 3: Navigating Medicaid Work Requirements and Care Continuity
A practical guide for Medicaid managed care organizations to adapt to work requirements, manage enrollment volatility, and protect health outcomes under challenging conditions.
Medicaid managed care organizations are bracing for unprecedented disruption as OB3’s work requirements take effect in December 2026, introducing enrollment volatility that breaks the link between coverage stability and medical risk. Enrollment could fluctuate by 30 to 40 percent, erasing months of care coordination and driving unpredictable costs while quality metrics and value-based payment models falter under continuous coverage rules. Plans face a strategic dilemma of choosing whether to focus on short-term efficiency by prioritizing stable members or invest in vulnerable populations who are most likely to lose coverage and return sicker and costlier. With rate negotiations constrained by political optics, success will depend on operational innovation. This includes integrating work requirement support into care coordination, expanding social determinants platforms to address employment and exemption needs, and maintaining light-touch engagement during coverage gaps. The organizations that adapt to preserve care continuity despite volatility will lead the way in proving managed care’s value under the toughest conditions.
The real challenge is time. With only 14 months before these requirements take effect, most plans are already behind. Building systems to manage enrollment volatility, integrate with state verification platforms, expand social determinants capabilities, train care teams, and secure community partnerships typically takes more than a year under ideal conditions. Success will depend on taking immediate steps such as conducting financial modeling to understand the impact, creating risk stratification tools to identify members most likely to lose coverage, and redesigning care coordination workflows to incorporate work requirement support. At the same time, plans must engage states now to influence system design, negotiate rate adjustments, and formalize partnerships with community organizations, employers, and education providers. Pilot early, iterate quickly, and scale before launch. Although the investment is considerable, the risks of doing nothing such as losing coverage, worsening health outcomes, and financial instability are far greater. Organizations that act now will be ready while those that delay will struggle to keep up.
Managing members who face medical risk, social complexity, and administrative barriers requires a different approach that integrates benefits navigation into health care. Traditional care coordination models break down when coverage is unstable and survival needs take priority, yet avoiding these members only leads to higher costs and worse outcomes. Intensive support strategies such as nurse and community health worker teams, peer navigation, flexible funding, and integrated behavioral health can reduce hospitalizations, improve engagement, and protect quality metrics. Plans also need to simplify exemption documentation and build verification systems that work for gig workers, seasonal employees, and those in cash economies. Success should be measured by coverage stability, crisis prevention, and member trust rather than compliance alone. With limited time before implementation, start with the highest-risk members, pilot quickly, and scale what works. Designing for the most complex cases creates systems that serve everyone.
Dive into Syam Adusumilli’s Series 3 articles for a deeper look into these strategies, detailed implementation checklists, and practical models for supporting the most complex populations.
Read Series 3 here:
3A: What Health Insurers Can Do: Turning Enrollment Volatility Into Care Continuity
3B: The 14-month Implementation Checklist: What MCOs Must Do Now
