Introduction

The 2025 reconciliation law eliminated access to federally funded health coverage for refugees and asylees without a green card as well as several other groups of lawfully present immigrants. Refugees and asylees can apply for Lawful Permanent Resident status (LPR status, or a green card) after one year in the country or one year after being granted asylum. Because the 2025 reconciliation law largely limits eligibility for federally funded coverage to lawfully present immigrants with LPR status, how quickly U.S. Citizenship and Immigration Services (USCIS) processes these applications directly affects whether refugees and asylees can keep or gain access to Medicaid, the Children’s Health Insurance Program (CHIP), subsidized Affordable Care Act (ACA) Marketplace, and Medicare coverage.

This data note highlights changes in green card (I-485) application processing for refugees and asylees between fiscal year (FY) 2021 and FY2025, as well as across the first three quarters of FY2025 to FY2026 (since FY2026 data are only available through the third quarter). It discusses the implications of these trends for access to federally funded health coverage following eligibility changes under the 2025 reconciliation law. It is based on KFF analysis of USCIS data.

In this analysis, we find a decrease in USCIS completion of applications for adjustment to LPR status for refugees and asylees between FY2025 and FY2026. While some of the decreases in application completions could be due to fewer humanitarian migrants being admitted into the U.S. in recent years, we find that the number of applications completed by USCIS as a share of all applications fell between FY2025 and FY2026 and the average processing time for applications increased during the same time period. As of June 30, 2026, there were over 275,000 pending green card applications from refugees and asylees awaiting a decision from USCIS, and between FY2025 and FY2026, the average processing time for applications had increased from 7.8 months to 13.3 months for refugees and from 10.7 months to 19.9 months for asylees. As a result, many refugees and asylees who have already applied for a green card will be left without access to federally funded health coverage for potentially long periods of time as they wait for USCIS to process their green card applications.

Changes in Health Coverage for Refugees and Asylees

Since 1980, the U.S. has had a formal system for admitting refugees and asylees—individuals and their families who are unable to return to their country of nationality due to a well-founded fear of persecution for certain protected reasons. The right to seek asylum is rooted in international law, and the system reflects the U.S.’s longstanding inclusion of humanitarian protection as a core principle of immigration law. Refugees and asylees are generally fleeing from unsafe conditions and arrive to the U.S. with few to no resources, with many experiencing traumatic experiences in their countries of origin and/or during their journey to the U.S. The U.S. historically provided refugees and asylees access to assistance with food, housing, and health care upon arrival to the country as well as other time-limited services to support their transition to the U.S. Since taking office, the Trump administration has taken steps to significantly reduce the entry of refugees and asylees into the U.S., including by pausing refugee applications, setting the lowest ceiling for refugee admissions on record, and effectively closing the southern border to most migrants, including asylum seekers.

 Under federal law, refugees and asylees (i.e. those who have officially been granted asylum) can apply for adjustment to LPR status once they have been physically present in the U.S. for at least one year. They apply by filling out Form I-485, “Application to Register Permanent Residence or Adjust Status.” Asylum seekers whose asylum applications are still awaiting approval are not considered asylees and are not eligible to apply for LPR status regardless of their length of stay in the country.

The 2025 reconciliation law eliminated refugees’ and asylees’ longstanding access to federally funded health coverage as well as other public assistance programs. Most lawfully present immigrants, including most LPRs, must wait five years after getting a “qualified” immigration status before they can enroll in federally funded coverage such as Medicaid and CHIP. Under longstanding policy, refugees and asylees previously were exempt from this waiting period if they met income and other state eligibility requirements. They could also enroll in subsidized ACA Marketplace coverage and Medicare if otherwise eligible. However, the 2025 reconciliation law eliminates eligibility for Medicaid and CHIP (except in states that use a Medicaid and/or CHIP option to cover lawfully residing children and pregnant people), subsidized Marketplace coverage, and Medicare for refugees and asylees without a green card, as well as certain other groups of lawfully present immigrants. The Medicaid and CHIP restrictions took effect October 1, 2026, with restrictions on subsidized Marketplace and Medicare coverage fully taking effect in January 2027. The Congressional Budget Office estimates that the law’s eligibility restrictions for lawfully present immigrants will lead to about 1.4 million people becoming uninsured by 2034.

Trends in Processing Green Card Applications for Refugees and Asylees

The number of I-485 applications received for adjustment to LPR status for both refugees and asylees increased between FY2021 and FY2025, but applications received for asylees dropped between FY2025 and FY2026. Between FY2021 and FY2025, I-485 applications received for adjustment to LPR status increased by 274% (22,906 to 85,743) for refugees and by 68% (44,837 to 75,292) for asylees. Lower numbers of I-485 applications received from refugees and asylees in FY2021 could reflect COVID-19-related reductions in the entry of migrants into the U.S. Between the first three quarters of FY2025 and FY2026, I-485 applications received for refugees continued to increase but at a lower rate of about 10% (59,754 to 66,013) and decreased by about 32% (58,682 to 40,344) for asylees. This pattern could reflect that the Trump administration lowered the refugee admissions cap from 125,000 in FY2025 to 7,500 for FY2026. Additionally, the Biden and Trump administrations effectively closed the border to individuals seeking asylum starting in 2024.

While the number of applications completed by USCIS for both refugees and asylees increased between FY2021 and FY2025, they decreased significantly between FY2025 and FY2026 (Figure 1). Between FY2021 and FY2025, completed I-485 applications, i.e., applications for which an approval or denial decision was made by USCIS, increased by 198% for refugees (14,697 to 43,763) and by 184% for asylees (22,095 to 62,750). However, between the first three quarters of FY2025 and FY2026, I-485 applications completed by USCIS decreased by about 90% (37,908 to 3,805) for refugees and by about 85% (57,369 to 8,660) for asylees.

