Jessica Rodriguez works 75 hours monthly between two part-time jobs in Baltimore, one as a restaurant server and another doing overnight stocking at a retail store. Neither job offers benefits or consistent scheduling. She enrolled in Maryland HealthChoice when the state expanded Medicaid in 2014. Starting January 2027, Jessica will need to document 80 hours monthly of qualifying activities to maintain coverage. Her unpredictable work schedules across two employers make hour tracking complicated, and neither employer provides documentation beyond pay stubs showing wages but not hours. Whether Maryland’s managed care organizations will provide navigation assistance to help her verify compliance, and whether the state’s simultaneous transition to the AHEAD healthcare payment model will support or distract from work requirement implementation, remains uncertain.
Maryland approaches work requirement implementation facing dual transformation unlike any other state: implementing Medicaid work requirements while simultaneously transitioning its entire hospital payment system from the Total Cost of Care model that ended December 31, 2025, to the AHEAD model beginning 2026. The state estimates approximately 300,000 to 330,000 expansion adults will face work requirements, with potential coverage losses of up to 100,000 Marylanders. Deputy Health Secretary Perrie Briskin has warned that with all H.R. 1 provisions fully implemented, Maryland could lose $2.7 billion in federal Medicaid funding, representing approximately 20 percent of current program funding.
The Federal Context#
H.R. 1 transforms work requirements from state-option demonstration projects into federal mandate affecting all Medicaid expansion adults. Beginning January 2027, adults aged 19 through 64 without dependent children, disabilities qualifying for SSI or SSDI, or other categorical exemptions must complete 80 hours monthly of work, education, job training, community service, job search activities, or vocational rehabilitation to maintain Medicaid eligibility. States must verify compliance through semi-annual redetermination cycles, with coverage termination for those who cannot document qualifying hours or exemptions.
The Centers for Medicare and Medicaid Services issued initial guidance on December 8, 2025, establishing data-first verification principles requiring states to check wage records and cross-program enrollment before requesting member documentation. States must provide 30-day cure periods allowing members to submit verification or exemption documentation after initial adverse determinations. CMS will issue comprehensive regulations by June 1, 2026, leaving Maryland less than seven months to build verification systems before the January 1, 2027 implementation deadline. States demonstrating good faith efforts may receive extensions through December 31, 2028.
The legislation includes $200 million in implementation funding distributed across all expansion states, though Maryland’s population means allocation will be insufficient relative to anticipated costs. The marketplace premium tax credit exclusion for individuals losing Medicaid due to work requirement non-compliance creates coverage void, as people terminated for verification failures cannot access subsidized marketplace coverage regardless of income.
H.R. 1 eliminated enhanced federal funding for Health Related Social Needs services effective March 2025, removing state flexibility to fund navigation supports through Medicaid. The law also restricts continuous eligibility waivers and reduces provider tax limits from 6 percent to 3.5 percent beginning 2028.
State Projections and Political Context#
Governor Wes Moore’s administration has projected significant impacts from H.R. 1 provisions. Deputy Health Secretary Briskin told state senators in January 2026 that with all provisions implemented, Maryland could lose $2.7 billion in federal funding, accounting for almost 20 percent of current Medicaid funding. This figure, which elicited gasps from lawmakers according to Maryland Matters reporting, reflects combined impacts of work requirements, immigration eligibility restrictions, and other H.R. 1 changes.
The Maryland Department of Health estimates up to 100,000 Marylanders could lose Medicaid coverage due to work requirement implementation. Additionally, approximately 15,000 non-citizens will lose coverage beginning October 2026 when restrictions on which undocumented immigrants can qualify for Medicaid activate. These projections position Maryland among states anticipating substantial coverage reductions.
The Moore administration has earmarked $13 million in general funds for implementing H.R. 1 changes, focusing on improving administrative operations to reduce needless coverage losses. Briskin emphasized that “this administration is investing to implement HR 1 in a way that will keep people covered,” reflecting commitment to coverage-protective implementation within federal constraints.
State legislators introduced LD782 in February 2025 proposing MaineCare financial eligibility changes including raising asset limits and expanding coverage for certain populations, suggesting legislative interest in expanding rather than restricting access. However, federal work requirements override state-level eligibility expansions for affected populations.
Healthcare System Transformation Context#
Maryland faces unprecedented challenge of implementing work requirements while managing Total Cost of Care model wind-down and AHEAD model launch. For over 40 years, Maryland held unique authority to set hospital payment rates for all payers including Medicare and Medicaid, creating cost consistency across health plans. The Total Cost of Care model, which provided this rate-setting framework, ended December 31, 2025.
The AHEAD (States Advancing All-Payer Health Equity Approaches and Development) model represents new hospital payment system negotiated first under Biden administration then revamped under Trump administration. The two-year initial period provides stability, but substantial policy complexities remain unresolved. Gene Ransom, CEO of MedChi (Maryland State Medical Society), noted “two years of stability is nice, but there’s still a lot of work to do — a lot of complexity that has not been worked out.”
