Patients often request a doctor’s letter or waiver to help them in a number of health-related situations.
Agreeing to or denying those requests could have long-term consequences for you and your patients, including the patient’s loss of important medical help or penalties levied against you.
Typical requests that doctors are — or will soon be — addressing include:
- Documentation supporting a medical exemption for the new Medicaid work requirements
- Recommendation for an emotional support animal (ESA)
- Medical certification for disabled parking placard or license plate
Here’s what physicians should know.
Qualifying for a Medicaid Work Exemption
Drastic changes are coming to healthcare, arising from H.R.1 (One Big Beautiful Bill Act), the federal budget reconciliation law passed in 2025.
Able-bodied Medicaid recipients aged between 19 and 64 years who were covered through the Affordable Care Act Medicaid expansion will now need to work or do volunteer service for at least 80 hours a month to maintain Medicaid eligibility. They’ll also need to frequently verify their work or exemption status.
People who have a disability or are in poor health will need to get a medical exemption to avoid the work requirement. (Those attending school, getting job training, disabled veterans, medically frail individuals, and several other groups are exempt from the work requirement.)
“Just because a patient has a diagnosis isn’t enough to qualify them for an exemption,” said David Machledt, PhD, director of the Delivery Systems Practice Area at the National Health Law Program in Washington, DC. The final rule added a requirement about whether someone’s condition significantly impairs their ability to meet the work requirement or other activities, he said.
“It’s the really important evaluation that many physicians will be having to make for these people who may have no other way to prove the severity of their condition,” Machledt said. “That will create a burden for patients and for physicians who have to make that call.”
“I don’t think the human impact of this can be overstated,” said Shandra Hartly, JD, attorney with the National Health Law Program. “Millions of people are going to be affected and are at risk of ending up uninsured. We shouldn’t lose sight of the individuals who are at risk because of this.”
Because of the new work requirements and necessary frequent eligibility verification, an estimated 4.9-10.1 million people could lose their Medicaid coverage in 2028. About 70% of office-based physicians take Medicaid patients; the percent varies widely, from about 39% in New Jersey to about 97% in Nebraska.
While many Medicaid patients can comply with the work or volunteer requirements, some with health issues may ask their physicians for a medical exemption. A large number will not qualify. Each state will decide its own criteria.
“I think the doctor’s role is to clearly and comprehensively identify the patient’s medical conditions and that includes diagnosis, symptoms, and needs for drugs,” said Hartly. “The doctors’ role is just to do what the doctor does: Make note of the condition, symptoms, and functional limitations. The state agency makes the final decision about whether the person is excluded.”
Some doctors who may want to help their patients get a medical exemption and keep their Medicaid coverage by giving the maximum diagnosis. However, doctors should be aware that this considered Medicaid fraud and can result in monetary penalties, loss of license, and potential jail time.
Doctors Can Still Have Input
Public comment on each state’s determination of its criteria for the work exemptions and how to demonstrate compliance is open until July 30.
“Doctors can get involved now with their state agency prior to July 30. CMS [Centers for Medicare & Medicaid Services] is allowing each state to set the standards,” said Hartly. Doctors can offer public comments about what the criteria should be.
Machledt added: “We’re extremely concerned with the additional requirements; they create a burden for individuals and a burden for providers.”
ESAs
“Requests for letters about [ESAs] are proliferating throughout the US, to the extent that states have actually implemented laws to try and regulate that situation,” said Jeanne Varner Powell, JD, director of risk management at Mutual Insurance Company of Arizona, a medical malpractice insurer.
Many landlords and some condo boards have a “no pet” policy. However, the federal Fair Housing Act (FHA) requires the landlord to make exceptions for service animals or ESAs.
The exception requires a note from a doctor or mental health care provider. Trouble bubbles up when a dog owner wants to have their beloved pet declared an ESA in order to keep the animal.
It’s important to be aware of the distinction between service animals and ESAs, said Varner Powell. According to the Americans with Disabilities Act (ADA), a service animal is trained to perform specific actions to help a person with a disability to perform daily tasks of life; the animals are considered working animals.