The percentage of completed applications as a share of all applications for refugees and asylees dropped sharply between FY2025 and FY2026 (Figure 2). Between FY2021 and FY2025, the percentage of I-485 applications completed by USCIS as a share of all applications (i.e., newly received and pending applications) decreased from 31% to 25% for refugees and increased from 17% to 37% for asylees. However, between the first three quarters of FY2025 and FY2026, completed I-485 applications as a share of all applications decreased sharply from 30% to just 2% for refugees and from 40% to just 5% for asylees.

At the same time, the number of pending green card applications for refugees and asylees grew to over 275,000 as of the third quarter of FY2026, and application processing times increased between 2025 and 2026. The number of I-485 applications pending a decision from USCIS increased 251% for refugees, from 24,983 as of the end of FY2021 to 87,573 as of the end of FY2025, and by about 7% for asylees, from 87,997 as of the end of FY2021 to 94,482 as of the end FY2025 (Figure 3). Between the third quarter of FY2025 and the third quarter of FY2026, pending applications from refugees increased by 121% (67,502 to 149,470) and from asylees by 51% (83,446 to 126,267), for a total of 275,737 pending applications as of June 30, 2026. This number is expected to continue to increase by the end of FY2026. Further, reflecting the decrease in completed applications, the average processing time for green card applications increased from 7.8 months to 13.3 months for refugees, and from 10.7 months to 19.9 months for asylees between the first three quarters of FY2025 and FY2026. Within FY2026, the processing time for green card applications from refugees and asylees has increased each quarter, more than doubling from 7.6 months in Q1 to 17.6 months in Q3 for refugees and from 12.1 months in Q1 to 25.6 months in Q3 for asylees.

Originally published on October 1, 2026, this policy watch has been updated on October 15, 2026 to reflect additional developments and updated measles death reports from Pennsylvania.

Overview

Amid the largest U.S. measles epidemic in decades, and one that threatens the country’s measles elimination status, a controversy has emerged regarding how to count deaths from measles. From August through October 15th this year, Pennsylvania has reported a total of six measles deaths had occurred in the state but so far, the Centers for Disease Control and Prevention (CDC) has recognized only two these in its official measles statistics. CDC announced in early September that it would change how it counts measles deaths, no longer relying solely on reports from state health departments and instead looking to official death records as tracked by the National Center for Health Statistics (NCHS, a sub-agency within CDC). This new CDC policy of relying on NCHS-based mortality data to count measles deaths marks a departure from historical norms and processes that have accepted measles death reports from state health departments.

This Policy Watch reviews how measles deaths are typically determined, how these deaths are counted by the federal government and the role of two distinct but related federal public health surveillance systems at the center of the controversy – the CDC’s Nationally Notifiable Diseases Surveillance System (NNDSS) and NCHS’ National Vital Statistics System (NVSS). NNDSS and NVSS are separate public health surveillance systems with their own strengths and limitations: with NNDSS focused on real-time disease tracking that at times can also provide preliminary mortality information, while NVSS is focused on collecting longer-term, retrospective data on deaths and providing final determinations regarding the cause(s) of death though not necessarily designed for real-time tracking.  These two systems are complements, but one does not entirely replace the other.

Context

On August 25, Pennsylvania Governor Josh Shapiro held a press conference to announce that two deaths attributed to measles had occurred, the first such deaths in the state since 1992. As is standard protocol for cases of infectious diseases of national interest such as measles, the Pennsylvania Department of Health (PA DOH) also reported these as “measles-associated” deaths directly to CDC via the Nationally Notifiable Disease Surveillance System (NNDSS). PA DOH relied on pre-existing definitions for measles and for respiratory disease-associated mortality – which include clinical, laboratory, epidemiologic, and vital records criteria – in making the determination that these particular deaths were measles associated.

The Secretary of Health and Human Services (HHS) Robert F. Kennedy, Jr. initially objected to Pennsylvania’s classification of these deaths as measles-associated, saying Shapiro’s announcement was “premature” and suggesting the deaths “may even have been altogether fabricated.” CDC staff initially accepting the state’s death reports, though Kennedy later asked the CDC Director to remove any reference to those measles deaths on the CDC website. After the coroner in Lancaster County confirmed that measles was a contributing cause to the reported deaths, on September 4 Kennedy recognized measles as the cause for “only the second infant’s death” and stated: “The National Center for Health Statistics does not currently have any death records from 2026 that indicate measles is the underlying cause” but indicated CDC will update its measles death statistics upon receipt of such records. On September 14, a CDC spokesperson stated the agency had changed how it will count measles deaths in its official statistics, and going forward CDC would “report measles deaths if and when the National Center for Health Statistics reports measles as the underlying cause of death.”  The next day, PA DOH reported two additional measles-associated deaths, bringing the state’s own total to four. However, at present the CDC measles outbreak tally reports two deaths for 2026, with a note saying: “This number is subject to change; CDC will update its reporting as additional information becomes available and relevant reviews are completed.” On September 30, the Pennsylvania Department of Health confirmed a fifth death and a sixth death was announced by the Franklin County Coroner on October 12.

Two Systems with Different Purposes

The dispute around reporting measles deaths has brought new focus to two separate federal public health surveillance systems: the Nationally Notifiable Disease Surveillance System (NNDSS) and the National Vital Statistics System (NVSS). Each of these has a long history, dating back to the early 20^th century, but serves different purposes. These systems are described below (see Table 1). 

