She Was Working When They Cut Her Medicaid. Arkansas Proved Work Requirements Don't Work. Congress Is Imposing Them Anyway.

Update, June 3, 2026: The Centers for Medicare & Medicaid Services published final regulations on June 1 detailing how states must implement Medicaid work requirements under the One Big Beautiful Bill Act, which President Trump signed into law last July. The rules reversed months of preparation by state governments, forcing them to rebuild eligibility systems with less than seven months before the January 2027 enforcement deadline, according to KFF Health News reporters Rachana Pradhan and Samantha Liss.

The regulations narrowed the “medical frailty” exemption by requiring states to assess the severity of a person’s condition — not the condition alone — to determine whether someone can keep coverage without working. CMS also ruled that homelessness cannot qualify as a medical frailty exemption because it is not a medical condition. Beginning in 2028, the rules will end self-attestation of qualifying conditions and require enrollees to submit documentation, a standard more than two dozen states had not built into their systems, according to KFF.

Nebraska, which launched its own work requirement on May 1 under a nearly 300-page list of qualifying conditions, must now overhaul its approach to match the stricter federal standard. Medicaid enrollees in Nebraska are scheduled to begin losing coverage this summer. Nebraska Appleseed program director Sarah Maresh called on the state to pause coverage terminations until it can implement the required changes.

Update, June 5, 2026: The Centers for Medicare and Medicaid Services released an interim final rule on Medicaid work requirements, mandating that people already diagnosed with conditions such as sickle cell disease provide additional proof they are “greatly impaired” from working, stripping automatic medical frailty exemptions that states including Nebraska had retained under voluntary programs. All states with Medicaid expansion must implement the requirements by January 1, 2027. A 60-day public comment period is now underway.

Jennifer Wagner, director of Medicaid eligibility and enrollment at the Center on Budget and Policy Priorities, told Mother Jones that state officials were blindsided by the new medical frailty definition, which was never raised in prior talks between states and the federal government. Wagner attributed the stricter standard to White House pressure and said accurate implementation by the January 1 deadline is not realistic for most states.

Maria Town, president and CEO of the American Association of People with Disabilities, noted that work performed through Medicaid-supported employment programs does not qualify as “community engagement” under the rule, disqualifying a category of paid labor already performed by disabled enrollees. The Urban Institute projects that work requirements and more frequent eligibility checks could reduce Medicaid enrollment by up to 10.1 million people by 2028, with the new rule’s restrictions expected to push outcomes toward the high end of that range.

Update, June 12, 2026: The Centers for Medicare & Medicaid Services released final rules on June 1 detailing how states must verify that Medicaid enrollees meet the new work requirements established by the One Big Beautiful Bill Act. The rules apply to roughly 18.5 million people covered through Medicaid expansion, who must now document 80 hours per month of qualifying activity such as paid work or approved coursework.

Most states face a January 1, 2027, enforcement deadline, though Nebraska began enforcing the rules in May and Arkansas plans a soft launch in July with no coverage penalties until 2028. Enrollees may self-attest to qualifying hours or medical exemptions in 2027, but states will begin requiring supporting documentation the following year, according to KFF Health News.

Consumer advocates and researchers warn that states face financial penalties for incorrectly granting medical exemptions, which could push agencies to deny coverage to people still eligible. The rules also leave the definition of “medically frail” to each state’s discretion, a gap that Carolyn Sheridan of the National Organization for Rare Disorders said will produce inconsistent outcomes for patients with serious conditions across state lines.

Update, June 25, 2026: West Virginia is moving to implement Medicaid work requirements set to take effect Jan. 1, 2027, under the One Big Beautiful Bill Act. The West Virginia Department of Human Services launched wvmedicaidhelp.org on June 24 to field questions about the new rules and is urging the state’s 161,184 Medicaid expansion enrollees to update their contact information with the state.

Under the law, adults ages 19 through 64 in the expanded Medicaid program must document at least 80 hours per month of work or approved community activity to keep coverage. Christy Donohue, DoHS Commissioner of the Bureau for Medical Services, said the department is on track to meet the federal deadline and is building automated data verification into its eligibility systems to reduce the paperwork burden on enrollees.

