CMS outlines Medicaid work‑requirement rule and steps to curb alleged ACA and Medicaid fraud

CMS Administrator Dr. Oz described a recently published rule implementing work requirements for certain able‑bodied Medicaid enrollees and outlined agency plans to strengthen program integrity.

Dr. Oz said the work requirement builds on concepts dating to the 1990s and was included in the working families tax cut legislation; the rule will allow states to require participation in work, education, volunteering or equivalent activities as part of eligibility for certain benefits. He framed the rule as a path to employment and said exemptions will apply for those who are medically or otherwise unable to work.

On program integrity, Dr. Oz said CMS is working with states to audit eligibility and that the agency plans technology investments to modernize Medicaid and Medicare systems. He said the administration is allocating additional funding and vendor contributions to support the change, citing roughly $200 million and other negotiated vendor support for implementation work.

Dr. Oz also said the agency has identified suspected fraud and improper enrollments on ACA marketplaces and in Medicaid, estimating earlier that roughly 35% of ACA enrollees "may never have used the program" and stating that the agency has pursued rulemaking to reduce improper enrollments after a prior court injunction. He said the administration has recouped about half of an asserted $2 billion in improper payments from California.

Why it matters: Changes to eligibility rules and enhanced audits could reduce program enrollment for some people while raising questions about continuity of coverage for workers and vulnerable populations. Investments in technology and clearer audit rules will affect state program administration.

What’s next: CMS said it will implement the work‑requirement rule and work with states and vendors on technical upgrades; legal challenges and state responses are likely.