Nationally Notifiable Disease Surveillance System (NNDSS): Timely Case Reporting

NNDSS is a collaboration between CDC and jurisdictions across the country that supports sharing and monitoring public health information for a set of diseases and conditions of national interest. NNDSS has roots extending to a system established in 1893 by Congress for jurisdictions to report cases of disease to the Surgeon General. Over time the system expanded, with responsibility for overseeing the system transferred to CDC in 1961. Local and state public health departments have the authority and responsibility to track cases of disease, typically through reporting from health care providers, laboratories, and other sources. In turn, jurisdictions then may provide case information to CDC through NNDSS. Key characteristics of NNDSS include:

• A set of approximately 120 diseases and conditions that are designated by CDC as “nationally notifiable,” meaning the agency requests state and local health departments report to CDC when new cases of any of these conditions are identified. Measles is a nationally notifiable disease, and has been since 1912. Importantly, CDC cannot require jurisdictions to report case information, but all do, especially for high consequence infectious diseases such as measles. CDC itself says “since continuous endemic measles transmission has been eliminated, measles is an immediately notifiable disease.”
• For each NNDSS disease or condition there is a pre-established definition that jurisdictions can consult to help determine if a notifiable case has occurred. These case definitions assure a level of standardization across jurisdictions. The definitions for nationally notifiable diseases are developed in collaboration with the Council of State and Territorial Epidemiologists (CSTE) and intermittently updated and refined. The current NNDSS case definition for measles dates to 2013.
• Jurisdictions determine the extent of detail provided in their reports. Information shared through NNDSS is “de-identified” (i.e. with personally identifying information removed), but jurisdictions may include demographic, clinical, and epidemiologic characteristics and the course of clinical illness (including whether death occurred) in their case reports.
• NNDSS reports can preliminarily indicate the cause of death in a particular case, but are not expected or designed to be a final determination. For this reason, Pennsylvania has reported the four deaths as being “measles-associated” rather than presenting a final determination of measles as the cause of death. The NNDSS definition for measles does not include specific guidance for when and how to report a death as being caused by measles infection, though CDC reports it is working with CSTE to update the definition “to promote consistent classification and reporting of measles deaths across jurisdictions.” 
• A relative strength of NNDSS is the ability for rapid communication of case-level epidemiologic information between jurisdictions and the CDC, which can allow for near real-time tracking of outbreaks and disease trends. A limitation is that rapidly reported information may only be preliminary in nature, and case reports could be incomplete or lacking in detail.

National Vital Statistics System (NVSS): Comprehensive Cause of Death Reporting

NVSS is the federal government’s primary mechanism for tracking mortality (and other vital statistics) data. The NVSS has roots going back to 1902, when Congress created a permanent Census Bureau and authorized the government to obtain copies of state vital records. By 1933, all states were required to record births and deaths and provide data to the Census Bureau. The NCHS was created in 1960, with responsibility for federal vital statistics transferred there.  The responsibility and legal authority for documenting births, deaths, and other vital statistics resides at the state and local level, but by statute NCHS has authority to collect and review these data – each state has a contract with NCHS that allows the federal government access to this information to produce national vital statistics. Key characteristics of NVSS include:

• Housing the most complete set of data on deaths and births in the U.S. Death certificate information captured through NVSS is the most comprehensive source for mortality information nationally.
• Death certificate information captured through NVSS is considered the benchmark for cause of death data. When completing a death certificate, a provider must include the best and final judgement on the proximate cause(s) of death as well as potential other factors that may have contributed to the death. Information from an autopsy, or laboratory and other test results may be included. Demographic details are also reported through the system such as age, sex, race/ethnicity, and education.
• Nuances regarding a possible chain of events leading to a death and potentially multiple contributing factors can introduce complexity in cause of death determinations. Regarding the Pennsylvania cases, there has been some debate about measles being a primary cause of the deaths reported by the PA DOH, especially in relation to one of the initial reported deaths – a newborn infant that died from a lacerated spleen but was also positive for measles. 
• State/local vital records offices are responsible for inspecting death certificates for timeliness, completeness, and accuracy of information, processing, and storing the records. Data files derived from these state/local records are then transmitted to NCHS.
• NCHS reviews and processes vital statistics data and codes mortality statistics according to the current revision of the International Classification of Diseases (presently ICD-10, which the U.S. began to use in 1999). ICD-10 provides definitions and rules for selecting the underlying cause of death when generating vital statistics through NVSS. Typically, NVSS will release “provisional” cause of death data with a 3 to 9 month lag (depending on the cause of death), though full provisional data may take up to one a year to be released. Final cause of death data is made available after about two years. For example, the most recent NVSS provisional cause of death data are for 2025 while the most recent final cause of death data are from 2024. In special circumstances, provisional death data can become available even earlier – for example, during the COVID-19 pandemic NVSS provided updated COVID-19 related death statistics on a weekly basis.
• A relative strength of the NVSS is its completeness and the comprehensiveness of its cause of death information. A relative weakness of the NVSS is the time lag between when deaths occur and the availability of cause of death data.

The 2025 reconciliation law requires 44 states to condition Medicaid eligibility for adults in the Affordable Care Act (ACA) Medicaid expansion group and enrollees in certain waiver programs, on meeting work requirements starting January 1, 2027, or sooner at state option. While the law specifies mandatory exclusions, including for individuals who are “medically frail,” the approach to determining medical frailty specified in the June 2026 interim final rule could make it difficult for some people to qualify for this exclusion. Medicaid expansion provides coverage to many adults with significant health care needs, including some with disabilities who are applying for the Supplemental Security Income Program (SSI). This coverage could be at risk for some because of the planned approach to defining medical frailty.

SSI is a means-tested federal program administered by the Social Security Administration (SSA) that pays monthly cash assistance to people with limited resources who are unable to work because of a disability and generally qualifies people to receive health coverage through Medicaid. Once approved for SSI, Medicaid enrollees would not be subject to work requirements, but the application for SSI can be a lengthy and complicated process, spanning months, if not years, during which time applicants may be at risk of uninsurance because they are unable to work. Medicaid can fill coverage gaps during the SSI application period, particularly in states that have adopted the Medicaid expansion.

