Learn About Medicaid Work Requirements Changes

What Are Medicaid Work Requirements?

Medicaid work requirements are rules that some states have added to their Medicaid programs. These rules require certain adults to work, participate in work-related activities, or report their work status to keep their Medicaid coverage. Work requirements vary significantly by state—some states have them, while others do not. Understanding what work requirements mean in your state is important because the rules differ in scope, who they apply to, and what activities count as meeting the requirement.

Work requirements typically apply to adults aged 19-64 who do not have dependent children and are not pregnant, disabled, or in other protected categories. Some states have broadened these categories over time. The basic concept is that individuals must work at least part-time or engage in qualifying activities for a set number of hours per week—commonly 20 to 30 hours. States that have implemented work requirements report varying numbers of people affected. For example, Arkansas, which implemented work requirements in 2018, reported that approximately 16,500 people lost coverage within the first year due to non-compliance, according to data from the Arkansas Department of Human Services.

The types of activities that count toward work requirements typically include:

• Paid employment (part-time or full-time)
• Self-employment
• Job training programs
• Vocational education programs
• Community service work
• School or educational programs
• Caregiving for family members (in some states)
• Participation in work-search activities

Practical takeaway: If you live in a state with work requirements, review the specific list of qualifying activities for your state's program. Each state defines these differently, and activities that count in one state may not count in another.

Which States Have Implemented Work Requirements?

As of 2024, several states have work requirements in place or have had them approved but not yet implemented. The landscape continues to change as states apply for federal waivers to modify their Medicaid programs. States that have implemented work requirements include Arkansas, Arizona, Indiana, Kentucky, Kansas, New Hampshire, Ohio, and several others. Additional states have received approval from the federal government to implement work requirements but have delayed implementation due to legal challenges or policy changes.

The process for a state to implement work requirements involves submitting a waiver request to the Centers for Medicare and Medicaid Services (CMS), which is part of the federal government. The CMS must approve these requests. Between 2017 and 2021, multiple states requested and received approvals, but some of these have faced legal challenges. In 2023, the Biden Administration announced policy changes that made it harder for states to implement new work requirements, though existing programs in some states continued.

States with active or recently active work requirements include:

• Arkansas (began 2018, suspended in 2020, resumed in 2023)
• Arizona (implementation delayed, legal challenges ongoing)
• Indiana (selective implementation)
• Kentucky (approved, implementation timeline varies)
• Kansas (approved)
• New Hampshire (approved with modifications)
• Ohio (approved)
• Tennessee (approved)
• Utah (approved)

It is important to note that work requirements have been particularly controversial. Research from the Urban Institute and other policy organizations has documented mixed results. A study of Arkansas's work requirements found that the policy led to coverage losses but did not significantly increase employment rates among those affected. Legal challenges have also shaped the implementation timeline, with several court cases ruling that certain work requirement programs violated federal Medicaid law or administrative procedures.

Practical takeaway: Check your state's Medicaid website or contact your state's Medicaid office to find out whether your state currently has work requirements and what the specific rules are. The status and details of these programs can change, so official state resources provide the most current information.

How Work Requirements Affect Coverage and Reporting

When a state has work requirements in place, people covered under Medicaid must typically report their work status or qualifying activities at regular intervals—usually monthly or quarterly. Failure to report or failure to meet the hour requirements can result in a loss of Medicaid coverage. The reporting process varies by state but often can be done online, by phone, by mail, or in person at a local office.

The consequences of not meeting work requirements can be severe. People who lose Medicaid coverage due to work requirement non-compliance may face gaps in health insurance, which can lead to delayed medical care, unpaid medical bills, and other financial hardship. Medical debt is one of the leading causes of personal bankruptcy in the United States, and loss of insurance coverage increases this risk. Data from the Kaiser Family Foundation indicates that people without insurance are significantly more likely to delay or skip needed medical care.

However, there are exemptions and hardship provisions in most work requirement programs. Common exemptions include:

• Pregnancy and the postpartum period (typically 12 months after birth)
• Disability or serious medical conditions
• Being the primary caregiver for a dependent child or disabled family member
• Being homeless or lacking housing stability
• Age—those under 19 or over a certain age (varies by state, often 65)
• Seasonal employment or temporary unemployment (varies by state)
• Inability to find work due to local labor market conditions

Many states have established "good cause" exceptions that allow people to miss the deadline for reporting without losing coverage if they have a documented reason, such as illness, loss of childcare, or a family emergency. These exceptions are not automatic—they require documentation and often must be requested. People who receive a notice of coverage loss due to work requirement non-compliance typically have a period to appeal or demonstrate that they meet an exemption.

Practical takeaway: If you live in a state with work requirements, establish a system for tracking your work hours and reporting deadlines. Mark the deadline on your calendar, keep records of your employment or qualifying activity, and understand your state's process for appealing a coverage loss. If you think you may qualify for an exemption, gather documentation of that circumstance before the reporting deadline.

Understanding Exemptions and Hardship Provisions

Exemptions and hardship provisions are critical protections within work requirement programs. These provisions recognize that not all adults can work due to circumstances beyond their control. However, obtaining an exemption typically requires actively requesting it and providing evidence to support the request. Many people who would otherwise qualify for an exemption lose coverage because they are not aware of the exemption, do not know how to request it, or fail to provide sufficient documentation within the required timeframe.

The documentation required for an exemption varies. For disability, a person might need to provide medical records or a letter from a healthcare provider. For caregiving responsibilities, documentation might include birth certificates for children or medical records for disabled family members. For homelessness, proof might include a letter from a shelter or social service agency. In some cases, the state's Medicaid office may contact the person's healthcare provider to verify medical conditions, but this is not automatic—individuals often must initiate the verification process.

Medical hardship exemptions are available in some states and allow individuals to request temporary exemptions if meeting work requirements would interfere with necessary medical treatment. For example, if someone requires chemotherapy or kidney dialysis and the treatment schedule makes full-time work impossible, they may request a hardship exemption. However, the definition of what qualifies as a medical hardship is narrow in some states and broader in others.

The duration of exemptions also varies. Some exemptions are temporary—such as the postpartum period, which lasts a defined number of months—while others may be permanent if the qualifying circumstance is permanent, such as a documented permanent disability. People must reapply for exemptions periodically to confirm that their circumstances have not changed. Failure to reapply when an exemption expires results in coverage loss unless the individual meets the work requirements or another exemption applies.

Research on work requirement exemptions shows that many people who qualify for exemptions do not receive them. A University of Michigan study of the Arkansas work requirement program found that among people who lost coverage, a substantial portion likely qualified for an exemption but either did not know