Maryland’s AHEAD Primary Care Programs launched August 1, 2025, with Medicaid Path beginning to enroll practice organizations in advanced primary care model. This creates opportunity for care coordination infrastructure that could support work requirement navigation, but also adds complexity as practices adapt to new payment models while potentially absorbing compliance verification support responsibilities.
Secretary of Health Meena Seshamani brings unique federal perspective to state implementation. Seshamani served as deputy administrator at Centers for Medicare and Medicaid Services from 2021 to 2025 before joining Moore administration. Her federal experience during Biden administration’s opposition to work requirements may inform Maryland’s coverage-protective approach, though her CMS tenure preceded current federal mandate.
The Affected Population#
Maryland Department of Health indicates approximately 300,000 to 330,000 Marylanders in the expansion population will face work requirements. These are adults ages 19 to 64 enrolled in Medicaid under Affordable Care Act expansion, which Maryland implemented in 2014 under then-Governor Martin O’Malley.
Current Medicaid enrollment includes approximately 1.5 million Marylanders total, with just under half (727,800) under age 21 and approximately 239,600 living with disabilities. Medicaid covers approximately 42 percent of births in the state. The expansion adult population subject to work requirements represents roughly 20 to 22 percent of total enrollment but faces disproportionate verification burden given monthly hour documentation requirements.
Opponents of work requirements argue that most recipients are already working and will be tripped up by increased paperwork needed to prove 80-hour monthly requirement. Maryland Health Connection and Maryland Department of Health have begun member outreach about upcoming changes, noting that work requirements “only apply to some adults ages 19 to 64 — around 300,000 Marylanders.”
The state’s projection of up to 100,000 coverage losses represents approximately 30 to 33 percent of the affected expansion population, aligning with other states’ projections based on Arkansas experience showing substantial procedural terminations among working or exempt populations unable to navigate verification systems.
Geographic Disparities#
Maryland’s geography creates stark contrasts in employment opportunities, healthcare access, and verification capacity. The Baltimore-Washington corridor concentrates population, employment, and healthcare infrastructure, while Eastern Shore and Western Maryland face rural healthcare deserts and limited economic opportunities.
Baltimore City and surrounding counties have dense provider networks, strong public transportation, and diverse employment sectors. However, Baltimore also has concentrated poverty and communities facing multiple barriers to employment including limited transportation, childcare access, and systematic discrimination. Work requirements will affect these communities disproportionately even within urban areas with theoretically better infrastructure.
The Eastern Shore presents opposite challenges. Eight rural counties have 76 percent of residents living in federally designated medically underserved areas. Caroline, Kent, Somerset, and Worcester counties each have 100 percent of their population in medically underserved areas. The five Maryland counties with the fewest primary care physicians per capita are all on the Eastern Shore, with Caroline County having only one provider per 2,500 residents compared to Baltimore County’s one per 1,000.
Agricultural work dominates Eastern Shore employment, creating seasonal patterns complicating monthly work hour verification. Immigrant farmworker populations face language access barriers and documentation challenges. The handful of health and social service workers serving the region, described by University of Maryland researchers as “stretched dangerously thin,” will struggle to absorb work requirement navigation responsibilities.
Western Maryland’s Allegany and Garrett counties share Appalachian characteristics with neighboring West Virginia and Pennsylvania, including higher poverty rates, older populations, and limited employment options. These counties had highest unemployment rates in Maryland before federal changes, suggesting substantial population may struggle to meet work requirements or document exemptions.
HealthChoice Managed Care Infrastructure#
Maryland operates HealthChoice, the state’s mandatory Medicaid managed care program since 1997. Nine managed care organizations serve the expansion population: Aetna Better Health, Amerigroup Community Care, JAI Medical Systems, Kaiser Permanente, Maryland Physicians Care, MedStar Family Choice, Priority Partners, United Healthcare, and University of Maryland Health Partners.
Four MCOs offer statewide network coverage, while others concentrate in specific regions. This infrastructure provides implementation capacity for work requirement verification and member communication that fee-for-service states must build from scratch. MCOs will need to develop new workflows for monitoring compliance status, providing member navigation, and supporting individuals at risk of termination.
The Maryland Managed Care Organization Association, formed in 2017, provides coordination mechanism for industry response to work requirements. MCOs have financial interest in maintaining enrollment, particularly for complex members generating risk-adjusted payments. However, work requirements create tension between coverage retention goals and administrative costs of verification support.
MCO contracts for calendar year 2026 include extensive quality requirements, care coordination mandates, and reporting obligations but were finalized before work requirement implementation details became clear. Contract amendments will be necessary to assign verification responsibilities, fund navigation services, and establish performance metrics around compliance support.