This issue brief finds that the percent of new SSI enrollees ages 19 through 64 with Medicaid prior to SSI entitlement is twice as high in ACA expansion states as it is in non-expansion states, and in 2023, over 100,000 new SSI enrollees had ACA Medicaid coverage prior to their SSI entitlement. It also describes the lengthy SSA process for determining SSI eligibility, particularly assessing ability to work, and how the current approach to determining medical frailty could cause some SSI applicants to undergo concurrent assessments of their ability to work using different processes and criteria. The new documentation requirements and processes could cause some people with disabilities to lose Medicaid coverage or be denied Medicaid enrollment while they are waiting on their SSI determination.  (For analysis on the implications of Medicaid work requirements for people applying for the Social Security Disability Insurance (SSDI) program or waiting for Medicare coverage, see What Could Medicaid Work Requirements Mean for People with Disabilities Waiting for Medicare Coverage?)

How does Medicaid provide coverage for people during the SSI application process?

Medicaid provides coverage for many people with disabilities, including those who are applying for SSI. One in five Medicaid enrollees have a disability, including 43% of adults ages 50-64, but only one-third of these individuals receive SSI income, generally qualifying for Medicaid for that reason. The remaining people with disabilities are covered through different Medicaid eligibility pathways, including the ACA Medicaid expansion. Because of the lengthy process for obtaining an SSI determination and the fact that people who are applying for SSI are unable to work, many people applying for SSI rely on Medicaid to avoid going uninsured.

In 2023, 223,000 SSI applicants ages 19 through 64 had Medicaid while they were waiting for an SSI determination, including over 106,000 with coverage through the ACA expansion. KFF analyzed detailed Medicaid administrative data to identify people who were ages 19 through 64 and became eligible for Medicaid because of SSI during the calendar year 2023 and whether those enrollees had Medicaid coverage in the months prior to their SSI-based eligibility (see Methods). Among the 337,000 people who started SSI during the calendar year, over 200,000 had prior Medicaid coverage through a different eligibility pathway, with roughly half receiving that coverage through the ACA expansion.

In ACA expansion states, 76% of new SSI enrollees ages 19 through 64 had Medicaid coverage through a different eligibility pathway prior to their disability determination (including 42% who were covered through the Medicaid expansion) compared with only 33% in non-expansion states (Figure 1). In both expansion and non-expansion states, roughly 1 in 3 new SSI enrollees ages 19 through 64 were enrolled in non-ACA Medicaid coverage (such as coverage for parents and caretakers) prior to becoming eligible for SSI. However, in expansion states, an additional 42% of new SSI enrollees were enrolled in Medicaid through the expansion, covering over 100,000 people in 2023. New SSI enrollees who were not covered by Medicaid prior to their SSI approval were likely uninsured because of their low income and inability to work.

How do people demonstrate eligibility for SSI?

To be eligible for SSI, people must have limited income (defined as no more than $2,073 per month in 2026), limited resources (defined as no more than $2,000 for an individual or $3,000 for a couple), and a disability that affects their ability to work for at least a year or result in death or be age 65 and older.

For applicants under age 65, demonstrating a disability is often the most complicated part of the SSI application process, involving a lengthy five-step process that starts by proving one is not gainfully employed (Figure 2). The federal government establishes verification processes that all states must use to determine applicants’ disability status, and funds state Disability Determination Services (DDS) offices to carry out these processes. The same processes are used for SSI and for Social Security Disability Insurance. Illustrating the high costs of this lengthy process, the Social Security Administration provided states with $2.6 billion in Fiscal Year (FY) 2025 to run the DDS offices. The first step requires people to demonstrate that their current earnings are below the threshold of “substantial gainful activity” (SGA, $1,690 per month in 2026).

The second step assesses whether applicants have a severe impairment, where impairment is defined based on which body system is affected. For adults, impairments are classified into the following categories with associated medical criteria: musculoskeletal disorders, special senses and speech, respiratory disorders, cardiovascular system, digestive disorders, genitourinary disorders, hematological disorders, skin disorders, endocrine disorders, congenital disorders that affect multiple body systems, neurological disorders, mental disorders, cancer, and immune system disorders.

The third step assesses whether the impairment qualifies as a disability that wouldn’t require further demonstration of an inability to work using established criteria for disabilities. Some impairments allow applicants to qualify for SSI without further demonstrating an inability to work, including blindness and several hundred specific disorders or conditions included in the “compassionate allowance program,” which quickly identifies diseases and other conditions that meet SSA’s standards for disability benefits. Examples of such conditions include Amyotrophic Lateral Sclerosis (ALS), certain cancers, and Duchenne Muscular Dystrophy. SSA reports that between 2008 and 2025, the agency approved more than 1 million people (for SSI and Social Security Disability Insurance combined) through the compassionate allowance program.

The final two steps respectively assess peoples’ ability to engage in “past relevant work” or any job in the national economy that is feasible considering the applicant’s residual functional capacity, age, education, and work experience. The SSA makes this assessment based on information provided in Form 3368 which requires people to provide personal information including their English language proficiency, current work activity, job history over the last 15 years, the claimed disability onset date, list of medical conditions, prescription list, and medical treatment history. Medical records from providers can be submitted with the application. Along with this form, the SSA will request any missing medical records and may request that the person have a consultative medical examination by an SSA medical consult. SSA also compares information about people’s jobs from the past 5 years (such as job title and pay; tasks performed; tools, machinery, and equipment used; knowledge, skills, and ability required; physical demands; and environmental conditions) with tables of rules about the requirements for jobs in the national economy.

Assessing ability to engage in any job requires information about all jobs in the economy, which can be difficult to implement in practice, and SSA is currently relying on outdated job information. SSA’s current jobs listing comes from the Department of Labor’s Dictionary of Occupational Titles which was last updated in 1991 and is not currently used by the Department of Labor. Since FY 2021, SSA has partnered with the Department of Labor to develop a survey that will be the main source of updated occupational information, but that new system has not yet been implemented. Congressional Research Services reports that between FYs 2012 and 2024, SSA spent $300 million on this project.

