After more than a year of eligibility reviews that have already removed hundreds of thousands of Hoosiers from Medicaid, the state’s low-income health insurance program is entering a new phase that could determine whether even more beneficiaries lose their coverage.
This story is part of “Uninsured in America,” a project led by Public Health Watch, a nonprofit newsroom based in Texas. The project focuses on life in America’s health-coverage gaps and the impact of potential Medicaid cuts and other changes.
Over the next 18 months, Indiana is expected to implement a series of state and federal policy changes that will require more frequent eligibility renewals with additional verification and, for many adults, new work or community engagement reporting requirements to maintain Medicaid coverage.
Providers, enrollment advocates and policy experts say the next phase will place even greater emphasis on helping eligible Hoosiers understand new rules, respond to state requests and avoid unnecessary interruptions in coverage.
For many beneficiaries, the hardest part is simply knowing which rules apply to them, said Karly Sciortino-Poulter of The Arc of Indiana.
“This is not just Medicaid anymore,” she said, noting that Indiana’s program includes dozens of eligibility categories with different rules, exemptions and requirements. “People assume one rule applies to everyone, and it doesn’t.”
More frequent eligibility reviews
Indiana has already increased how often it checks for possible changes in Medicaid eligibility. In January 2025, FSSA Secretary Mitch Roob said the agency would begin conducting eligibility checks quarterly rather than annually.
Those interim checks are separate from a beneficiary’s scheduled renewal. Beginning Jan. 1, 2027, Senate Enrolled Act 1 requires participants in the Healthy Indiana Plan, Indiana’s Medicaid expansion program, to undergo a formal eligibility redetermination at least once every six months instead of annually.
The change coincides with a new federal requirement directing states to conduct eligibility redeterminations every six months for adults covered through the Medicaid expansion population.
Asked what responsibility FSSA has to prevent eligible members from losing coverage because they can’t navigate the new requirements, Roob said the agency would provide assistance but that members are ultimately responsible for documenting their eligibility.
“We will help you to prove to us that you are eligible, but ultimately, particularly the HIP members who are able-bodied adults, they are responsible for documenting that they are in fact eligible,” he told the Indiana Capital Chronicle. “It is not our desire for them to lose eligibility, but we have been given the responsibility to discern whether they are or are not.”
The agency also points to a new analysis from the Paragon Health Institute that estimates Indiana experienced the nation’s third-largest increase in improper Medicaid expansion enrollment from 2019 to 2024. The report notes that 267,185 of Indiana’s 572,088 expansion enrollees in 2024 — about 47% — were improperly enrolled.
Improperly enrolled Hoosiers could include those who exceeded income or other eligibility limits, as well as those who qualified for Medicaid through another category but were improperly classified as expansion enrollees, according to the Paragon report.
Supporters of the tightened rules say those changes will help ensure taxpayer-funded benefits go only to people who qualify.
“If a person isn’t truly eligible for coverage, Hoosier taxpayers should not be on the hook for paying for that person,” Sen. Chris Garten, R-Charlestown, said last year. “We want to shore up the sustainability of this program for the truly needy by not improperly paying for those who don’t qualify.”
Enrollment advocates agree that program integrity matters but worry the added administrative burden could make it harder for eligible people to stay enrolled — particularly if they misunderstand notices, miss deadlines or never receive requests for information.
“We’re seeing more communication from FSSA for renewal requirements and eligibility checks,” said Ann McCafferty, who directs Indiana Healthy Families Alliance, an initiative led by the Indiana Rural Health Association to help Hoosiers access healthcare. “It’s putting more burden on the member.”
That burden can be especially challenging in rural Indiana, where mail service may be slower, enrollment assistance is more limited and residents often must travel farther to reach state offices.
McCafferty said one of the most common problems, however, comes after people move without updating their address, causing renewal notices to arrive late or not at all.
“FSSA notices can be very confusing,” McCafferty said. “That’s actually one of the biggest pieces of feedback we’re hearing.”
She said those issues aren’t necessarily new, but become more significant as members are asked to complete eligibility reviews more frequently. Much of her organization’s work, McCafferty said, now focuses on helping families understand what the notices mean and what documentation they need before their coverage is interrupted.
Work requirements begin
The most significant change is scheduled to take effect Jan. 1, 2027, when Indiana must begin enforcing new federal work and community engagement requirements for certain adults enrolled through the Healthy Indiana Plan, the state’s Medicaid expansion program.
Those adults generally will have to complete and report at least 80 hours per month of work, job training, education, community service or another qualifying activity to remain covered. The state will review compliance at least every six months.
Because the state will look back at the previous three months of activity, many Hoosier beneficiaries will need to begin meeting the requirement in October to avoid losing coverage when enforcement begins.
The changes will not apply to everyone on Medicaid. Children, pregnant women, older adults, people enrolled in Medicare and many people with disabilities or caregiving responsibilities are among those expected to be exempt. A parent caring for a child age 13 or younger, for example, would not have to meet the requirement, while a child enrolled in Medicaid would never be expected to report work.
But even among HIP members, many are already working or doing activities that could satisfy the requirement. The challenge, advocates say, will be making sure they know what counts and can prove it to the state.
