The Trump administration has issued final rules on how states should ensure that millions of Medicaid enrollees prove they’re working or completing other activities, such as job training, volunteering, or being enrolled in an educational program.
The Centers for Medicare & Medicaid Services released the rules on June 1. That deadline was set last year in the GOP tax-and-spending law known as the One Big Beautiful Bill Act, which established a work requirement for certain people enrolled in Medicaid, the state-federal health insurance program for people with low incomes or disabilities.
Medicaid agencies are scrambling to rework IT systems and make sure they have staff to effectively enforce the rules, while also keeping enrollees from losing coverage for administrative reasons, such as difficulty navigating state eligibility portals.
The newly announced regulations offer a clearer picture of what roughly 18.5 million Medicaid enrollees will have to do to prove they qualify for benefits.
Jim Torres, who helps people enroll in health coverage at the Samuel U. Rodgers Health Center in Kansas City, Missouri, said a “very small percentage” of his clients have heard of the changes coming to Medicaid.
“These folks have very busy lives. They’re doing the best they can to get by,” he said. “It’s just not a top-of-mind thing for most of them.”
Health policy researchers and consumer advocates said enrollees should keep a few things in mind as the Jan. 1, 2027, rollout approaches in most states.
1. The Work Rules Won’t Apply to Everyone.
The new rules will apply to people covered through what’s known as Medicaid expansion. Since 2014, more than 40 states and the District of Columbia have decided to allow more people into their Medicaid programs, generally low-income adults without dependents. Georgia and Wisconsin offer coverage to some people in this group, so they’ll be subject to the rules.
Children and pregnant people, as well as individuals with disabilities who receive Social Security payments — all groups that already qualify for Medicaid — won’t be subject to the rules. Nor will people determined to be “medically frail,” or too sick to work.
People subject to the work rules are “crowding out” people in the Medicaid program who are “truly in need,” CMS Director Mehmet Oz claimed during a June 1 press call. “Work requirements are going to turn this around, we hope.”
The rules are set to take effect in most places in January. Nebraska started enforcing them in May. Montana plans to start in July but won’t kick people off until October. Arkansas will do a “soft” launch in July — it will start enforcing the rules but with no penalties until next year.
2. States Will Take Your Word That You’re Too Sick To Work. For Now.
Federal officials have stressed that states should make the process of reporting hours and requesting exemptions as simple as possible for Medicaid enrollees by creating automated systems and using existing data sources, such as unemployment and education records.
If states cannot determine you’re performing 80 hours of qualifying activities a month using those data sources, you may be allowed to “self-attest” to that in 2027, health policy researchers said.
People will also be allowed to “self-attest” that they are too sick to work in 2027, and do so one time in 2028. Then states will start asking for proof, if they can’t find it through available data.
But after the initial rollout, the burden of proof is likely to still fall on many enrollees, said researchers and consumer advocates.
People may need to dig up pay stubs, medical records, and doctors’ notes and submit them for state review, said Morgan Henderson, who has studied Medicaid work programs in Georgia and Arkansas at The Hilltop Institute, a research center at the University of Maryland-Baltimore County.
“The higher this manual reporting burden, the less people are going to do it,” he said. “That means that we’re going to see coverage drop-offs.”
3. The Rules Are Tougher Than Expected for People Too Sick To Work.
One of CMS’ primary goals has been to “protect vulnerable populations” through “strong exemptions to make sure people who can’t reasonably be expected to work are not subject to the requirements,” Dan Brillman, a deputy administrator at the agency, said during the June 1 press call.
Consumer and patient advocates, however, said the final rules’ exemptions are more restrictive than expected. Enrollees will eventually have to provide documentation, such as a statement from a medical professional, to prove that a health condition keeps them from working. And each individual state will have to determine the severity of beneficiaries’ medical conditions.
“Someone could be medically frail in Nebraska but not medically frail in Delaware,” said Carolyn Sheridan, associate director of state policy for the National Organization for Rare Disorders, which lobbies for patients with rare diseases. She said her group had hoped the rules would offer a standardized definition of who counted as medically frail and not leave the decision up to states.
Trump administration officials have publicly crusaded against fraud in government health programs, such as Medicaid, and states could face financial penalties for incorrectly granting people exemptions from the work rules, said Jennifer Tolbert, who researches Medicaid at KFF, a health information nonprofit that includes KFF Health News.
“States may be more cautious,” she said. “That will likely lead to people losing coverage who may still be eligible.”
4. Only Certain Qualifying Activities Count.
Enrollees can satisfy the rules by working 80 hours a month. They can also be enrolled in college courses, volunteer through a community organization, or do “in-kind” work that doesn’t result in pay.
The rules set out, in detail, how many academic credit hours translate to 80 hours a month — students need to be enrolled in six credit hours per semester to meet the “half-time” requirement. An unpaid internship can count toward the 80 hours.
People can also prove they’re volunteering with “a document from a community service organization.”
Consumer advocates say it might be hard for people to obtain proof they’re performing these kinds of informal activities. But supporters of the rules say volunteerism can already be tracked.
“If you run into trouble with the law and the judge says, ‘Hey, you need some volunteering and community service to serve your time,’ there are already ways that we verify that,” said Niklas Kleinworth, who works on state health policy for the conservative Paragon Institute.
5. You Have Time To Prepare.
Make sure your state Medicaid agency has your current mailing address and keep your eye on your mailbox, said researchers and consumer advocates. State Medicaid agencies must inform you in two ways if you’ll be subject to the rules — by either regular mail or email, and by one other form of communication, such as a text or phone call or by posting a notice online.
“The important stuff comes by mail,” Henderson said.
And check in with your state Medicaid agency, said researchers and advocates. Some states, including Arkansas, California, and Wisconsin, have already posted information about the work rules on their websites. If you can’t find what you’re looking for there, visit or call a local office. A caseworker should be able to tell you whether you’ll be subject to the rules.
“Get ahead of this,” said Joan Alker, who is executive director of the Georgetown University Center for Children and Families and studies Medicaid. “So that you don’t end up going to the pharmacy one day and they say ‘Oh, you’re not insured anymore’ when you’re trying to get your prescriptions refilled.”
KFF Health News correspondent Samantha Liss and senior correspondent Rachana Pradhan contributed to this report.
Have you tried to prove your eligibility for Medicaid under new rules that require people to show they are working, going to school, or participating in another qualifying activity? Click here to contact KFF Health News.