The application for disability benefits can be a lengthy and complicated process, spanning months, if not years, meaning hundreds of thousands of people are currently waiting for determinations. As of May 2026, the initial processing time for all disability applications was 184 days—over 6 months—and roughly 862,000 people were waiting for their initial determinations. (This number includes applications for SSI and applications for Social Security Disability Insurance, a related program that uses the same disability determination process.) Many people receive initially unfavorable decisions and choose to appeal, which can considerably lengthen the process. Having a lawyer increases the likelihood of being approved at the initial stage and, on average, can reduce the time it takes to reach a final decision by nearly one year.

How might work requirements affect Medicaid coverage for people during the SSI application process?

Starting in January 2027, individuals applying for or enrolled in coverage through the ACA expansion and in certain waiver programs will be required to work or engage in qualifying activities, such as community service, for 80 or more hours per month, attend school half-time, unless they qualify for an exemption or exclusion from the requirements. SSI applicants enrolled in the ACA Medicaid expansion will be subject to these new requirements. SSI applicants may face challenges proving their eligibility for the medical frailty exclusion while they wait for an eligibility determination from SSA.

People applying for SSI are generally unable to work, but current rules could make it challenging for them to qualify for a medical frailty exclusion. Because individuals must have earnings below the SGA level to be eligible for SSI, they are unlikely to be able to work 80 or more hours in a month and are unlikely to be able to meet the Medicaid community engagement requirements through education or volunteering. Instead, to obtain or retain Medicaid, individuals applying for SSI who are subject to the work requirements will need to qualify for an exclusion from the requirements, most likely through the medical frailty exclusion. The interim final rule implementing Medicaid work requirements issued on June 1, 2026, adopts a restrictive definition of medical frailty that requires individuals to have a physical or mental health condition that impairs their ability to meet community engagement requirements. This two-part test for medical frailty will require navigating a verification process that may lead to some people who would qualify for the exclusion losing coverage because they cannot provide the required documentation.

Different requirements for Medicaid eligibility determinations mean SSI applicants covered through the Medicaid expansion could face two concurrent assessments of their ability to work: one for SSI and one for Medicaid. Medicaid eligibility determinations of whether an individual meets the medical frailty exclusion will need to be done on a faster timeline than SSI determinations. States are required to process Medicaid applications for individuals who qualify based on income within 45 days, and starting January 1, 2027, they must conduct renewals for individuals enrolled through the Medicaid expansion every six months instead of annually. That makes it likely that many SSI applicants will not have a disability determination before they have an assessment of their ability to work to meet the medical frailty exclusion from Medicaid work requirements. These new requirements could place additional administrative burdens on individuals who are experiencing significant physical or mental health challenges and could cause people to lose health insurance while they wait for an SSA disability determination.

New guidance from the Centers for Medicare & Medicaid Services (CMS) may help to mitigate but will not eliminate the risk that SSI applicants may lose Medicaid coverage. The interim final rule requires states to verify medical frailty on an ex parte basis where possible, using reliable information available to the state without requiring the individual to submit additional information. CMS recently released a slide deck that outlined a tiered medical frailty framework that states may follow using data from claims and other sources to identify people who meet the medical frailty exclusion.  While states are not required to adopt this approach, the tiered medical frailty framework would enable states to identify individuals as medically frail using claims data alone (tier 1), using claims data in combination with encounter or other data (tier 2), or, in cases where states have no or insufficient data on file, using an individualized manual process that requires additional documentation (tier 3). As they develop processes for verifying medical frailty, states will rely more heavily on provider determinations or other documentation and self-attestation, to the extent permitted by the rule, for individuals who cannot be automatically verified. Self-attestation will be permitted in 2027, but starting in 2028, it will only be permitted once per continuous enrollment period, meaning states will need to collect documentation at renewal for medically frail individuals. Even with use of data to verify medical frailty, the documentation requirements could cause some people with disabilities to lose Medicaid coverage or be denied Medicaid while they are waiting on their SSI determination.

Methods

Data: Data are from the 2023 Transformed Medicaid Statistical Information System (T-MSIS) Analytic Files (TAF) Research Identifiable Files (RIF) files.

State inclusion criteria: National estimates include enrollees living in 49 states and DC and exclude residents in the U.S. territories. Non-expansion states include AL, FL, GA, KS, MS, NC (Medicaid expansion started 12/1/23), SC, TN, TX, and WY. WI is excluded from this analysis because it has an 1115 waiver that offers coverage similar to the ACA expansion. The pre-SSI Medicaid coverage rates look much more similar to those of an ACA expansion state, but the T-MSIS data do not clearly identify people enrolled in the 1115 coverage.

Identifying new SSI enrollees using Medicaid administrative data: Enrollees are classified as new SSI enrollees if their latest eligibility group in the year is SSI (having ELGBLTY_GRP_CD_LTST with value of 11-22, 37, 38, 40, or 41) but in January, they are either not enrolled in Medicaid or they are enrolled through some other pathway (ELGBLTY_GRP_CD_01 not having value of 11-22, 37, 38, 40, or 41). The analysis is limited to enrollees ages 19 through 64 who are in Medicaid only (and not CHIP) during the year.

Assessing prior Medicaid coverage in the year for new SSI enrollees: Monthly eligibility group codes (ELGBLTY_GRP_CD_01-ELGBLTY_GRP_CD_12) are used to determine the first month of SSI enrollment (first monthly eligibility group code with value of 11-22, 37, 38, 40, or 41). Then, all monthly eligibility group codes prior to the first month of SSI enrollment are used to assess prior Medicaid enrollment during the year as follows:

• Prior Medicaid coverage through the expansion pathway: having at least one monthly eligibility group code indicating enrollment through the ACA expansion group (value of 72, 73, 74, or 75) before the first month of SSI enrollment.
• Prior Medicaid coverage through non-expansion pathway: having at least one non-missing monthly eligibility group code and no monthly eligibility group codes indicating enrollment through the ACA expansion group (value of 72, 73, 74, or 75) before the first month of SSI enrollment.
• No prior Medicaid coverage: eligibility group codes for all months before the first month of SSI enrollment are missing.

