$911 Billion in Medicaid Cuts Are Now Law. Here's What Hits First.

Update, June 3, 2026: The Centers for Medicare and Medicaid Services released regulations on June 1 establishing how states must implement Medicaid work requirements under the One Big Beautiful Bill Act. The rules require states to evaluate the severity of a medical condition before granting a “medical frailty” exemption, not simply confirm that a condition exists, a standard stricter than what states had spent months building their systems to meet.

Nebraska launched its own work requirement on May 1 and had already published a nearly 300-page list of qualifying conditions. State advocates, including Sarah Maresh of Nebraska Appleseed, are calling on Nebraska to halt coverage terminations scheduled for this summer until the state revises its approach to match the new federal standard.

Starting in 2028, the regulations will also end self-attestation for medical frailty exemptions and require documentation instead. More than two dozen states had planned to allow self-attestation, according to KFF Health News, and consultants advising states say they will now need to reprogram eligibility systems at additional cost before the January 2027 enforcement deadline.

Update, June 5, 2026: The Centers for Medicare and Medicaid Services released an interim final rule tightening the conditions under which Medicaid enrollees can claim exemption from the work requirement mandate. People diagnosed with conditions such as sickle cell disease must now provide proof beyond their diagnosis that they are “greatly impaired” from working, eliminating automatic “medically frail” classifications for many current enrollees. All states with Medicaid expansion must implement work requirements by January 1, 2027.

The rule is stricter than what Nebraska enacted voluntarily eight months ahead of the federal deadline, which retained automatic exemptions for specific medical conditions. Jennifer Wagner, director of Medicaid eligibility and enrollment at the Center on Budget and Policy Priorities, told Mother Jones that state officials were not briefed on the medical frailty definition during prior negotiations with federal officials. The rule also excludes Medicaid-supported employment from qualifying as “community engagement” under the law.

A 60-day public comment period is now open, and states have until the end of 2026 to finalize implementation plans. Maria Town, president and CEO of the American Association of People with Disabilities, said the exclusion of supported employment signals that disabled workers’ labor will go uncompensated. The Urban Institute projects that between 4.9 million and 10.1 million people could lose Medicaid enrollment by 2028 as a result of work requirements and more frequent eligibility checks.

Update, June 12, 2026: The Centers for Medicare and Medicaid Services released final rules on June 1 governing how states must enforce Medicaid work requirements, a deadline set by the One Big Beautiful Bill Act. The rules apply to roughly 18.5 million enrollees in Medicaid expansion programs and require 80 hours of qualifying activity per month, including paid work, college enrollment, and volunteering. Most states must begin enforcement by January 1, 2027; Nebraska began enforcement in May.

In 2027, enrollees who cannot verify their hours through state data systems may self-attest to compliance or to being too sick to work. That self-attestation option is available once more in 2028, after which states will require documentation such as medical records or doctors’ notes. States face financial penalties for incorrectly granting exemptions, a provision that Jennifer Tolbert of KFF said will likely push states toward stricter screening.

The final rules leave the definition of “medically frail” to each state rather than setting a federal standard, a gap that Carolyn Sheridan of the National Organization for Rare Disorders said will produce inconsistent outcomes across state lines. Morgan Henderson of The Hilltop Institute at the University of Maryland-Baltimore County said high manual reporting burdens will cause coverage losses regardless of eligibility. Enrollees should confirm their current mailing address with their state Medicaid agency, as required notices must arrive by mail or email plus one additional form of contact.

(https://kffhealthnews.org), June 12, 2026]

Update, June 29, 2026: Twenty-five Democratic-led states and the District of Columbia filed suit against the Trump administration on June 29, targeting an interim final rule from the Department of Health and Human Services and the Centers for Medicare and Medicaid Services that narrows who qualifies as “medically frail” under the work requirement exemptions. The lawsuit names HHS Secretary Robert F. Kennedy Jr. and CMS Administrator Mehmet Oz as defendants, according to reporting by Stateline and Mother Jones.

The rule, published in early June, requires Medicaid recipients to document both a significant health condition and a significant impairment in their ability to work — a two-part standard that state officials say Congress never wrote into the One Big Beautiful Bill Act. Massachusetts Attorney General Andrea Joy Campbell, who helped lead the suit, said the change left states no workable time to adjust enrollment systems or notify members.

States face an August 31, 2026 deadline to inform Medicaid recipients about the revised “medically frail” criteria, with financial penalties attached for missing it. The lawsuit asks a federal judge to stay the interim final rule and vacate parts of it before the work requirements take effect January 1, 2027.

Update, July 10, 2026: New federal Medicaid work requirements, enacted under the One Big Beautiful Bill Act signed by President Trump last July, will take effect Jan. 1 in 43 states and the District of Columbia, requiring adult enrollees to document at least 80 hours per month of work, education, or community service. A KFF Health News investigation published today found the rule poses direct risk to the estimated 1 million-plus farmworkers who are U.S. citizens or legal permanent residents and rely on Medicaid. Farmworkers routinely exceed 80 hours during harvest season but fall below the threshold in off-months, often taking informal construction or landscaping jobs that produce no payroll documentation.