Pregnant people, Native Americans, and caregivers of children under 14 or disabled adults are exempt from the requirements. The state is asking recipients to monitor correspondence before Jan. 1 and check the new site for updates, according to West Virginia Watch.

Update, June 29, 2026: Twenty-five Democratic-led states plus the District of Columbia filed suit against the Trump administration over an interim final rule that narrows who qualifies as “medically frail” under Medicaid work requirements, Stateline reported. The lawsuit names HHS Secretary Robert F. Kennedy, Jr. and CMS Administrator Mehmet Oz as defendants.

The rule, published by HHS and CMS earlier in June, requires Medicaid recipients to demonstrate both a significant health condition and significant impairment in their ability to work before claiming the “medically frail” exemption. State officials, including Massachusetts Attorney General Andrea Joy Campbell, who helped lead the suit, said the two-part standard was never raised during months of prior implementation talks with CMS.

States face an August 31, 2026, deadline to notify Medicaid recipients of the new definition and will face financial penalties for missing it. The lawsuit asks a federal court to stay the rule and vacate parts of it before the broader work requirements take effect on January 1, 2027.

Update, July 7, 2026: Indiana has become one of the first states to publish implementation rules for Medicaid work requirements under the 2025 federal tax law. The Indiana Family and Social Services Administration announced that able-bodied adults ages 19-64 enrolled in the Healthy Indiana Plan must log 80 hours of work, school, or volunteering per month beginning Jan. 1, 2027. New applicants must satisfy the requirement starting in October, under a three-month lookback rule.

FSSA Secretary Mitch Roob told reporters he cannot project how many enrollees will fail to qualify for an exemption. Healthy Indiana Plan enrollment has already dropped from 671,000 when Gov. Mike Braun signed the work requirement law last April to approximately 487,000 in June, six months before compliance checks begin.

Roob also confirmed the requirements are not expected to produce savings for Indiana’s general fund, because the expansion population is financed primarily through federal dollars and hospital assessment fees. The Urban Institute and Robert Wood Johnson Foundation estimate that 102,000 to 116,000 Hoosiers could lose eligibility once the mandate takes effect, according to the Indiana Capital Chronicle.

Update, July 10, 2026: A KFF Health News investigation published July 10 found that the Medicaid work requirements in the One Big Beautiful Bill Act create compounded obstacles for more than one million farmworkers who are U.S. citizens or legal permanent residents. Beginning Jan. 1, 2027, 43 states and the District of Columbia must require many Medicaid enrollees to document at least 80 hours of monthly work or education. Alexis Guild, vice president of strategy and programs at Farmworker Justice, told KFF Health News that farmworkers routinely exceed that threshold during harvest season but fall below it in off-season months when informal jobs replace farm work.

The law also doubles verification frequency, requiring beneficiaries to prove eligibility at least twice a year rather than once. Akeiisa Coleman, an assistant vice president at The Commonwealth Fund, said missed letters and unfiled forms could strip coverage from workers who are legally entitled to it. CMS Administrator Mehmet Oz announced a nationwide implementation framework in June but did not address seasonal or migrant worker circumstances.

A 2021-22 California survey cited in the report found that 47% of female farmworkers and 37% of male farmworkers had at least one chronic health condition. Adriana Cadena, executive director of Protecting Immigrant Families, said workers without preventive coverage turn to emergency rooms, raising costs and wait times across the healthcare system. Farmworkers who relocate between states face the additional burden of transferring coverage while moving.

Update, July 12, 2026: Arkansas officials have launched a “soft launch” of Medicaid work requirements set to take effect in January under the One Big Beautiful Bill Act, signed by President Donald Trump. The state is now verifying whether expansion enrollees meet those requirements before the January deadline, with no coverage losses permitted until then.

State officials estimate up to 42,000 Medicaid expansion enrollees could lose coverage once the requirements activate. Centene, one of two insurers administering the state’s Medicaid expansion, has announced it will exit the program in January, compounding the disruption for enrollees already facing termination risk.

