The Trump administration has issued final rules on how states must ensure that millions of Medicaid enrollees prove they are working or completing other activities, such as job training, volunteering or being enrolled in an educational program.
The Centers for Medicare and Medicaid Services published 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, 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 ensure they have staff to effectively enforce the rules, while preventing enrollees from losing coverage for administrative reasons, such as difficulty navigating state eligibility portals.
The newly announced regulations offer a clearer picture of what approximately 18.5 million Medicaid enrollees will have to do to prove they qualify for benefits.
Jim Torres, who helps people sign up for health coverage at the Samuel U. Rodgers Health Center in Kansas City, Missouri, said a “very small percentage” of his clients have heard about the coming changes to Medicaid.
“These people have very busy lives. They are doing the best they can to get by,” he said. “It's just not a priority for most of them.”
Health policy researchers and consumer advocates said enrollees should keep a few things in mind as the Jan. 1, 2027, launch approaches in most states.
1. Labor rules will not apply to everyone.
The new rules will apply to people covered through what is 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, typically low-income adults without dependents. Georgia and Wisconsin offer coverage to some people in this group, so they will be subject to the rules.
Children and pregnant people, as well as people with disabilities who receive Social Security payments (all groups that already qualify for Medicaid) will not be subject to the rules. Nor will people who are determined to be “medically fragile” or too sick to work.
People subject to work rules are “displacing” people from the Medicaid program who are “truly in need,” CMS Director Mehmet Oz said during a June 1 news conference. “We hope that work requirements will change this.”
The rules will come into force in most places in January. Nebraska began applying them in May. Montana plans to start in July, but won't kick people out until October. Arkansas will have a “soft” launch in July: It will begin enforcing the rules, but without penalties until next year.
2. States will take your word that you are too sick to work. For now.
Federal officials have emphasized that states should make the process of reporting hours and requesting waivers for Medicaid enrollees as simple as possible by creating automated systems and using existing data sources such as unemployment and education records.
If states can't determine that you're doing 80 hours of qualifying activities a month using those data sources, you may be allowed to “self-certify” it in 2027, health policy researchers said.
People will also be allowed to “self-certify” that they are too sick to work in 2027, and to do so once in 2028. States will then begin ordering tests, if they cannot find them in the available data.
But after the initial launch, the burden of proof will likely still fall on many enrollees, researchers and consumer advocates said.
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 greater the burden of manual reporting, the fewer people will do it,” he said. “That means we're going to see drops in coverage.”
3. The rules are stricter than expected for people who are too sick to work.
One of CMS's main goals has been to “protect vulnerable populations” through “strong exemptions to ensure that people who cannot reasonably be expected to work are not subject to the requirements,” Dan Brillman, the agency's deputy administrator, said during the June 1 news conference.
However, consumer and patient advocates said the exemptions in the final rules are more restrictive than expected. Members will eventually have to provide documentation, such as a statement from a medical professional, to show that a health condition prevents them from working. And each individual state will have to determine the severity of beneficiaries' medical conditions.
“Someone might be medically fragile in Nebraska, but not medically fragile in Delaware,” said Carolyn Sheridan, associate director of state policy at the National Organization for Rare Diseases, which lobbies on behalf of patients with rare diseases. He said his group hoped the rules would offer a standardized definition of who is considered medically fragile 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 improperly granting people exemptions from work rules, said Jennifer Tolbert, who researches Medicaid at KFF, a nonprofit health information organization that includes KFF Health News.
“States can be more cautious,” he said. “That will likely cause people who may still be eligible to lose coverage.”
4. Only certain qualified activities count.
Members can meet the rules by working 80 hours a month. They can also enroll in university courses, volunteer through a community organization, or do “in-kind” work that does not generate remuneration.
The rules state, in detail, how many academic credit hours translate into 80 hours per month: Students must 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 are volunteers with “a document from a community service organization.”
Consumer advocates say it could be difficult for people to obtain evidence that they are engaging in these types of informal activities. But supporters of the rules say volunteering can already be tracked.
“If you get in trouble with the law and the judge says, 'Hey, you need some volunteering and community service to serve your sentence,' there are already ways to 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 an eye on your mailbox, researchers and consumer advocates said. State Medicaid agencies must let you know if you will be subject to the rules in two ways: by mail or email and by another form of communication, such as a text message or phone call, or by posting a notice online.
“The important things come in the mail,” Henderson said.
And check with your state's Medicaid agency, researchers and advocates said. Some states, including Arkansas, California and Wisconsin, have already posted information about labor 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 if you will be subject to the rules.
“Get ahead of this,” said Joan Alker, executive director of Georgetown University's Center for Children and Families who studies Medicaid. “So that one day you don't end up going to the pharmacy and being told, 'Oh, you're no longer insured' when you try 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 the new rules that require people to prove that they are working, attending school, or engaging in another qualifying activity? Click here to contact KFF Health News.
