More than 300,000 Missourians who receive health coverage through Medicaid expansion could face new requirements beginning in January, including more frequent eligibility checks and, for some, requirements involving work, school or community service.
The changes come as Missouri has struggled with Medicaid coverage losses tied to paperwork. More than 333,000 Missourians lost Medicaid coverage from January 2025 through February 2026, and nearly 92% of those cases were procedural terminations — meaning the state could not determine whether recipients remained eligible because of missing forms, incomplete information or other administrative issues.
That history is adding to concerns in St. Louis as Missouri prepares to implement requirements created by the federal budget law known as the One Big Beautiful Bill Act. Paraquad, a St. Louis organization that serves people with disabilities, is particularly concerned about how the changes could affect people who qualify for exemptions.
“People with disabilities already navigate systems that can be complicated and difficult to access,” said Colleen Burdiss, an independent living specialist and advocate at Paraquad. “Adding more frequent reviews, verification requirements, and another process to demonstrate an exemption creates real concern.”
Beginning Jan. 1, adults ages 19 to 64 covered through Missouri’s Medicaid expansion program, known as the Adult Expansion Group, will have their eligibility reviewed every six months instead of once a year.
Some also will have to meet what the state calls “community engagement requirements.” Those can be satisfied through paid or unpaid work, community service, an approved work program, education or a combination of activities.
For people renewing coverage, the requirement can be met by completing at least 80 hours of qualifying activities during one month of the six-month review period. Income also can be used to meet the requirement.
The Missouri Department of Social Services says it will first use information it already has to determine whether recipients meet the requirements or qualify for an exemption. If the state cannot verify the information, recipients may be asked to provide pay stubs, school or training records, volunteer records or other documentation.
The additional requirements are drawing scrutiny because of Missouri’s record of procedural terminations.
Joel Ferber, director of advocacy at St. Louis-based Legal Services of Eastern Missouri, told the Missouri Independent that paperwork isn’t always missing when coverage is terminated.
“We have all these clients that send in all their paperwork, and it doesn’t get processed, but the system closes the case,” Ferber said.
Tim McBride, a Washington University public health professor who previously served on Missouri’s Medicaid oversight board, said notices sent to recipients also can be difficult to understand.
“I’ve seen the letters, and they’re really complicated,” McBride told the Independent. “They’re kind of abstruse, to be honest with you.”
The Department of Social Services says procedural terminations generally occur when information is missing or recipients don’t complete a required step, such as returning a renewal form or providing requested verification. The department has been working to automate more of the process and reduce the amount of information workers must handle manually.
Not everyone covered through Medicaid expansion will have to meet the new community engagement requirement.
Exemptions include people who are pregnant or recently had a pregnancy, some veterans with disabilities, people considered medically frail, people participating in drug or alcohol treatment programs and people caring for a child 13 or younger or a person with a disability.
People with physical, intellectual or developmental disabilities that significantly limit their daily activities also may be considered medically frail and exempt.
Paraquad is concerned that people who qualify for an exemption could still encounter difficulties demonstrating that they qualify. The state says it will first try to verify exemptions using information it already has. If it cannot, recipients will have to provide additional information through the renewal process.
Paraquad President and CEO Latosha R. Fowlkes said repeatedly reviewing people with documented disabilities that do not change could waste time and state resources while increasing the risk of interrupted coverage.
The state is sending informational notices to more than 300,000 MO HealthNet participants who may be affected. Receiving a notice does not mean someone’s coverage is ending, and recipients do not need to provide work, community service or exemption information now.