Adrian McGonigal Worked at a Chicken Plant and Reported His Hours. The State Cut His Medicaid Anyway. He Died.

Update, June 3, 2026: The Trump administration released final Medicaid work requirement regulations on June 1, giving states less than seven months to overhaul eligibility systems before the federal enforcement deadline. The rules, issued by the Centers for Medicare and Medicaid Services under the One Big Beautiful Bill Act, would require roughly 18.5 million adults across 42 states and the District of Columbia to prove they are working or enrolled in an approved activity to keep their coverage.

The regulations narrowed the medical frailty exemption, requiring states to assess the severity of a person’s condition rather than accept a diagnosis alone, and explicitly excluded homelessness as a qualifying condition. More than two dozen states had planned to allow enrollees to self-attest to qualifying conditions; the new rules will require supporting documentation starting in 2028, a shift that consultants advising states described as a “significant policy pivot,” according to KFF Health News. CMS Administrator Mehmet Oz, on a June 1 press call, described the standard as “forgiving, but not foolish.”

Nebraska, which launched its own work requirement on May 1 using a nearly 300-page list of qualifying conditions, now faces a direct conflict with the federal standards. Sarah Maresh of Nebraska Appleseed called on the state to pause coverage terminations until it can reconcile its program with the new rules. Nebraska’s Department of Health and Human Services said it is reviewing the regulation.

Update, June 5, 2026: The Centers for Medicare and Medicaid Services released an interim final rule on Medicaid work requirements that tightens the standard McGonigal and others like him faced. Under the rule, people already enrolled in Medicaid with diagnoses such as sickle cell disease must now prove they are “greatly impaired” from working, going beyond a formal diagnosis to satisfy the “medically frail” exemption. All states with Medicaid expansion must implement the requirements by January 1, 2027.

Jennifer Wagner, director of Medicaid eligibility and enrollment at the Center on Budget and Policy Priorities, told Mother Jones that state officials were not informed about the new medical frailty definition during prior discussions with federal agencies. The Urban Institute projects that work requirements combined with more frequent eligibility checks could reduce Medicaid enrollment by between 4.9 and 10.1 million people by 2028. Wagner said states “are not going to be able to do this accurately by January 1.”

The rule carries a 60-day public comment period before finalization. Maria Town, president and CEO of the American Association of People with Disabilities, said the rule bars Medicaid-supported employment from counting as qualifying “community engagement” under the new standard. The rule is part of the One Big Beautiful Bill, which cuts nearly $1 trillion from Medicaid over the next decade.

Update, June 12, 2026: The Centers for Medicare and Medicaid Services released final rules on June 1 governing how states must verify that Medicaid enrollees are working or completing qualifying activities. The rules, required by the One Big Beautiful Bill Act, will affect roughly 18.5 million enrollees covered through Medicaid expansion, with most states required to begin enforcement by Jan. 1, 2027.

The rules leave the definition of “medically frail” to each state, meaning a health condition that qualifies someone for an exemption in Nebraska may not qualify them in Delaware. Carolyn Sheridan, associate director of state policy for the National Organization for Rare Disorders, said her group had sought a standardized federal definition. States also face financial penalties for incorrectly granting exemptions, a pressure that Jennifer Tolbert of KFF said will push states toward caution and toward dropping enrollees who remain eligible.

Enrollees may self-attest to their work hours and health status in 2027, but states will begin requiring documentation, including pay stubs and medical records, in 2028. Morgan Henderson of The Hilltop Institute said a high manual reporting burden will produce coverage losses among people who are still technically eligible. Nebraska began enforcing the rules in May; Arkansas and Montana plan to start in July, per KFF Health News reporting by Sam Whitehead.

Update, June 24, 2026: West Virginia’s Department of Human Services launched wvmedicaidhelp.org on June 24 and began asking the state’s 161,184 expanded Medicaid enrollees to update their mailing addresses, email addresses, and phone numbers ahead of new federal work requirements. Under the One Big Beautiful Bill Act, enrollees ages 19 through 64 must document at least 80 hours per month of qualifying work or training to remain eligible, starting Jan. 1, 2027.

Christy Donohue, the DoHS Commissioner of the Bureau for Medical Services, said the state is on track to implement the requirements and is building automated verification systems to pull work-history data from electronic sources when available. The department said the automated approach is intended to reduce the amount of documentation enrollees must submit on their own, according to West Virginia Watch.

Recipients must read all eligibility correspondence the state sends and watch for additional notices before January. The requirement applies to the same expanded Medicaid population — working adults earning up to 138% of the federal poverty line — that McGonigal was enrolled in when the state terminated his coverage.

Update, June 29, 2026: Twenty-five Democratic-led states and the District of Columbia filed suit against the Trump administration over new Medicaid work requirement rules, according to Stateline and Mother Jones. The lawsuit names HHS Secretary Robert F. Kennedy Jr. and CMS Administrator Mehmet Oz as defendants. Massachusetts Attorney General Andrea Joy Campbell helped lead the filing; Rhode Island Attorney General Peter Neronha is among the co-plaintiffs.

The suit targets an interim final rule published this month by HHS and CMS that narrows who qualifies as “medically frail” and therefore exempt from the 80-hours-per-month work requirement under the One Big Beautiful Bill Act. Under the new guidance, a recipient must show both a significant health condition and a significant impairment in their ability to work, a two-part standard that states say Congress never authorized and that federal officials never raised during months of implementation talks.

