New Medicaid work requirements will challenge enrollees, states 

Medicaid officials in 42 states have until Jan. 1, 2027, to put new work rules in place so that millions of Americans can enroll or remain enrolled in Medicaid, as KFF reported in August.

Many, if not all, of those states, including the District of Columbia, Georgia and Wisconsin, will struggle to meet that deadline to write, implement and explain the new work rules, according to experts at a KFF Health Wonk Shop webinar, “How Will States Implement Medicaid Work Requirements?” Also, states have the option to proceed sooner, as Nebraska did this week, according to reporter Juan Salinas II for the Nebraska Examiner.

A work requirement is a significant shift for Medicaid members in all states except those that did not expand enrollment in Medicaid. Previously, eligibility has been based mostly on income, according to the Commonwealth Fund report, “Work Requirements for Medicaid Enrollees.” 

Eight states are exempt from the new work rules because they did not expand Medicaid enrollment under the Affordable Care Act: Alabama, Florida, Kansas, Mississippi, Tennessee, Texas, South Carolina and Wyoming. Georgia and Wisconsin have done partial expansions of Medicaid enrollment.

Among the 42 states that must implement bew work rules, 40 of them and the District of Columbia expanded Medicaid enrollment under the Affordable Care Act and two others (Georgia and Wisconsin) have partial expansions, said Jennifer Tolbert, deputy director of KFF’s Medicaid policy program during the KFF webinar. Those 42 states will need to implement the new work requirements included in the budget megabill that Congress passed this summer and President Trump signed on July 4, she added. 

The other featured webinar experts were Caprice Knapp, Ph.D., the principal deputy of the federal Center for Medicaid and CHIP Services, and a former director of the Medicaid program in North Dakota; Emma Sandoe, Ph.D., Oregon’s Medicaid director and a former Medicaid director in North Carolina; and Jennifer Strohecker, who previously served as the Medicaid director in Utah. Larry Levitt, KFF’s executive vice president for health policy, moderated the event. 

Expansion states face enrollment challenges

After Congress passed the budget megabill, officially, H.R. 1, in July, KFF reported that an estimated 18.5 million adults will need to comply with new, more stringent work rules or prove they have an exemption when applying for Medicaid. After enrolling, each Medicaid adult will need to prove compliance again at least every six months, the KFF report added. The law will reduce the number of  members with Medicaid coverage by 7.5 million in 2034, including about half (3.75 million) who will lose coverage under the new work requirements, KFF reported Nov. 13, citing a Congressional Budget Office analysis.

In July, 70.5 million adults under age 65 were enrolled in Medicaid, and 7.2 million children aged 18 and younger were enrolled in the Children’s Health Insurance Program, Medicaid.gov reported in July. In 2023, the Medicaid program cost $900.3 billion, including $619.9 billion in federal spending and $280.4 billion from the states, according to the federal Medicaid and CHIP Payment and Access Commission, which advises Congress.

By the end of next year, or earlier if states choose, the Medicaid departments in those 42 states and D.C., will need to enroll all adults who qualify for Medicaid, Tolbert explained. Under the same deadline, all Medicaid enrollees and those seeking to enroll in those states and D.C. will need to comply with new, more strict rules next year, meaning millions of Americans could lose their Medicaid coverage, Tolbert estimated.

Stories to cover

For health care journalists, the challenges inherent in verifying Medicaid enrollment will be an important story to cover in the coming months. Related stories include the following: 

• How will states implement the rules, and will state Medicaid departments have the systems to identify residents who need to comply and the staff to provide such help? “Conceptually, a work requirement for Medicaid enrollees is simple, but actually making it work, especially in a way that avoids eligible people falling through the cracks, is anything but simple,” Levitt commented.
• How much will each state spend to implement work requirements? Michigan spent $30 million to enroll 30,000 people when it implemented a work requirement in 2020, according to reports by Simar Bijaj for The New York Times and Kate Wells for NPR.

• What difference will work requirements make? Research shows that more than 90% of Medicaid enrollees are already working, as KFF reported, “5 Key Facts About Medicaid Work Requirements.”
• Will the work requirement raise the number of uninsured in each state? In the “5 Key Facts” report, KFF cited federal data showing that a national work requirement would increase the number of people without health insurance but would not increase employment.
• One of the biggest stories to cover comes from a directive the Trump administration issued to have state Medicaid programs investigate the eligibility of Medicaid enrollees based on their immigration status, according to reporting by reporting by Phil Galewitz Nov. 3 for KFF Health news. Only U.S. citizens and some lawfully present immigrants are eligible for Medicaid, he wrote. 
• Another significant story is the impact of Medicaid work requirements in counties with high unemployment rates. Under the budget law, Medicaid enrollees in counties where unemployment is at least 8% or 1.5 times the national unemployment rate would be exempt from the new work rules as long as those states apply for an exemption, Galewitz explained in this article, “Where Jobs Are Scarce, Over 1 Million People Could Dodge Trump’s Medicaid Work Rules.”