The Social Security Disability Insurance (SSDI) program provides monthly benefits to people who are unable to work on account of a long-term disability. SSDI beneficiaries qualify for Medicare, but in most cases, must wait 24 months between their entitlement to receive SSDI benefits and Medicare eligibility, referred to as the “Medicare waiting period.” The SSDI application process can take months, if not years. During this time and the subsequent Medicare waiting period, some people may be at risk of going without health insurance because they do not have Medicare but are unable to work due to a disability.

The Affordable Care Act (ACA) Medicaid expansion provides coverage for some SSDI applicants and SSDI beneficiaries waiting to become eligible for Medicare. The 2025 reconciliation law requires 44 states to condition Medicaid eligibility for adults in the ACA Medicaid expansion group and enrollees in certain waiver programs on meeting work requirements starting January 1, 2027, or sooner at state option. While the law specifies mandatory exclusions, including for individuals who are “medically frail,” the approach to determining medical frailty specified in the June 2026 interim final rule could make it difficult for some people, including SSDI applicants and SSDI beneficiaries waiting for Medicare, to qualify for this exclusion.

This issue brief explains how Medicaid provides coverage to some SSDI applicants and SSDI beneficiaries waiting for Medicare. KFF used linked Medicare and Medicaid administrative data from 2023 to analyze prior Medicaid coverage for SSDI beneficiaries ages 19 through 64 newly enrolling in Medicare (see Methods). The analysis finds that Medicaid through the expansion pathway covered over 1 in 4 SSDI applicants and beneficiaries waiting to become eligible for Medicare (120,300 people out of a total 415,300 in 2023). In future years, people applying for and new to SSDI may experience difficulties maintaining Medicaid prior to becoming eligible for Medicare because of the new work requirements. (For analysis on the implications of Medicaid work requirements for people applying for the Supplemental Security Income (SSI) program, see What Could Medicaid Work Requirements Mean for SSI Applicants?)

How does Medicaid provide coverage for people who are applying for and receiving SSDI?

Medicaid provides coverage for many people with disabilities, including some who are applying for SSDI or are receiving SSDI benefits but are not yet eligible for Medicare. One in five Medicaid enrollees have a disability, including 43% of enrollees ages 50-64. One-third of those people receive Supplemental Security Income (SSI). SSI is a separate federal program that provides monthly income to people who are unable to work because of a disability and who have income and financial resources below federal limits. The remaining people with disabilities are covered through different Medicaid eligibility pathways, including the ACA Medicaid expansion. During the SSDI application process, which can take months, if not years, or the Medicare waiting period, people may rely on Medicaid for their health coverage before becoming eligible for Medicare to avoid going uninsured.

In 2023, 240,300 SSDI beneficiaries enrolled in Medicare after having prior Medicaid coverage, including 120,300 who were enrolled through the Medicaid expansion (Figure 1). KFF used linked Medicare and Medicaid data to examine how many SSDI beneficiaries ages 19 through 64 newly enrolling in Medicare had any prior Medicaid coverage in 2023 (see Methods). Among the 415,300 SSDI beneficiaries newly enrolling in Medicare in 2023, 240,300 (58%) had prior Medicaid coverage through any eligibility pathway, with 120,300 of those having coverage through the expansion pathway specifically.

How do people become eligible for Medicare through SSDI?

People must first demonstrate eligibility for SSDI, a process that can take months and often years. To qualify for SSDI, enrollees must have a sufficient work history and a disability that affects their ability to work and is expected to last for at least a year or result in death. A sufficient work history varies by age but generally requires 10 years of employment, at least five of which were within the past decade. Some individuals with a disability can qualify based on a relative’s work history.

The SSDI application process can be a lengthy and complicated process, spanning months, and in some cases years. Demonstrating a disability is often the most complicated part of the SSDI application process. The federal government establishes verification processes that all states must use and utilizes the same five-step process to determine applicants’ disability status for both SSDI and SSI. (For a more detailed description of this process, see What Could Medicaid Work Requirements Mean for SSI Applicants?). As of July 2026, the initial processing time for all disability applications was 186 days, and 885,000 people were waiting for their initial determinations. (This number includes applications for both SSDI and SSI.) Many people receive initially unfavorable decisions and choose to appeal, which can lengthen the process (Figure 2). Because of the process for obtaining an SSDI determination and the fact that people who are applying for SSDI are unable to work, some people applying for SSDI may rely on Medicaid to avoid going uninsured.

SSDI beneficiaries become eligible for Medicare two years after they are entitled to SSDI benefits. Beneficiaries in most cases must wait 5 months for SSDI payments from the disability onset date, followed by a 24-month waiting period between becoming entitled to receive SSDI payments and Medicare eligibility, referred to as the “Medicare waiting period.” Because of the length of the SSDI application process and the fact that SSDI eligibility is retroactive, applicants may complete some or all of the waiting period prior to receiving SSDI benefits.

While many SSDI beneficiaries waiting for Medicare rely on Medicaid to avoid going uninsured, others face health insurance coverage gaps during the Medicare waiting period. SSDI beneficiaries in the Medicare waiting period tend to have low incomes, poor health, and fragile ties to the workforce. SSDI beneficiaries who are uninsured during the Medicare waiting period are more likely to report being in poor health, having more difficulties in activities of daily living, and having higher out-of-pocket medical expenditures than those with insurance. Research predating the ACA Medicaid expansion found that about a quarter of SSDI beneficiaries in the Medicare waiting period were uninsured.

How might Medicaid work requirements affect Medicaid coverage for SSDI beneficiaries before they become eligible for Medicare?

