The Trump administration signaled Monday it’s taking a muscular approach to one of its signature and most controversial health initiatives: new work requirements that could force millions of low-income people off Medicaid.

The new regulation — anxiously awaited by states who are due to implement the work requirements Jan. 1 — takes a stricter stance on verification and exemptions than state officials and patient advocates had hoped for. Administration officials said they sought to minimize enrollee paperwork and ensure everyone eligible for a work exemption receives it, while closing the door to fraud.

“We’re forgiving but we’re not foolish,” Mehmet Oz, the administrator of the Centers for Medicare and Medicaid Services, or CMS, said at a press briefing.

The regulations, while weedy, will affect how many millions of Americans could drop off Medicaid under a raft of new requirements included in President Donald Trump’s tax bill that congressional Republicans passed last year.

Starting next year, those on expanded Medicaid — about 20 million people who earn up to 138% of the federal poverty line — will have to work, go to school or volunteer at least 80 hours a week to remain qualified for the program. They can be exempted if they’re pregnant, disabled, medically frail, in substance-abuse treatment or are full-time caregivers for a family member.

“If your condition significantly impairs your ability to engage in work … then you are likely not subject to the work requirements,” Dan Brillman, the director of Medicaid, said at the briefing.

Patient advocates had been especially concerned about the details around the medical frailty exemption — what qualifies and how people must prove they are medically frail before being allowed to enroll.

The Monday regulation — using language that goes further than the law — stresses that the condition must “significantly impair” one’s ability to comply with the work requirement.

It also gives Medicaid patients a one-year runway where they can self-attest to qualifying for an exemption. But in 2028, they’ll have to start providing documentation like an insurance claim or a doctor note if the state isn’t able to find documentation on its own, CMS officials said.

That could eventually make it harder for people who aren’t considered disabled but nonetheless have life-altering medical conditions like sickle cell disease, uncontrolled diabetes or cancer to get excused from the work requirements, patient advocates said.

Lisa Lacasse, the president of the American Cancer Society Cancer Action Network, said the rule “piles on additional documentation and logistical challenges.”

“Cancer will not wait while Medicaid offices sift through paperwork,” she said in a statement.

Many states and patient advocates had hoped the administration would take a lighter approach to the new rules, allowing people to skip providing documentation altogether. CMS officials stressed they’re taking a “data-first” approach where states must exhaust other channels of verifying a patient’s condition before asking them to document it.

Medicaid work requirements have been a longtime Republican priority. The first Trump administration tried to let states volunteer for work requirements, but those efforts were largely blocked by the courts. Now federal health officials stress Medicaid should incentivize people to improve their circumstances instead of staying in the program long term.

“For able-bodied adults … Medicaid should be a short-term hand up, not a lifetime handout,” the new regulation said.

The Department of Health and Human Services also released an internal study Monday that found the requirements could reduce poverty by as many as 2.9 million people.

The new work requirements will result in 5.3 million more uninsured people a decade from now, according to the Congressional Budget Office.

“These are literally decisions that will determine whether millions of people will lose coverage,” said Anthony Wright, the executive director of the consumer-advocacy group Families USA.

Brian Blase, the president of the conservative Paragon Health Institute, whose work influences administration policies, had urged the administration to prohibit self-attestation. He points to how fraud skyrocketed in the Affordable Care Act marketplaces after the Biden administration paused verification rules during the COVID-19 pandemic.

He said the regulation “strikes the appropriate balance between necessary program-integrity protections and accommodations for those who genuinely need assistance.”