By contrast, an ESA is a pet that provides companionship and eases symptoms of mental or emotional disability. “It’s only under FHA laws that ESAs are lumped together with service dogs for the purpose of requiring housing providers to provide reasonable accommodations to people with one of these two types of animals.” The ADA protects service animals but not ESAs.
Often the physician feels such a diagnosis is not fully warranted, and they could face penalties for attesting to such a diagnosis.
“Most state licensing laws prohibit a physician from giving a statement that’s fraudulent, either written or oral, that could subject them to licensing board discipline,” said Varner Powell. In Florida, according to Senate Bill 1084, it is a misdemeanor to give a fraudulent support letter for an ESA and can result in fines or even possible jail time.
“If you’re willing to entertain those requests, you need objective data about the person’s medical disability that affects their activities of daily living,” said Varner Powell. “You have to do some investigation by talking to the patient, about how the animal removes their symptoms.” “For those who do, first, consider whether you have objective data that would support your opinion that this ESA would assist this person with the impairment or symptoms or issues their conditions causes,” said Powell.
When writing the letter, make sure you’re not vouching for the animal or talking about its safety, Powell cautions. “Make it a simple brief statement; don’t disclose any protected health information. It could read something like, ‘[T]his person has a recognized emotional disability, and a support animal assists them in alleviating some of their symptoms.’”
But if after speaking with the patient, you don’t have a diagnosis of mental health conditions, that would be concerning, Varner Powell said.
According to the American Psychiatric Association (APA)’s Resource Document on Emotional Support Animals, it’s ethically permissible to decline to write such a letter.
“According to the APA, there is a paucity of research that would show that an ESA actually improves people with psychological conditions or helps with their symptoms of daily living,” said Varner Powell. Because there is still controversy about the medical value of an ESA, many doctors are not willing to write such a letter.
If you decline the request, “You have to be able to explain to the patient why you will or will not undertake this role for the patient,” said Varner Powell. “It’s a matter of setting boundaries, which physicians have to do on a daily basis. A physician has to say no sometimes.”
Disabled Parking Permit Requests
Disabled parking permits are necessary for some of the roughly 61 million Americans with a disability. Requests from patients for disabled placards are common.
“In my specialty, I’m involved with rehabilitation [and] chronic pain, so because almost every patient’s main complaint is pain, in their mind they feel that they are justified to ask for a disabled permit,” said Francisco M. Torres, MD, physical medicine and rehabilitation specialist with Florida Spine Institute in Clearwater, Florida.
“It’s to the point that it’s so overwhelming, I have to tell patients, it’s my policy that I’m not even going to consider this if you’re younger than 65. Everyone who comes here is in pain, so if I give you one, I have to give it to every patient.”
Torres attributes his strong feelings about this to the fact that overall, there are a very limited number of disabled spaces. “If everyone who comes to the clinic gets a permit, there will not be accommodations for people who really need it.”
However, Torres was threatened and attacked by a patient for whom he denied a disabled permit. “One patient got really violent because I said ‘no’ to a disabled permit.” Torres said he had to defuse the situation and get out of the room.
Another patient left the practice because he would not prescribe a disabled permit. “One patient was a woman in the military; she wanted to make me feel guilty because she was a service person. She had this disability, but I thought that the patient could do more. She was doing things around the house and outside the house. I didn’t think a disabled permit was appropriate. She felt betrayed and she left upset.
“It’s a very delicate situation,” said Torres. “As a physician, my job is to keep people moving. The first law of medicine is use it or lose it. And a permit that removes walking from a patient can exacerbate the disability we’re trying to treat.”
“The doctor is caught between being kind and…mak(ing) some clinical distinctions based on the art of medicine.”
Doctors can be disciplined for writing disabled permit request letters that aren’t justified. For example, in New Jersey, making a false statement or providing misinformation to help someone get a disabled placard or license is a fourth-degree crime and can earn up to a $10,000 fine and up to 18 months in jail.
“The doctor’s role is to legally and clinically verify that a patient’s medical condition or mobility impairment meets state-specific criteria. Don’t treat the permit request as paperwork,” Torres said. “It’s a clinical and ethical decision that can meaningfully affect your patient’s long-term mobility, their disability status and the availability of resources for patients with far greater functional limitations.”
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