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An Overview of the One Big Beautiful Bill Act's Community Engagement Requirements for Individuals with a Mental Health or Substance Use Condition, P.L. 119-21 (H.R.1)

Makeba Royall, LCSW Senior Practice Associate, Behavioral Health

February 2026

In the first six months of 2025 there was lots to grasp related to policy and politics. In March, Medicaid was one of the many issues which raised concerns around Congress’ recommendation to reduce the budget for Medicaid by at least $880 billion over the next 10 years. This recommendation left many people with questions and worries to grapple with about the impact this would have on their health and access to care. The cuts would not only negatively impact communities, but it would also add a heavy responsibility and burden on social workers to support individuals and families without the resources they needed to help individuals and families thrive and flourish.

By July, Public Law 119-21 (H.R.1) also known as the One Big Beautiful Bill Act (OBBBA) was enacted and it contained health provisions that again would impact Medicaid, the State Children's Health Insurance Program (CHIP), Medicare, private health insurance, and rural hospitals and providers. One of the provisions established work requirements for individuals ages 19 to 64 with some exemptions to include those with a mental health or substance use condition.

Medicaid is an insurance plan that has provided access to care to 78 million people, and it has played a significant role in access to substance use and mental health treatment. The new federal rules will require more than 18 million Medicaid enrollees nationwide to show they are working, volunteering, or going to school for 80 hours a month to keep their coverage (Whitehead, 2025).

The new work requirements will affect Medicaid recipients in 42 states and Washington, D.C. Eight states – Alabama, Florida, Kansas, Mississippi, South Carolina, Tennessee, Texas, and Wyoming, did not expand their Medicaid programs to cover additional low-income adults so they won’t have to implement the work rules (Whitehead, 2025).

While H.R.1 has made some recommendations regarding the work requirements, states have been provided with some flexibilities that could lessen the unnecessary burdens required of the new work requirement provisions. Nonetheless, with very little directive and guidance the new changes and requirements will affect millions of people, especially our vulnerable populations and communities. The federal government has indicated it would provide follow up guidance no later than June 1, 2026.

What are the Work Requirements

Work requirements had not been necessary for Medicaid enrollment prior to the enactment of P.L. 119-21. With the enactment of P.L. 119-21 states are required to establish Medicaid community engagement/work requirements for certain individuals. This new provision is effective as of December 31, 2026, with work requirements starting January 1, 2027, or sooner depending on states.

Nonpregnant, nondisabled adults, aged 19 through 64, who are eligible for (or are enrolled under) the ACA Medicaid expansion pathway or a waiver that provides minimum essential health coverage are to complete a minimum of 80 hours of qualifying community engagement for one month prior to an initial application, as a condition of eligibility (Health Provisions in P.L. 119-21, the FY2025 Reconciliation Law, 2025).

What Are Qualifying Community Engagement Activities

Qualifying community engagement will be considered participating in one or more of the following activities for a combined total of at least 80 hours per month:

  • Work
  • Participation in a work program or community service
  • Enrollment in Education program, at least half time

States are required to notify individuals at least 3 months prior, which is September 2026, if starting the work requirements as of January 1, 2027. Notification must be made by mail, electronic format, telephone, text message, website, or any other available means. When providing notification states must also inform individuals of the process, stating who is impacted, how to comply, how to report compliance and consequences for noncompliance (Health Provisions in P.L. 119-21, the FY2025 Reconciliation Law, 2025).

What is also vital to mention is the new provision offered exemptions for “Specified Excluded Individuals.” While there are 9 specified excluded individuals mentioned in the provision, this document will only make mention of the following three:

Who are Specified Excluded Individuals

As documented in the Health Provisions in P.L. 119-21, the following have been identified as exempted individuals:

  • individuals who are medically frail or otherwise have special medical needs, as defined by the HHS Secretary, including individuals who are blind or disabled (as defined in SSA Section 1614) or who have a substance use disorder; a disabling mental disorder; a physical, intellectual, or developmental disability that significantly impairs their ability to perform one or more activities of daily living; or a serious or complex medical condition;
  • individuals who are participating in a drug addiction or alcoholic treatment and rehabilitation program (as defined under Section 3(h) of the Food and Nutrition Act of 2008 [P.L. 95-113, as renamed and amended]);
  • individuals who are inmates of a public institution, or who had been in a public institution within the last 3 months.

