Complex healthcare policies are often challenging to implement, a reality that states across the country will face as new Medicaid work requirements begin next year. The new federal rule, part of the Budget Reconciliation Act of 2025 (HR 1), requires adults enrolled under the Affordable Care Act expansion of Medicaid eligibility to complete at least 80 hours per month of qualifying work or community engagement activities or meet exemption criteria to maintain their coverage starting Jan. 1, according to an Aug. 7 report.
A Special Communication published in JAMA Health Forum on Aug. 7 suggests that artificial intelligence may help state Medicaid agencies keep eligible individuals enrolled by improving implementation of these policies. The authors say AI could assist states and local governments in rolling out and enhancing other healthcare policies as well.
One major concern is that people who are working or qualify for exemptions might still lose coverage due to difficulties submitting documentation. Although the law requires states to use existing databases for verification when possible, many cases will require enrollees to submit documents themselves if compliance or exemption status cannot be verified with available information. Previous research cited in the Special Communication found that some eligible Arkansas enrollees lost coverage due to similar documentation issues.
Dr. McGinty and her co-authors Drs. Yongkang Zhang, Fei Wang, William Schpero, and John Ayanian suggest that AI tools can help states better utilize existing data sources: "For example, states can use AI to link Medicaid enrollment records with payroll and tax data or enrollment data for other public programs," said Dr. Schpero, associate professor at Weill Cornell Medicine and associate center director at the Cornell Health Policy Center. "This would allow agencies to verify if someone is working or qualifies for an exemption without asking the enrollee to fill out more forms or submit more documentation." He also said AI tools embedded in online application portals could identify where applicants struggle most with navigation.
Dr. McGinty said about a quarter of state Medicaid programs already use AI chatbots for consumer assistance; these could be extended further under the new requirements so digital assistants explain rules and help applicants understand necessary documentation.
Dr. Schpero added that analyzing call center transcripts and website activity with AI could reveal bottlenecks in real time: "Using AI to provide real-time learning for state Medicaid programs has promise," he said.
However, Dr. McGinty noted disparities in technological readiness among states: "There are biases baked into our data that AI implementation will 100% reproduce here, and so having a human in the loop and really careful monitoring and oversight of AI is needed," she said.