Cross-Program Coordination#
Maryland could coordinate Medicaid work requirement verification with SNAP work requirements, though integration requires system interfaces and data sharing protocols. The state faces new SNAP costs exceeding $300 million due to high payment error rates, creating fiscal pressure around benefit program administration that affects Medicaid implementation planning.
Maryland Health Connection, the state-based marketplace, provides enrollment infrastructure for individuals transitioning from Medicaid. However, H.R. 1 provisions making work requirement non-compliant individuals ineligible for premium tax credits eliminate marketplace as safety net for procedural terminations. The marketplace cannot serve transition pathway for those losing coverage due to verification failures.
Wage record systems could support automated verification for traditionally employed workers, but gig economy workers, self-employed individuals, and those in informal employment may not appear in state databases. Baltimore has substantial informal economy, while rural areas have self-employment in agriculture and small businesses where wage documentation may be irregular.
Implementation Timeline and Challenges#
Maryland must implement immigration eligibility restrictions beginning October 1, 2026, affecting an estimated 15,000 non-citizens. Work requirements begin January 1, 2027, unless state receives extension. Semi-annual redetermination begins December 2026, increasing administrative frequency from annual to twice-yearly reviews.
The compressed timeline between June 2026 federal guidance release and January 2027 implementation creates substantial pressure. The state must build verification systems, train MCO staff, conduct member outreach, establish exemption processes, and coordinate across state agencies while managing AHEAD model implementation, immigration eligibility changes, and other concurrent H.R. 1 provisions.
Moore administration’s $13 million investment in implementation infrastructure represents state commitment to coverage protection but may be insufficient relative to Georgia’s experience spending $109.8 million to enroll 9,881 of 250,000 eligible residents. Scaling verification systems to serve 300,000 expansion adults requires resources substantially exceeding federal allocation.
Fiscal Implications#
Briskin’s warning that Maryland could lose $2.7 billion in federal Medicaid funding has created budget crisis context for implementation planning. Governor Moore projected $1.5 billion deficit in fiscal year 2027 due to federal changes, ruling out tax increases during 2026 legislative session. The combination of coverage losses reducing federal matching, provider tax reductions, and implementation costs creates fiscal pressure across state government.
Medicaid costs represent significant portion of state budget. The proposed fiscal 2027 budget funds Medicaid services at $16.9 billion, up from $14.6 billion in current fiscal year. Federal dollars make up most costs, with state contribution coming just under $5.7 billion, up $227 million from current year. Work requirement coverage losses would reduce federal matching for healthcare services while potentially increasing uncompensated care costs at hospitals.
The provider tax reduction from 6 percent to 3.5 percent beginning 2028 eliminates state revenue leveraging federal matching funds, compounding fiscal pressure precisely when coverage losses increase uncompensated care. Maryland hospitals already face financial strain from rising costs and post-pandemic recovery challenges.
Political Environment and Advocacy#
Maryland has unified Democratic control with Governor Moore and strong majorities in both legislative chambers. Senator Sarah Elfreth told Maryland Matters that “there’s going to be people who are going to lose their care. It’s really going to be sad, because if they don’t pay for their health insurance… they’re going to be at our hospitals which are already really overcrowded.”
Delegate Jheanelle Wilkins, chair of Health and Government Operations Committee, noted that H.R. 1 “puts at risk a lot of the gains we’ve made when it comes to expanding coverage for Medicaid patients. Things like work requirements and burdens and documentation are now all being imposed on a population that is just struggling to put food on the table with the rising cost of everything. They are now being required to jump through a lot of hoops just to maintain their health coverage.”
This political environment ensures Maryland will design implementation to minimize coverage losses within federal constraints rather than aggressively enforce compliance. The state’s advocacy ecosystem including healthcare organizations, consumer groups, and community organizations will closely monitor implementation and document procedural terminations.
The Path Forward#
Maryland will implement work requirements by January 2027 or receive extension through December 31, 2028. The state’s investment in administrative infrastructure, commitment to coverage protection, and strong MCO network provide advantages for minimizing procedural terminations. However, the dual challenge of work requirement implementation and AHEAD model transition creates unprecedented complexity.
Secretary Seshamani’s federal experience may inform Maryland’s navigation of CMS guidance and waiver processes. The state could potentially pursue innovative approaches within federal parameters, though compressed timeline limits design flexibility. Whether Maryland’s managed care infrastructure, geographic disparities, and fiscal constraints allow coverage-protective implementation preventing projected 100,000 coverage losses remains the central question.
Maryland did not choose work requirements but must implement federal mandates affecting 300,000 expansion adults while managing healthcare system transformation. Success will be measured by coverage retention among working or exempt populations unable to navigate verification systems, not by policy enthusiasm state leadership does not possess.