Megabill restricts states’ flexibility

The law also limits what states can do to help those who are enrolled or are seeking to enroll. “There are a couple places where the statute clearly dictates what states can or can’t do,” Tolbert said.

For example, people who do not meet the new work rules would be disenrolled from Medicaid and could not enroll in an ACA marketplace plan, Tolbert said. “There is already a prohibition against people with income levels below 100% of the federal poverty level who cannot get subsidized coverage in the marketplace,” she explained. For one person, 100% of FPL is $15,650 annually, and for a family of four, the limit is $32,150. 

New income restrictions in the budget law would prevent anyone from enrolling in an ACA plan if their income falls between 100% and 138% of FPL and they do not meet the Medicaid work requirements, Tolbert added. For one person, 138% of FPL is $21,597, and for a family of four, it’s $44,367, federal data show.

Before Congress passed the megabill, a person denied eligibility for Medicaid could use that denial to apply for a subsidized ACA marketplace plan, if that person’s income was above 100% of FPL, Tolbert noted. The goal behind the new limitation was to keep costs down in Medicaid and in the ACA marketplace, she added. 

The megabill also prevents states from waiving the Medicaid work requirements by using a Section 1115 waiver, Tolbert explained. Under Section 1115 of the Social Security Act, the secretary of Health and Human Services can let states waive Medicaid rules to evaluate innovative approaches for beneficiaries. Often, states will ask for a specific flexibility or to interpret the law differently, Tolbert said. “But the [megabill] law is very explicit in saying you can’t waive this requirement,” she added. 

In the meantime, states will need to interpret any unclear parts of the bill while they await guidance from the federal Centers for Medicare and Medicaid Services (CMS), Tolbert explained. That CMS guidance is due by the end of June, she noted. 

Exemptions for some enrollees

Under the budget law, the Medicaid expansion states must impose work requirements on adults ages 19 to 64. Previously, Medicaid eligibility was based on income primarily, but H.R. 1 adds work requirements as a new condition, according to this September report from The Commonwealth Fund, “Work Requirements for Medicaid Enrollees.” 

Those enrolled or seeking to sign up must prove they work at least 80 hours each month or have another approved activity, such as volunteering or going to school a minimum number of hours, the Commonwealth Fund explained. “The law exempts some Medicaid enrollees, including pregnant women, people with disabilities and caregivers of dependent children under age 14,” the report noted.

During the webinar, Tolbert added that people seeking to meet the requirements could engage in qualifying activities such as community service for at least 80 hours a month or be enrolled in school half-time. The law also exempts parents of children ages 13 and under, those who are medically frail and people enrolled in programs such as those for substance-use disorder, she noted. “States can also allow for certain hardship exceptions for people in specific circumstances, including those who are in the hospital and those living in counties with high unemployment rates,” she added.

Also, when a person applies, states will need to confirm that the applicant has been in compliance over the previous one to three consecutive months immediately before the application month, Tolbert explained. If a state cannot verify compliance, people in question would need to document within 30 days or prove they are meeting the requirements before being disenrolled, Tolbert noted.

Resources

• How Medicaid’s New Work Requirement Will Work, The New York Times, Nov. 5, 2025
• New Federal Medicaid Cuts Will Devastate Coverage for Reproductive Health Care, Guttmacher Institute, November 2025 
• Officials Show Little Proof That New Tech Will Help Medicaid Enrollees Meet Work Rules, KFF Health news, Oct. 23, 2025
• Medicaid Work Requirements Don’t Boost Employment, Study Shows, The New York Times, Sept. 30, 2025
• Where Jobs Are Scarce, Over 1 Million People Could Dodge Trump’s Medicaid Work Rules, KFF Health news, Sept. 29, 2025
• New Medicaid work rules could strip coverage from millions of Americans, NBC news, Sept. 29, 2025
• Who Cares for Our Nation’s Children? Federal Medicaid Cuts Will Magnify Challenges for Child Care Workforce and the Young Families They Support, Georgetown Center for Children and Families, Sept. 11, 2025
• Health Provisions in the 2025 Federal Budget Reconciliation Law, KFF, Aug. 22, 2025
• States Pursuing Medicaid Work Requirement Waivers Must Make Changes: How the OBB Changed the Landscape for Medicaid Work Requirements, Georgetown Center for Children and Families, July 23, 2025
• Medicaid work rules could leave a million Californians with no health insurance, CalMatters, May 30, 2025