Medicaid work rules are coming. Can states handle it?
By Jaymie Baxley/North Carolina Fellow
Medicaid beneficiaries in states that expanded access to the government-funded health insurance program will soon be subject to a federal work requirement that researchers warn will leave millions of Americans without coverage.
Beginning Jan. 1, non-disabled adults who signed up for Medicaid after their states adopted the Affordable Care Act expansion option will need to prove they are working, volunteering or attending school for at least 80 hours a month to remain enrolled.
The rule, which is part of the tax-cut bill signed into law last summer by President Donald Trump, has been framed by Congressional Republicans as an effort to reduce fraud and waste in the program. Meanwhile, Democratic lawmakers and health policy experts believe it will create administrative hurdles for beneficiaries who are either already working or unable to work.
“This is a complicated change to Medicaid,” said Joanne Kenen, a journalist-in-residence at Johns Hopkins Bloomberg School of Public Health who moderated a panel discussion about the requirement at HJ26. “It is the biggest change, arguably, in its existence.”
Getting people to talk in public about that change proved difficult. Kenen said she spent three months “wrangling” an official from the Centers for Medicare and Medicaid Services who ultimately decided not to attend the conference. A representative from a Republican-led state also canceled at the last minute after agreeing to participate, she said.
The panel did feature Hemi Tewarson, president and executive director of the nonpartisan National Academy for State Health Policy, and Kirsten Johnson, secretary of Wisconsin’s Department of Health Services. During the session, they outlined the scope and complexity of what states must accomplish before the requirement goes live.
Tewarson explained that the rule includes exemptions for pregnant women, caregivers of children under age 14, disabled veterans, foster youth and people with substance use disorders. It will primarily impact adults ages 19 to 64 who fall outside those exempted groups and live in one of the 40 states — along with the District of Columbia — that expanded Medicaid under the Affordable Care Act.
Wisconsin and Georgia, two non-expansion states that broadened eligibility through waiver programs, must also carry out the mandate.
When possible, the states are expected to verify compliance using existing data from sources like the Supplemental Nutrition Assistance Program and the Temporary Assistance for Needy Families program. If a beneficiary is found to be in violation, they’ll have 30 days to come back into compliance. There is no waiting period to re-enroll, Tewarson said.
“The statute really envisions that states automate some of these pieces, which means not requiring the individual to fill out a ton of paperwork [or] to do a lot of additional work on their behalf to actually comply,” she said.
States must conduct more frequent checks to confirm that people meet the new criteria. The policy requires beneficiaries’ ongoing eligibility for Medicaid, which is currently reviewed annually, to be determined at least twice a year.
“Once January 2027 happens, people have to be redetermined every six months, so every six months you’re going to have to prove that you have met the communication requirements for that period of time,” Tewarson said. “Right now, states redetermine people once a year, so this is a significant change with respect to how frequently you have to check to make sure people are meeting the community engagement requirements and also everything else that would make them qualify for Medicaid.”
Despite the increased workload, a handful of states — including Nebraska, Arkansas and Montana — have opted to begin implementing the rule ahead of its Jan. 1 launch.
Wisconsin, which is home to more than a million Medicaid enrollees, estimates about 63,000 residents will actually be affected. Johnson said her state is trying to minimize the burden on those beneficiaries by drawing on integrated eligibility systems that already link Medicaid with SNAP and other records.
Johnson said Wisconsin is not planning to launch early. “We are taking our time to make sure that when we have to go live on January 1, that we can get it right.”
The session took place before CMS released a rule on June 1 that established standards for verifying compliance and more clearly defined who qualifies for exemptions. Experts and advocates have since said the rule gives states less flexibility than anticipated, and defines “medical frailty” exemptions much more narrowly.
Jaymie Baxley is a reporter for North Carolina Health News, where he covers Medicaid and rural health.
