State officials remain unsure how to enforce the requirement that many adults enrolled in Medicaid prove they are working (even as one state launches its program this week) and are taking a variety of approaches to work, including, in a handful of states, the use of artificial intelligence.
A KFF survey of Medicaid officials from 42 states and the District of Columbia offers insight into the key policy decisions facing state officials as the January 1, 2027 deadline to implement the work requirement approaches. Remaining questions include what diseases will qualify Medicaid beneficiaries for waivers and how to automate compliance verification.
Federal guidance is not expected to be released until June. But some states are moving forward with their own definitions of “medical frailty,” which congressional Republicans' One Big Beautiful Bill says will allow Medicaid enrollees to escape the requirement.
The law, President Donald Trump's signature national achievement, renews Medicaid in more than 40 states that, along with Washington, D.C., have fully or partially expanded the low-income program to cover childless adults who do not obtain insurance through a job. While most adult Medicaid recipients already work or are disabled, are caregivers or in school, many Republicans argue that people enrolled in the program who are not working drain resources that should support low-income children, pregnant women and people with disabilities.
About 20 million people gained Medicaid coverage thanks to the expansion, created by the Affordable Care Act, a law that most Republicans still oppose.
The new work rules require that a person be a student at least part-time or work or participate in other qualifying activities, such as community service, for at least 80 hours each month. The requirement could potentially change who is eligible for Medicaid and applies to people already enrolled.
The Congressional Budget Office estimates that work requirements will reduce federal Medicaid spending by about $326 billion over 10 years. The agency also estimates that 4.8 million more people will become uninsured in 2034 due to the need to work.
“Many states are working on a super-condensed timeline,” said Amaya Diana, a KFF policy analyst who worked on the survey. “They're still making these big decisions less than a year into implementation.”
KFF is a nonprofit health information organization that includes KFF Health News.
The law allows brief exemptions from work requirements for members who experience certain hardships: natural disasters, residing in a county with a high unemployment rate, admission to a hospital or nursing home, or having to travel for an extended period of time to obtain medical care.
While 28 states and Washington, D.C., will offer hardship waivers, three of those states will not adopt the four waivers allowed by law and two, Iowa and Indiana, do not plan to adopt any.
People can also be exempt from work requirements if they are “medically fragile.” But the federal government has not told states how to define that term or how to determine whether an enrollee falls into the category.
The survey showed that, as of March, 21 states had not defined medical frailty. Nebraska, which will implement its work requirement on May 1, recently published a list of thousands of health conditions that could qualify enrollees as “frail” and exempt them from working.
Some states plan to allow patients to attest to their medical frailty, while others will require confirmation from a medical professional. The most common way to verify medical frailty, which will be used in just over 30 states, is by examining Medicaid claims data.
Mehmet Oz, administrator of the federal Centers for Medicare and Medicaid Services, told KFF Health News in an interview this week that “we don't like self-certification” and that “documentation is critical.”
Many beneficiaries and their advocates have expressed concern about losing coverage for administrative reasons. When Arkansas briefly implemented Medicaid work rules, for example, most lost coverage not because they didn't meet the requirements but because they didn't properly file paperwork on time.
Six states plan to use AI to help with the implementation of work requirements in some way, such as processing documents or comparing beneficiary data from different sources, KFF found. Two states, Maryland and New Mexico, plan to use AI to analyze claims data.
Three states (Arkansas, Missouri and Oklahoma) plan to use AI to directly interact with people on Medicaid and help them identify and upload documents and verification data.
Adults with Medicaid will have to reverify that they are working or are exempt from the requirement at least every six months. Some states plan to conduct quarterly checks.
When possible, states should use available data sources to verify exemptions or compliance with work requirements.
For example, about 10 states will use data from the National Student Clearinghouse to verify school attendance. Some states also plan to turn to sources such as the Department of Veterans Affairs, AmeriCorps and service commissions.
But more than half of states told KFF researchers they don't have enough time to add new data sources and cited current costs as a challenge.