Arkansas already leads the nation in the share of rural hospitals vulnerable to closure, and labor and delivery units have been disappearing from communities across the state. When Arkansas ran work requirements in 2018, 18,000 people lost coverage, and a 2019 New England Journal of Medicine analysis found no measurable employment gains.

Update, July 20, 2026: Final federal regulations issued in June require Medicaid enrollees subject to the work rule to begin proving 80 hours of monthly qualifying activity starting Jan. 1, 2027, in most states. Enrollees seeking a medical exemption must obtain documentation of “medical frailty” from a clinician, a standard that 25 mostly Democratic-led states are now challenging in federal court.

Physicians including Alice Thornton, who has treated patients living with HIV in Lexington, Kentucky, for more than two decades, say they are not trained to evaluate whether a patient’s condition prevents employment. The American Medical Association president Willie Underwood III said the rule “transforms the clinical encounter into an eligibility gatekeeping process,” warning that patients who fear their disclosures could affect coverage will stop communicating honestly with their doctors.

CMS administrator Mehmet Oz said on June 1 that “documentation should be relatively easy to provide,” and the agency confirmed that states will make final medical frailty determinations. Enrollees who cannot secure provider documentation may self-attest under penalty of perjury, but only twice in 2027 and once in 2028. [Source: KFF Health News, July 20, 2026]

Update, July 22, 2026: Nevada and 24 other states with Democratic attorneys general, joined by the District of Columbia, sued the Trump administration in July over the Medicaid work requirements, targeting federal guidelines that narrowed the definition of “medically frail.” The Trump administration published those 300-page interim guidelines on June 1, leaving states seven months before the January 1, 2027 deadline to comply.

Nevada health officials have since finalized a “medically frail” definition that requires both a qualifying condition, such as a disabling mental health disorder or serious medical condition, and documented impairment in a person’s ability to work, attend school, or volunteer for the required 80 hours per month. Starting October 1, 2026, about 5,000 legally present immigrants in Nevada will lose Medicaid coverage regardless of whether they meet the work requirements, under a separate provision of the law.

On September 1, the Nevada Health Authority will notify all 280,000 Medicaid expansion enrollees by email, text, and mail about the coming changes, according to spokesperson Chloe Chism. Enrollees can self-attest work compliance through 2027 but must provide documentation starting in 2028. The agency has hired additional navigators using new grant funding to help members facing coverage loss.

Update, July 24, 2026: Idaho plans to begin enforcing Medicaid work requirements on Jan. 1, 2027, following the state’s adoption of the One Big Beautiful Bill Act this spring. Idaho Medicaid Administrator Sasha O’Connell said a state review found 68,400 of roughly 83,000 Medicaid expansion enrollees already met the 80-hours-per-month threshold. The Idaho Department of Health and Welfare is sending outreach letters to affected households this month ahead of the January start date.

Idaho adopted a three-month lookback period, the maximum allowed under federal law, requiring applicants to document qualifying activity in the three months before applying. According to KFF, a nonpartisan health policy research organization, only two other states, Indiana and North Carolina, plan to use a lookback period that long. Enrollees will also be required to reapply for coverage every six months, up from once per year.

An analysis by the Urban Institute and the Robert Wood Johnson Foundation projects the law’s work requirements and other changes could remove between 20,000 and 34,000 Idahoans from Medicaid expansion by 2028. Roughly 85,000 Idahoans are currently enrolled in the program, which voters approved through a 2018 ballot initiative. The Department of Health and Welfare plans to hold virtual town halls in the coming months to inform enrollees of the new requirements.

Update, July 31, 2026: A federal judge in Massachusetts denied a bid from 25 Democratic-led states to pause implementation of the Medicaid work requirements mandated by the One Big Beautiful Bill Act, leaving the Jan. 1 deadline set by Congress intact. U.S. District Judge Richard Stearns ruled that the states had not shown their implementation costs clear the threshold required for injunctive relief, and noted that CMS has agreed to cover 90% of those costs.

