Under the H.R.1 Medicaid community-engagement requirements, most adults in the expansion population must report 80 hours per month of qualifying activity or fall under a recognized exemption. Enforcement begins January 1, 2027, and states open their first member-notice window between June 30 and August 31, 2026. For people in treatment for a substance-use disorder (SUD), the law recognizes that recovery itself is the work that matters most. This post explains how the SUD treatment exemption operates and where it tends to break down.
Who the exemption covers
The exemption generally applies to members who are participating in, or medically determined to need, treatment for a substance-use disorder. In practice this includes people in medication-assisted treatment (MAT) for opioid use disorder, those in inpatient or residential rehabilitation, and members in structured outpatient programs. Critically, time spent in treatment can also count toward the 80-hour activity requirement for those who do not qualify for a full exemption, so the same documentation often serves two purposes.
The exemption is not limited to a single diagnosis or program type. A member in early recovery attending intensive outpatient sessions, a person stabilizing on buprenorphine, and someone in a 30-day residential program are all within the intended scope. The barrier is rarely eligibility; it is proof.
Where members lose coverage anyway
The Arkansas experience from the first wave of work requirements is the warning every state should study: roughly 18,000 people lost coverage, and analyses found that about one in four affected adults were disenrolled not because they failed to qualify but because they could not navigate the reporting process. People in active SUD treatment are especially exposed. Treatment schedules, transportation gaps, and the cognitive load of early recovery all collide with monthly online reporting portals.
A second failure point is verification. Many treatment providers are not set up to generate the attestation documents a state eligibility system will accept, and members may not know they can ask. When a portal demands a specific form and the clinic hands over a generic appointment slip, the claim stalls.
What plans and providers should do now
Health plans should flag members with SUD-related claims or MAT prescriptions before the notice window opens and reach them in plain language, in their preferred language, with the exact documentation their state accepts. FQHCs and behavioral-health providers should build a standard attestation letter that maps to state form requirements, and should hand it to patients proactively rather than on request. State officials can reduce churn dramatically by allowing treatment providers to verify enrollment directly, removing the member as the single point of failure.
The mechanics of the SUD exemption are favorable on paper. The risk is entirely procedural. Coverage will be lost in the gap between qualifying and proving it, and that gap is where outreach has to live.