Work Requirements for Medicaid Enrollees

For most of its history, Medicaid, the joint state and federal health insurance program for people with low income, has not tied eligibility to employment. This changed during the first Trump administration, which encouraged state Medicaid agencies to test work requirements.

Under President Trump, the Centers for Medicare and Medicaid Services (CMS) approved 11 state proposals for implementing waiver-based demonstration programs. Most of these states’ work requirement proposals were never implemented owing to court challenges, the threat of legal challenges, and the economic disruption of the COVID-19 pandemic. The Biden administration then rescinded approval of all proposals in early 2021.

In July 2025, however, Congress passed H.R. 1, which added the first-ever national work requirements to the Medicaid program.

What exactly are Medicaid work requirements?

Federal and state policymakers have periodically proposed and established “community engagement” requirements — more commonly known as work requirements — for people enrolled in Medicaid. Whereas Medicaid eligibility is primarily based on income, work requirements add a new condition of eligibility for adults, making coverage contingent on working, volunteering, or engaging in educational activities for a minimum number of hours.

Under H.R. 1, states will be required to impose work requirements on working-age adults (ages 19 to 64) in states that have expanded eligibility for Medicaid coverage. Enrollees subject to work requirements must prove that they are performing 80 hours of work, or another approved activity, each month. The law exempts some Medicaid enrollees, including pregnant women, people with disabilities, and caregivers of dependent children under age 14.

Nationwide, work requirements will impact an estimated 18.5 million adults per year, who will have to regularly demonstrate compliance or prove that they qualify for an exemption. States must verify compliance both at the time an individual applies for Medicaid coverage and, once enrolled, at least every six months thereafter.

For people who don’t meet the reporting requirements, the state must issue a notice alerting them they are noncompliant. They then have 30 days to demonstrate compliance before their application is denied (if they are not yet enrolled in Medicaid) or they will be disenrolled from Medicaid. Individuals losing their Medicaid coverage for failure to meet the work requirement are also locked out of financial help to purchase coverage through the health insurance marketplaces.

What do we know about Medicaid enrollees’ employment status?

The majority of adult Medicaid beneficiaries who can work already do. A 2023 analysis found that a large proportion of working-age adults on Medicaid, 71 percent, were working either full- or part-time or were in school. An additional 12 percent were caregivers, and 10 percent were unable to work because of an illness or disability.

Are Medicaid enrollees able to comply with work requirements?

Medicaid’s main objective is to provide health coverage to people with low income. Experts have raised concerns that adding work requirements to the program could cause many people to lose access to critical health services. Some believe the new policy cannot be tested safely or ethically in low-income communities because it risks participants losing coverage, which could negatively impact their health.

Because of the challenges they face in securing and maintaining employment, complying with work requirements can be especially difficult for Medicaid beneficiaries. Employed adults who rely on Medicaid frequently work in low-wage positions with variable hours, such as service or retail jobs, which often do not offer employer-sponsored insurance or affordable coverage. These jobs can prevent them from consistently meeting monthly requirements to work 80 hours. Low-income people are also likely to experience other barriers to employment, such as limited access to transportation, lack of internet access, caregiving responsibilities, and chronic health problems — any of which can make finding or keeping a job challenging.

Work requirements also place significant reporting burdens on Medicaid enrollees. People who should be exempt could lose coverage, especially if the process isn’t fully automated and they have to submit additional documentation. Even those who work more than 20 hours a week risk losing their coverage if they are unable to consistently document and submit proof of the number of hours they’ve worked. Reporting work hours can be especially difficult for people with multiple jobs, people without access to the internet or a computer, and people with limited English proficiency.

It remains to be seen whether forthcoming CMS guidance for states — and how states go about implementing the new policy — will ease, or add to, the known burdens of complying with work requirements.

What is the current status of Medicaid work requirements?

The Medicaid work requirements from H.R. 1 are scheduled to start by January 1, 2027. To implement them, state Medicaid agencies will have to make major changes to their eligibility and enrollment systems.