Verifying Compliance at Application and Redetermination

States will be able to determine whether enrollees will need to meet engagement requirements for one month or more and whether engagement must occur consecutively or not to meet eligibility requirements. States will also need to verify engagement requirements every 6 months or more frequently, at state discretion (Kffmichaelp, 2025).

Even though the provision requires states to verify compliance with community engagement requirements at eligibility redeterminations, it also indicates states should not require an individual to submit additional information to demonstrate compliance. The work rules are expected to be the largest driver of health insurance coverage losses over the next decade (Whitehead, 2025).

Social Work and Advocacy

Because of the complexities of this new provision, it is imperative that social workers stay informed and raise awareness of the potential impact work requirements may have on access to coverage and who exactly meets exemption criteria. If vulnerable populations and communities are not properly informed and made aware of the eligibility requirements this unexpected and drastic change will certainly have an impact on access to health care and substance use services. Disruption in coverage due to work requirement non-compliance can limit access to treatment and harm recovery attempts. Social workers would also have to rely on extremely limited resources to help fill in the gaps of providing appropriate care.

Since states have been provided with certain flexibilities around eligibility requirements, the frequency of eligibility and whether additional information is required to demonstrate compliance, it is essential for social workers to advocate for processes and criteria that will support treatment and not provide unnecessary burdens. To do this social workers can start letter writing campaigns to their state leaders which express the impact this drastic change can have on those seeking mental health and substance use treatment; meet with elected state officials to educate them on how this change would potentially disrupt treatment and lastly social workers can work closely with local organizations or associations who can provide resources and advocacy support.

NASW will continue to pay close attention to the work requirements and provide updated information as we have it available.

NASW Resources

The Crucial Role Medicaid and Social Workers Play in Providing Access to Substance Use Treatment (May 2025)

Federal Spending and Tax Bill Will Harm Millions of Vulnerable Americans (Spring 2025)

Reducing Federal Investments in Human Needs Hurts Us All | Social Work Blog (June 2025)

Social Workers: Budget Bill Will Deepen Health, Hunger Crises, Drive Social Workers Away from Profession > www.socialworkers.org (July 2025)

Now the Reconciliation Bill Passed, What is Next? (August 2025)

NASW signs onto coalition letter to Centers for Medicaid & Medicare Services (CMS) related to guidance on community engagement requirements for individuals with mental health conditions and substance use disorders (December 2025)

Resources

A Short History of SNAP | Food and Nutrition Service

Health Provisions in P.L. 119-21, the FY2025 Reconciliation Law. (2025, November 25). https://www.congress.gov/crs-product/R48633

Kffmichaelp. (2025, December 3). Tracking Implementation of the 2025 Reconciliation Law: Medicaid Work Requirements. KFF. https://www.kff.org/medicaid/medicaid-work-requirements-tracker-overview/?utm_campaign=KFF-Medicaid&utm_medium=email&_hsenc=p2ANqtz--axRLf7T2zHRzMbG8XH1385A_YXlvOkiMwmYnBp-C0JIQdlPshxaFjX7Ji4sqQoKwhPdIPIdOoazvZ4MKqzW6IfvDikuMqLHuHX8Ijo1i19lJppBg&_hsmi=392803108&utm_content=392803108&utm_source=hs_email

Medicaid-SNAP-WR-Comparison.pdf

Red Tape and Roadblocks: How Work Requirements Deny Medicaid Access

Social Security Act §1614

Whitehead, S. L. S. (2025, December 1). Medicaid work rules exempt the ‘Medically Frail.’ Deciding who qualifies is tricky. - KFF Health News. KFF Health News. https://kffhealthnews.org/news/article/medicaid-work-rules-exempt-medically-frail-who-qualifies/