The new work requirements may make it difficult for SSDI applicants and SSDI beneficiaries waiting for Medicare to maintain Medicaid coverage before becoming eligible for Medicare. Starting in January 2027, individuals applying for or enrolled in Medicaid coverage through the ACA expansion and in certain waiver programs will be required to work or engage in qualifying activities, such as community service, for 80 or more hours per month, attend school half-time, or qualify for an exemption or exclusion from the requirements. SSDI applicants and SSDI beneficiaries waiting for Medicare enrolled in the ACA Medicaid expansion will be subject to these new requirements. SSDI applicants and SSDI beneficiaries waiting for Medicare may face challenges proving they meet the requirements or that they are eligible for exemptions or exclusions, although the issues each group will encounter may differ because they are in different stages of the SSDI determination process.

People applying for SSDI are generally unable to work, but current rules could make it challenging for them to qualify for a medical frailty exclusion. Because individuals must have earnings below the level of “substantial gainful activity” (SGA, $1,690 per month in 2026) to be eligible for SSDI, they are unlikely to be able to work 80 or more hours in a month. Additionally, most people with new impairments significant enough to qualify for SSDI will likely also face challenges meeting the Medicaid work requirements through education or volunteering. Instead, to obtain or retain Medicaid, individuals applying for SSDI who are subject to the work requirements will need to qualify for an exclusion from the requirements, most likely through the medical frailty exclusion. The interim final rule implementing Medicaid work requirements issued on June 1, 2026 adopts a definition of medical frailty that requires individuals to have a physical or mental health condition and that the condition must impair their ability to meet work requirements. This two-part test for medical frailty will require navigating a verification process that may lead to some people who would qualify for the exclusion losing coverage because they cannot provide the required documentation.

New guidance from the Centers for Medicare & Medicaid Services (CMS) may help to mitigate but will not eliminate the risk that SSDI applicants may lose Medicaid coverage. The interim final rule requires states to verify medical frailty on an ex parte basis where possible, using reliable information available to the state without requiring the individual to submit additional information. CMS recently released a slide deck that outlined a tiered medical frailty framework that states may follow using data from claims and other sources to identify people who meet the medical frailty exclusion. While states are not required to adopt this approach, the tiered medical frailty framework would enable states to identify individuals as medically frail using claims data alone (tier 1), using claims data in combination with encounter or other data (tier 2), or, in cases where states have no or insufficient data on file, using an individualized manual process that requires additional documentation (tier 3). As they develop processes for verifying medical frailty, states will rely more heavily on provider determinations or other documentation and self-attestation, to the extent permitted by the rule, for individuals who cannot be automatically verified. Self-attestation will be permitted in 2027, but starting in 2028, it will only be permitted once per continuous enrollment period, meaning states will need to collect documentation at renewal for medically frail individuals. Even with increased use of data to verify medical frailty, the documentation requirements could cause some people with disabilities to lose Medicaid coverage or be denied Medicaid while they are waiting on their SSDI determination.

SSDI beneficiaries waiting for Medicare should qualify for the medical frailty exclusion from work requirements but may still be at risk of losing Medicaid coverage depending on how states implement new systems. The medical frailty exclusion includes people who are blind or disabled according to the Social Security Administration (SSA) definition of disability. SSDI beneficiaries waiting for Medicare have already been determined to meet the SSA definition of disability and have a disability that limits their ability to work, meaning that they would likely qualify for the medical frailty exclusion. However, depending on state processes, SSDI beneficiaries waiting for Medicare may not be automatically identified as medically frail and may be required to show documentation of their SSDI determination.

Appendix: Timelines for Disability Determinations and Medicare Coverage

Disability Determination Process for Applicants Who Appeal

Timeline from Disability Onset to Medicare Coverage

The over 120,000 SSDI beneficiaries newly enrolling in Medicare with prior Medicaid coverage through Medicaid expansion may either be SSDI applicants or SSDI beneficiaries waiting for Medicare in the months in the calendar year prior to Medicare enrollment. Because SSDI eligibility is retroactive, some SSDI applicants may complete some or all of the Medicare waiting period prior to receiving SSDI benefits (Figure 3). This means that some SSDI applicants may become eligible for Medicare as soon as they are determined to qualify for SSDI. Other SSDI beneficiaries newly enrolling in Medicare receive SSDI payments and are in the Medicare waiting period in the months immediately preceding enrollment in Medicare (Figure 4). Using the data available, it is not possible to determine the exact number of SSDI beneficiaries newly enrolling in Medicare who are SSDI applicants or SSDI beneficiaries waiting for Medicare in the months prior to Medicare enrollment in the year.

Methods

Data: Data are from KFF analytic files that merge the Centers for Medicare & Medicaid Services (CMS) Chronic Conditions Data Warehouse (CCW) 2023 research-identifiable Master Beneficiary Summary File (MBSF) Base and the 2023 Transformed Medicaid Statistical Information System (T-MSIS) Analytic Files (TAF) Research Identifiable Files (RIF) using a CCW beneficiary identifier crosswalk.

State inclusion criteria: National estimates include enrollees living in 50 states and DC and exclude residents in the U.S. territories. 

Identifying SSDI beneficiaries newly enrolling in Medicare using administrative data: Enrollees are classified as SSDI enrollees newly enrolling in Medicare if they have a coverage start date (COVSTART) February 2023 through December 2023, did not have Medicare Part A or Part B in January 2023 (MDCR_ENTLMT_BUYIN_IND_01 not having value 1, 2, 3, A, B, or C), have a current entitlement reason equal to disability insurance benefits (DIB) or both DIB and end-stage renal disease (ESRD) (ENTLMT_RSN_CURR with value 1 or 3), and are ages 19 through 64 at the end of the calendar year.