States face a tight timeline in preparing for the 2027 rollout. Currently, states are waiting for CMS to issue a rule providing them with implementation guidance, which H.R. 1 gives the agency until June 2026 to do. States can request an extension to implement work requirements until December 31, 2028, but approval is at the discretion of the Secretary of Health and Human Services. States can also seek approval to implement work requirements before the 2027 deadline; as of August 2025, seven states have a pending section 1115 waiver for work requirements.

Before Congress passed H.R. 1, only two states had fully implemented Medicaid work requirements. Arkansas, the first to do so, launched its program in June 2018 and ended it in March 2019 because of a court order. While the policy was in effect, the state required Medicaid beneficiaries ages 19 to 49 to report 80 hours of approved work or community engagement activities each month through an online portal. Failure to report hours for any three months, without an exemption, resulted in a loss of coverage for the remaining calendar year.

In July 2023, Georgia implemented its Pathways to Coverage program, which includes a Medicaid work requirement for parents and childless adults under age 65 with annual income up to 100 percent of the federal poverty level ($26,650 for a family of three in 2025). Georgia has not expanded Medicaid to adults with incomes up to 138 percent of the federal poverty level, as allowed under the Affordable Care Act, so before the Pathways program, parents in Georgia were only eligible for Medicaid if their income fell below 31 percent of the federal poverty level ($7,700 for a family of three in 2023). Nondisabled childless adults under age 65 were not eligible for the program at any income level. Pathways to Coverage therefore incrementally expands the population that is eligible for Medicaid in the state. However, to get coverage, the newly eligible populations must comply with work requirements.

Georgia’s work requirement policy is considered particularly restrictive because, unlike other state proposals to date, it does not systematically exempt populations that tend to struggle with employment, like adults with disabilities or those caring for a young child. Since its rollout, Pathways to Coverage has cost nearly $87 million, with the majority of spending on program administration, not medical services.

How have work requirements impacted Medicaid enrollees?

In Arkansas, more than 18,000 Medicaid enrollees lost coverage in the nine-month period in which the work requirement was in effect. Survey research revealed that the reporting process was a major driver of coverage losses: many Medicaid enrollees who were subject to the work requirements found the reporting process confusing or inaccessible, and nearly a third of the target population was unaware of the policy altogether. People who lost coverage reported delaying care and skipping medications because of costs, as well as incurring serious medical debt. Critically, there was no increase in employment among the target population.

In Georgia, where the work requirement only applies to people newly eligible for Medicaid, coverage gains have fallen far short of what policymakers anticipated. In the first year of Pathways to Coverage, just over 4,200 people had enrolled in Medicaid through the program, well below the state’s first-year projection of 100,000. Georgia’s stringent requirements for documenting and reporting work hours have contributed to low enrollment.

Georgia officials have proposed easing some of the reporting requirements in their application to extend Pathways to Coverage, but it’s unclear if these modifications will align with H.R. 1 requirements and forthcoming CMS guidance.

How have work requirements fared in other safety-net programs?

Other safety-net programs have had work requirements in place for more than 20 years, with only brief suspensions during economic declines and the COVID-19 pandemic. This includes the Temporary Assistance for Needy Families (TANF), which provides time-limited cash assistance to low-income families with children through federal block grants to states, and the Supplemental Nutrition Assistance Program (SNAP), a federally funded, state-administered program to subsidize food costs for people with low income. TANF and SNAP have work requirements with varying exclusions, and both are allocated federal funding for employment training and work supports, such as childcare subsidies, though evidence suggests this funding is insufficient to meet the need. CMS, on the other hand, does not allow Medicaid funding to be used for broad work supports.

The Congressional Budget Office has found that work requirements in TANF and SNAP have had mixed results. While work requirements in both programs have led to slight gains in employment, they have not increased average income among target populations. That’s largely because income gains that resulted from people working more have been offset by income losses from people removed from the programs for not complying with the requirements. Many people who lose SNAP or TANF benefits because of work requirements remain in poverty as they have few, if any, alternative sources of income.