The same law now requires beneficiaries to verify eligibility twice a year, up from once. Akeiisa Coleman, assistant vice president at the Commonwealth Fund, told KFF Health News that missed letters and unfiled forms could terminate coverage for workers who remain technically eligible. CMS Administrator Mehmet Oz announced the agency’s nationwide implementation framework in June.

Adriana Cadena, executive director of Protecting Immigrant Families, and Alexis Guild, vice president of strategy at Farmworker Justice, both warned the documentation burden will redirect workers to emergency rooms, raising costs and delaying treatment for chronic conditions. A 2021-22 California survey found 37% of male farmworkers and 47% of female farmworkers had at least one chronic health condition. Several states have already moved to implement the 80-hour rule ahead of the January deadline.

Update, July 15, 2026: As states face a January deadline to enforce federal Medicaid work requirements, California lawmakers are seeking to revive an expired law that would require the state to identify companies with 100 or more employees enrolled in Medi-Cal. State Sen. Lola Smallwood-Cuevas, the bill’s author, says nearly 5 million of California’s 14 million Medi-Cal enrollees will be subject to the rule. New Jersey Gov. Mikie Sherrill signed a bill in June requiring businesses with 50 or more Medicaid-enrolled employees to pay an annual fee ranging from $325 to $725 per person, depending on company size.

Nevada’s most recent employer report, published in January 2026, found that Amazon had 4,914 full-time employees on Medicaid in fiscal year 2025, the highest of any private company in the state for the fifth consecutive year. Walmart followed with 3,503 workers enrolled. Nevada Medicaid spent nearly $950 million covering those employees and more than 140,000 of their dependents, per the state report.

Nebraska and Montana have already begun enforcing work requirements ahead of the federal deadline. A KFF analysis found that more than 2 million fewer children were enrolled in Medicaid and the Children’s Health Insurance Program in April 2026 than in January 2025, with California among the states recording the steepest losses.

Update, August 3, 2026: U.S. District Judge Richard Stearns of Massachusetts denied a preliminary injunction on July 29, keeping a January 1 deadline for states to implement Medicaid work requirements. The ruling came after 25 Democratic-led states filed suit on June 29 against CMS and HHS, challenging federal guidance that narrows the definition of who qualifies as “medically frail” and therefore exempt from the requirements.

Stearns rejected the states’ irreparable-harm argument in part because CMS has committed to covering 90% of states’ implementation costs. His ruling also noted that the January 1 deadline was set by Congress, not CMS, and raised questions about CMS Administrator Dr. Mehmet Oz’s “faithfulness to Congressional intent” without finding those questions sufficient to grant relief.

The requirements, enacted under the One Big Beautiful Bill Act, mandate that Medicaid expansion enrollees log at least 80 hours per month of work or qualifying community activity to retain coverage. The Urban Institute estimates that between 3 million and 7 million people could lose coverage from the work requirements alone, rising to 10 million over the next decade when more frequent eligibility checks are included.

Update, August 5, 2026: Indiana must begin enforcing federal work requirements for Healthy Indiana Plan adults on Jan. 1, 2027, under Senate Enrolled Act 1. Adults covered through the state’s Medicaid expansion will need to document at least 80 hours per month of work, job training, education, or community service to keep their coverage. Because Indiana will apply a three-month lookback period, beneficiaries must begin meeting the requirement in October 2026 to avoid losing coverage at enforcement’s start.

Starting Jan. 1, 2027, HIP members will also face formal eligibility redeterminations every six months instead of annually, matching a new federal requirement for Medicaid expansion populations. FSSA Secretary Mitch Roob said the agency began conducting quarterly interim eligibility checks in January 2025, separate from scheduled renewals. Enrollment advocates, including Ann McCafferty of the Indiana Healthy Families Alliance, say the combined requirements place a growing administrative burden on members who miss notices, move without updating their address, or cannot navigate what documentation the state requires.

A Paragon Health Institute analysis cited by FSSA estimates that 267,185 of Indiana’s 572,088 Medicaid expansion enrollees in 2024 were improperly enrolled, placing Indiana third nationally for the largest increase in improper expansion enrollment between 2019 and 2024. Covering Kids & Families of Indiana executive director Susan Jo Thomas said most affected adults are already working but will need a clear reporting mechanism to document their activity to the state before the January deadline, according to the Indiana Capital Chronicle.

Update, August 9, 2026: Indiana’s Family and Social Services Administration began rolling out compliance tools for the state’s Medicaid work requirements, which take effect January 1, 2027, for adults enrolled in the Healthy Indiana Plan. Covered adults must log at least 80 hours per month of work, job training, education, or community service to remain eligible. The state will review compliance every six months using a three-month lookback period, meaning anyone applying on January 1 must show qualifying activity dating back to October 2026.

FSSA started sending informational texts to HIP members on July 21 from the number 43816, and launched an anonymous online screening tool that lets enrollees check whether they qualify for an exemption before the deadline hits. Exemptions cover children, pregnant women, Medicare enrollees, and parents caring for children age 13 or younger, among others.

FSSA and Covering Kids & Families will host in-person town halls for members, providers, and community partners, with the first two scheduled for August 17 at Ivy Tech’s Elkhart Community Center and September 1 at Ivy Tech Fort Wayne. Additional dates will be announced through the end of the year, according to the Indiana Capital Chronicle.