Nebraska became the first state to implement the requirements, applying them to new enrollees on May 1 and to existing enrollees starting Aug. 1. As of July 19, state officials reported 317 initial applications denied and 65 renewal applications denied for failure to meet the 80-hour-per-month work rule, according to the Nebraska Examiner. Health advocates at a Nebraska Appleseed forum described wait times of up to 90 minutes on the state’s Medicaid phone line and said the Spanish-language help line was out of service for more than six weeks between May 15 and July 1.

Nebraska’s Department of Health and Human Services has not set a date to begin public reporting on coverage losses under the new rules. Dawson County received a temporary exemption after the closure of a Tyson Foods plant drove local unemployment above state averages. State Sen. John Fredrickson, a mental health professional on the Legislature’s Health and Human Services Committee, said implementation disruptions could trigger medical crises that would otherwise be preventable.

Update, August 3, 2026: U.S. District Judge Richard Stearns of Massachusetts rejected a motion by 25 Democratic-led states to pause implementation of Medicaid work requirements. States must now meet a January 1 compliance deadline set by Congress under the One Big Beautiful Bill Act, which requires Medicaid expansion enrollees to document at least 80 hours per month of work, school, or volunteer activity to keep their coverage.

The states, along with the governors of Kentucky and Pennsylvania, sued CMS and HHS on June 29 over federal guidance that narrowed the definition of “medically frail,” the designation that exempts people with serious disabilities from the monthly reporting requirement. Stearns ruled the plaintiffs had not demonstrated sufficient harm to justify blocking implementation, citing a federal commitment to cover 90% of states’ administrative costs and noting that Congress, not CMS, set the January 1 deadline.

The court acknowledged “difficult issues” around the scope of authority Congress delegated to HHS and raised questions about CMS Administrator Dr. Mehmet Oz’s “faithfulness to Congressional intent.” The Urban Institute estimated that between 3 million and 7 million people could lose Medicaid coverage under the new requirements, with that figure rising to 10 million over the next decade when more frequent eligibility checks are included.

Update, August 5, 2026: Indiana will begin enforcing federal Medicaid work requirements on Jan. 1, 2027 for adults enrolled in the Healthy Indiana Plan, the state’s Medicaid expansion program, under Senate Enrolled Act 1. Those adults must complete and report at least 80 hours per month of qualifying activity — including work, job training, or community service — to keep their coverage. Because Indiana will review the prior three months of activity, many enrollees must begin logging hours by October 2026 to avoid losing coverage when enforcement starts.

FSSA Secretary Mitch Roob announced in January 2025 that Indiana would shift from annual to quarterly eligibility checks, and starting Jan. 1, 2027, HIP members will face formal redeterminations every six months rather than once a year, per the Indiana Capital Chronicle. Advocates including Ann McCafferty of the Indiana Rural Health Association and Susan Jo Thomas of Covering Kids and Families of Indiana say that confusing notices and a lack of reporting infrastructure will cause eligible people to lose coverage through paperwork failures, not actual ineligibility.

Children, pregnant women, adults over 65, Medicare enrollees, and parents of children age 13 or younger are exempt from the new requirement. FSSA has cited a Paragon Health Institute analysis of Indiana’s Medicaid expansion enrollment as justification for the tighter verification rules.

Update, August 9, 2026: Indiana will implement Medicaid work requirements for its Healthy Indiana Plan expansion population on January 1, 2027, the Indiana Capital Chronicle reported. Adults on HIP must document at least 80 hours per month of qualifying activities to retain coverage. New applicants starting January 1 must show compliance going back to October 2026 under a three-month lookback rule.

The Indiana Family and Social Services Administration began texting HIP members from the number 43816 on July 21 with general information about the new requirements. The agency, partnering with Covering Kids & Families, will host public town halls in Goshen on August 17 and in Fort Wayne on September 1.

The FSSA has also launched an anonymous online screening tool for enrollees to determine whether they qualify for an exemption; parents caring for children age 13 or younger are among those who would not face the requirement. The state will review each member’s compliance at least every six months.