States face an August 31, 2026, deadline to notify Medicaid recipients of changes to the medically frail designation, with financial penalties for missing it. Full implementation of work requirements is set for January 1, 2027, though CMS could grant extensions through 2028. The lawsuit asks a federal court to stay the interim final rule and vacate portions of it.

Update, July 7, 2026: Indiana’s Family and Social Services Administration released implementation details this week for Medicaid work requirements affecting able-bodied adults enrolled in the Healthy Indiana Plan. Starting Jan. 1, 2027, participants ages 19 to 64 must log 80 hours of qualifying activity per month or earn at least $580 to keep coverage, according to the Indiana Capital Chronicle. Qualifying activities include paid employment, school enrollment at half-time or more, apprenticeships, and volunteer work.

New applicants must prove three consecutive months of compliance before their application date, with that window opening Oct. 1, 2026. FSSA Secretary Mitch Roob said the agency will run quarterly compliance checks using a three-month lookback period and will host town halls and webinars this summer to explain the rules.

HIP enrollment has already fallen from roughly 671,000 when Gov. Mike Braun signed the work requirement law in April 2025 to about 487,000 in June 2026, six months before requirements take effect. Roob said he could not project how many current enrollees will fail to qualify for an exemption or meet the 80-hour threshold.

Update, July 10, 2026: President Trump signed the One Big Beautiful Bill Act, which requires most Medicaid recipients in 43 states and the District of Columbia to document at least 80 hours per month of work or qualifying activities to maintain coverage, with a compliance deadline of Jan. 1 for most states. KFF Health News reported that the rule will affect more than one million farmworkers who hold U.S. citizenship or legal permanent resident status and who participate in Medicaid at rates between 71% and 79% of eligible households.

For farmworkers, the documentation burden compounds existing coverage gaps. Alexis Guild, vice president of strategy and programs at Farmworker Justice, told KFF Health News that seasonal schedules and informal off-season work in construction or landscaping make it difficult to produce pay stubs or records that satisfy the new standard. Workers who log well above 80 hours during harvest may fall below the threshold during slower months.

The law also doubles the frequency of eligibility verification, requiring proof twice a year rather than once. Akeiisa Coleman, an assistant vice president at the Commonwealth Fund, said missed notices and unfiled forms could strip coverage from workers who are otherwise eligible. Adriana Cadena, executive director of Protecting Immigrant Families, said the combined effect could end coverage for workers’ children as well.

Update, July 12, 2026: Arkansas has begun a “soft launch” of Medicaid work requirements established by the federal One Big Beautiful Bill Act, signed by President Trump. The state is verifying whether Medicaid expansion enrollees meet the requirements before enforcement begins in January 2027.

State officials estimate as many as 42,000 Medicaid expansion enrollees could lose coverage once the requirements take effect. A 2019 New England Journal of Medicine analysis of Arkansas’ first work requirement found no significant employment gains and determined that more than 95% of targeted enrollees already met the requirement or qualified for an exemption.

Centene, one of two insurers administering Arkansas’ Medicaid expansion, announced it will leave the program in January, according to the Arkansas Advocate. Arkansas leads the nation in the share of rural hospitals at risk of closure, and labor and delivery services have shut down in multiple communities across the state.

Update, July 17, 2026: Federal officials have approved a temporary hardship exemption from Medicaid work requirements for Dawson County, Nebraska, home to the Lexington Tyson Foods plant that closed in January and eliminated roughly 3,000 jobs. Gov. Jim Pillen directed the Nebraska Department of Health and Human Services to seek the exemption after Dawson County recorded the highest monthly unemployment rate in the state. The Centers for Medicare and Medicaid Services approved the waiver, which covers anyone who has lived in Dawson County at any point since Feb. 1, according to the Nebraska Examiner.

The hardship provision, authorized under the 2025 federal law that established the work requirements, allows states to seek county-level exemptions where unemployment exceeds 8% or reaches at least 1.5 times the national average. Nebraska became the first state in the country to enforce the new requirements on May 1. All states must comply by Jan. 1, 2027.

Nebraska DHHS estimates up to 29,000 of the 72,000 Nebraskans enrolled in Medicaid expansion could be subject to the 80-hours-per-month threshold. The Dawson County exemption stays in place until the county’s unemployment rate falls below the federal thresholds. Pillen has directed state agencies to continue coordinating workforce and community assistance for families affected by the Tyson closure.

Update, July 20, 2026: The One Big Beautiful Bill Act established Medicaid work requirements that take effect Jan. 1 in most states, requiring adults without dependents to document 80 hours of qualifying activity per month. Enrollees who cannot work may claim a “medically frail” exemption, but final regulations issued in June indicate that exemption will in many cases require written documentation from a clinician.

Physicians say they are not trained to evaluate work capacity, and the American Medical Association president, Willie Underwood III, wrote to CMS administrator Mehmet Oz in May arguing the rule “transforms the clinical encounter into an eligibility gatekeeping process.” Alice Thornton, who has treated HIV patients in Lexington, Kentucky for more than 25 years, said her team already struggles with complex disability paperwork. CMS declined to respond on the record to physicians’ concerns.

Twenty-five mostly Democratic-led states sued the Trump administration at the end of June over the medical frailty standard. Beginning in 2027, states may accept a patient’s self-attestation of medical frailty twice per year; that drops to once per year in 2028.