Assessing prior Medicaid coverage in the calendar year for SSDI enrollees newly enrolling in Medicare: The Medicare coverage start date (COVSTART) is used to determine the first month of enrollment in Medicare during the year. Then, all Medicaid monthly eligibility group codes in 2023 (ELGBLTY_GRP_CD_01-ELGBLTY_GRP_CD_12) prior to the first month of Medicare enrollment are used to assess prior Medicaid enrollment during the year using the following hierarchy:

• Prior Medicaid coverage through the expansion pathway: having at least one Medicaid monthly eligibility group code indicating enrollment through the ACA expansion group (value of 72, 73, 74, or 75) before the first month of Medicare enrollment.
• Prior Medicaid coverage through other pathway: having at least one non-missing Medicaid monthly eligibility group code and no Medicaid monthly eligibility group codes indicating enrollment through the ACA expansion group (value of 72, 73, 74, or 75) before the first month of Medicare enrollment.
• No prior Medicaid coverage: Medicaid eligibility group codes for all months before the first month of Medicare enrollment are missing or the Medicare beneficiary did not have any records in T-MSIS.

Enrollment in the individual health insurance market fell 18% between June 2025 and June 2026. The individual market is composed primarily of people with Affordable Care Act (ACA) Marketplace coverage as well as some people who buy similar coverage off-exchange. This represents an even steeper drop in enrollment than had previously been reported. Previous data on ACA Marketplace enrollment showed that effectuated enrollment fell 12% from February. Although more current data for the ACA Marketplace population are not yet available, data on the individual market—of which roughly nine in ten people are enrolled through the ACA Marketplaces—suggest enrollment continued to decline, falling 16% as of March and 18% as of June. This decrease includes both on- and off-exchange coverage. In total, we estimate that individual market enrollment has fallen by over 4.6 million people, from 25.2 million in June 2025 to 20.5 million in June 2026.

The enrollment decline coincides with the expiration of the enhanced premium tax credits and other policy changes that are expected to reduce enrollment. As of earlier this year, ACA Marketplace enrollment had fallen in every state except New Mexico, with wide variation in the size of the declines.

The decline in the individual market enrollment began during the 2026 ACA Marketplace Open Enrollment Period and continued throughout the year. Plan selections, or sign-ups, during the 2026 Open Enrollment Period fell by 1.2 million people from 2025. But plan selections may include people who do not pay their premiums and so never have coverage take effect. Returning subsidized enrollees also have a three-month grace period for nonpayment: those who do not make their premium payments are not dropped from coverage until the grace period elapses. Enrollees that did not make their January premium payment likely were not recorded as terminated until after March 31, with coverage terminated retroactively to the end of January. As a result, February ACA Marketplace effectuated enrollment (measured retrospectively after the grace period elapsed on May 15, 2026) fell by 12%, from 21.8 million to 19.2 million.

Year-over-year March enrollment in the composite individual market showed a continued decrease, falling 16%. By June, enrollment had fallen 18% compared with the same period in 2025. While these numbers include off-exchange enrollment, the bulk of individual market coverage is purchased on-exchange through ACA Marketplaces. Off-exchange coverage, purchased directly from insurers or brokers, does not provide access to financial assistance through premium tax credits but allows insurers additional flexibility in plan design.

These declines approach the Congressional Budget Office (CBO)'s projection of a roughly 25% drop in enrollment through 2026 after the expiration of the enhanced tax credits, and they are consistent with KFF polling of Marketplace enrollees. In KFF’s Follow-Up Survey of ACA Marketplace Enrollees, one in six returning enrollees (17%) said they were not confident they could afford their premiums for all of 2026, which puts them at risk of losing coverage later in the year. Among all 2025 Marketplace enrollees, 22% said they had moved to another source of coverage, and nearly one in ten (9%) said they were now uninsured.

Further enrollment declines may continue this and in upcoming plan years. The second-quarter data provide a mid-year snapshot, and enrollees who fall behind on premiums later in the year may still lose coverage. These June enrollment figures do not account for the drop in enrollment expected from the recent announcement of plan cancelations, which occurred after the end of the second quarter. While enrollment has fallen sharply this year, individual market enrollment is still higher than before the introduction of enhanced premium tax credits by over seven million from June 2019, a change of 53%.

Premiums are also expected to keep rising in 2027. Marketplace insurers have proposed a median premium increase of 15% for 2027, the second consecutive year of double-digit increases. On average, insurers raised premiums by an additional four percentage points in anticipation of further expected enrollment declines and a subsequently sicker risk pool in 2027. As some enrollees encounter higher premiums during the upcoming ACA Open Enrollment Period this fall, enrollment in the individual market may continue to shrink, and more people could become uninsured.

Methods

Data used in this analysis come from the Mark Farrah Associates Health Coverage Portal™. Data from the “Enrollment by Segment” exhibit and the “Accident & Health Policy Experience Exhibit – by Domicile” were used (accessed September 23, 2026). The dataset analyzed in this report includes plans filing the Exhibit of Premiums, Enrollment and Utilization (EPEU)—or the Supplemental Health Care Exhibit (SHCE) when EPEU is not available—with the National Association of Insurance Commissioners (NAIC) and California HMOs regulated by California’s Department of Managed Health Care. Only plans that were categorized as having a “medical” focus were included; “specialty” plans, which is composed of ancillary or supplemental benefit plans, were excluded. Enrollment from the U.S. territories was excluded. Enrollment counts were adjusted to exclude Children’s Health Insurance Program (CHIP) enrollment that may be captured as individual market enrollment for all plans with available data in the Policy Experience exhibit. Enrollment in plans that file SHCE annually at the end of the year (such as life plans that may sell health insurance in the individual market) was also adjusted by the national growth rate from the end of the preceding year to estimate second quarter enrollment. The share of total individual market enrollment derived from SHCE was 2.8% in 2025 and 1.5% in 2026. Among insurers that report quarterly, there was a 5% drop in enrollment between March and June 2026.

Mark Farrah Associates released a report that estimated enrollment fell about 17.2% year-over-year in the second quarter of 2026. The KFF analysis differs by including only plans with a medical focus in the U.S. excluding territories, adjusting for plans that file annually and for CHIP enrollment.