“Most of these families do work,” said Susan Jo Thomas, executive director of Covering Kids & Families of Indiana, which helps Hoosiers enroll in health coverage. “It’s just reporting what they do. We just have to be able to give them the mechanism to get that reporting done, so that it gets to the system.”
Still, national reports suggest many Medicaid members do not yet understand the coming rules.
A spring survey by the Health Management Academy found nearly half — 47.4% — of Indiana Medicaid enrollees did not know work requirements are scheduled to take effect in 2027. The survey also found 42.1% said they would ration medications if they lost coverage, and 31.6% said they would rely more heavily on emergency rooms.
Indiana currently has five hospitals considered at heightened risk of financial strain if Medicaid coverage declines further, according to the analysis.
National findings point to similar confusion.
A June survey by CITIZ3N Government Solutions found one-third of Medicaid beneficiaries across the country had not previously heard about the new work requirements, while roughly one-quarter were unsure whether the rules would apply to them personally. More than half also said they had received no information about the upcoming changes from their state Medicaid program.
“Our phones are ringing off the hooks because parents are calling, saying, ‘My kid’s six years old, how’s he going to go to work? My grandmother’s 96 years old and in the nursing home, how’s she going to go to work?’” Thomas said. “Everyone thinks it’s all of Medicaid.”
Robin Rudowitz, director of the Kaiser Family Foundation’s Program on Medicaid and the Uninsured, said most working-age adults enrolled in Medicaid are already employed or report barriers that keep them from working. Those who are employed often work lower-wage jobs that do not offer private health insurance, while adults who are not working are commonly attending school, caring for someone or dealing with an illness or disability.
“Many people who are working or may qualify for an exemption may lose their coverage not because they’re not eligible, but because they might have difficulty navigating their ways to document or report their current status,” Rudowitz said during a recent KFF and States Newsroom webinar.
Determining who qualifies for an exemption could create another layer of paperwork.
Federal rules provide an exemption for people considered medically frail, but require them to have both a qualifying medical condition and evidence that it limits their ability to work, attend school or volunteer. Jennifer Tolbert, deputy director of KFF’s Medicaid program, said state databases often do not contain enough information to make that determination automatically, leaving beneficiaries and healthcare providers to supply additional documentation.
That could include a person with a serious chronic condition who is able to work some months but not others, or someone whose disability has not been formally recognized by the Social Security Administration.
Tolbert said the process could leave some vulnerable people without coverage “not because they don’t qualify as medically frail, but because they simply can’t provide the required documentation within the specified time frame.”
Indiana has faced similar logistical problems before. When the state previously sought to impose HIP work requirements, Sciortino-Poulter said beneficiaries struggled to report their hours and wages, particularly if they lacked a computer or reliable internet access.
“We know that this is going to be confusing. We know this is going to be scary,” she said. “Anytime there is a new system or a new program put into place, there are always going to be hiccups.”
Preparing for more changes
The biggest concern for medical providers and hospitals, however, is less about whether patients ultimately qualify for Medicaid than whether they experience repeated interruptions in coverage.
Dr. Amy Hale, a primary care physician at Columbus Regional Health who cares for many Medicaid and uninsured patients, said those disruptions can quickly unravel months — or even years — of progress managing chronic conditions.
“One thing I think is completely undervalued in health care is continuity of care,” she said. “We maybe think about that as, ‘Oh, it’s good for building relationships,’ but it’s also associated with lower costs, less emergency department utilization, less hospitalizations.”
Hale said she has seen more patients over the last several years lose coverage, stop scheduling routine appointments or delay filling prescriptions because they can no longer afford them. Some call asking for medication refills but can’t come into the office. Others disappear from care altogether until a medical crisis sends them to the emergency room.
For patients with chronic illnesses like diabetes, she said, it doesn’t take long for those interruptions to snowball.
A patient whose condition is well controlled with medication, regular lab work and routine visits, for example, can return just a few months later with dangerously high blood sugar after going without treatment.
Instead of managing the disease through preventive care, Hale said providers are suddenly treating a health crisis that could have been avoided.
“It would have been just really easy to maintain,” she said. “We don’t intervene until they’re sick.”
Hale said “it feels like one step forward, two steps back.”
“People are hanging on until they get really, really sick and they end up having a health crisis,” she continued. “Then they’re back in, and we’re restarting that Medicaid enrollment process.”
State Rep. Wendy Dant Chesser, D-Jeffersonville, said she’s already helped constituents who lost Medicaid after missing a single mailing or not realizing additional documentation was required.
She maintained that the state should focus less on finding people who no longer qualify and more on making sure eligible Hoosiers don’t lose benefits because they couldn’t navigate the process.
“I believe that both the administration and the Indiana General Assembly need to work together to ensure that people who are eligible for these benefits do receive these benefits uninterrupted,” Dant Chesser said.
Enrollment organizations are preparing for that next phase, too, helping beneficiaries understand new reporting requirements, identify exemptions and respond quickly to requests from the state before coverage is interrupted.
“I think what we should all want is for people to be well and healthy and contribute to our communities,” Hale said. “The value is investing in preventive care and chronic disease management and making access to care a top priority.”
Indiana Capital Chronicle is part of States Newsroom, a nonprofit news network supported by grants and a coalition of donors as a 501c(3) public charity. Indiana Capital Chronicle maintains editorial independence. Contact Editor Niki Kelly for questions: info@indianacapitalchronicle.com.
