Federal Medicaid work requirements are no longer just a policy debate. As of 2026, they are law. The One Big Beautiful Bill Act, signed in 2025, mandates that states condition Medicaid eligibility for expansion adults (ages 19 to 64) on meeting community engagement requirements starting January 1, 2027. Several states are not waiting for the federal deadline. Nebraska, Montana, Iowa, and Arkansas have announced early implementation through 2026. Georgia has operated a work requirement program since 2023 under a Section 1115 waiver.
This article tracks every state with an active, pending, or planned Medicaid work requirement as of May 2026, explains what the federal law requires, and outlines who is exempt.
What Are Medicaid Work Requirements?
Medicaid work requirements, also called community engagement requirements, condition Medicaid coverage on meeting a monthly threshold of qualifying activities. These activities include:
- Employment (paid work)
- Job training or a workforce development program
- Education enrollment (at least half time)
- Volunteering or community service
- A combination of the above
Under the 2025 federal law, the minimum threshold is 80 hours per month. Some states with pending 1115 waiver requests have sought to require more than the federal minimum.
Work requirements apply only to the Medicaid expansion population: adults ages 19 to 64 who gained coverage under the ACA Medicaid expansion. People on traditional Medicaid, including children, pregnant women, seniors, and people with disabilities, are not subject to these rules.
Federal Law: What the 2025 Reconciliation Act Requires
The 2025 budget reconciliation law established mandatory work requirements for Medicaid expansion adults nationwide. Key provisions:
- Who it covers: Adults ages 19 to 64 enrolled in the ACA Medicaid expansion group
- Hours required: At least 80 hours per month of qualifying activity
- Federal deadline: States must implement by January 1, 2027
- Early implementation: States may implement sooner through a state plan amendment (SPA) or an approved Section 1115 waiver
This is a significant shift. Under previous administrations, work requirements required CMS approval via Section 1115 waivers and were frequently overturned in court. The 2025 law removes that barrier, making them mandatory for expansion states and enforceable regardless of waiver status.
Who Is Exempt from Work Requirements?
The federal law includes several mandatory exemptions. Individuals who do not have to meet the work requirement include:
| Exempt Group | Details |
|---|
| Parents and caregivers | Must be caring for a child age 13 or younger, or a disabled individual |
| Pregnant women | Covered during pregnancy and the postpartum period |
| Medically exempt individuals | Those receiving care in hospitals, nursing facilities, or psychiatric facilities |
| Disaster-affected individuals | Residents of a federally declared disaster area |
| High-unemployment county residents | Counties with unemployment above 8%, or 1.5 times the national rate (subject to HHS approval) |
| Long-distance medical travelers | Individuals or dependents required to travel outside their home county for extended medical care |
States may also add additional exemptions beyond the federal floor. For example, Georgia extended exemptions to parents of children under age 6 in its 2026 program extension.
2026 State-by-State Tracker
States with Active Work Requirements
Georgia
Georgia is the only state currently operating a Medicaid work requirement program, known as Georgia Pathways to Coverage. Launched in July 2023 under a Section 1115 waiver, the program requires 80 hours of qualifying activity per month. CMS approved an extension of the program through December 31, 2026. After that date, Georgia must transition to the new federal framework effective January 1, 2027.
Enrollment has been far lower than projected. As of March 2026, roughly 16,183 people were enrolled. The Georgia Budget and Policy Institute estimates that only about 18,301 will be enrolled by October 2026, compared to the 359,000 who would gain coverage under full Medicaid expansion.
Key program changes for 2026: participants now report activities annually rather than monthly, and caregivers of children under age 6 are newly exempt.
| Detail | Georgia Pathways |
|---|
| Status | Active (1115 waiver) |
| Launched | July 2023 |
| Hours required | 80 per month |
| Expiration | December 31, 2026 |
| Reporting | Annual (changed from monthly in 2026) |
| Current enrollment | Approx. 16,183 (March 2026) |
States Implementing Early in 2026
These states are moving ahead before the January 2027 federal deadline, using state plan amendments rather than 1115 waivers.
Nebraska
Nebraska is the first state to implement work requirements under the new federal law. Enforcement began May 1, 2026, via a state plan amendment. Expansion adults who do not meet the 80-hour monthly requirement are subject to disenrollment.
Montana
Montana announced implementation effective July 1, 2026. Montana had also submitted a Section 1115 waiver requesting work requirements for expansion adults ages 19 to 64 and seeking additional state-level exemptions, though the waiver pathway has become less relevant given the federal mandate.
Arkansas
Arkansas announced a "soft implementation" starting July 1, 2026. Under this approach, the state will begin tracking work activity but will not disenroll anyone for noncompliance until January 1, 2027, when the federal requirement takes effect nationwide. Arkansas is notable for its history with work requirements: it was the first state to implement them under a 2019 waiver, before a federal court struck the program down.
Iowa
Iowa has set a December 1, 2026 implementation date via a state plan amendment, just one month before the federal deadline.
| State | Implementation Date | Method | Disenrollment Begins |
|---|
| Nebraska | May 1, 2026 | State plan amendment | May 2026 |
| Montana | July 1, 2026 | State plan amendment | July 2026 |
| Arkansas | July 1, 2026 (soft) | State plan amendment | January 1, 2027 |
| Iowa | December 1, 2026 | State plan amendment | December 2026 |
States with Pending 1115 Waiver Requests
Several states submitted Section 1115 waiver applications to CMS requesting approval for work requirements. With the passage of the federal mandate, most of these states are not expected to continue pursuing waiver approval, since a state plan amendment is now sufficient. However, the following states had pending waiver requests as of early 2026:
| State | Waiver Status | Notes |
|---|
| Arizona | Pending | Submitted under second Trump administration |
| Arkansas | Pending | Also pursuing SPA for early implementation |
| Iowa | Pending | Also pursuing SPA for early implementation |
| Montana | Pending | Also pursuing SPA for early implementation |
| Ohio | Pending | No early implementation announced |
| South Carolina | Pending | No early implementation announced |
| Utah | Pending | No early implementation announced |
States with No Active, Pending, or Announced Plans
Expansion states not listed above have not publicly announced early implementation plans. All expansion states, including California, New York, Illinois, Michigan, and others, will be required to implement work requirements by January 1, 2027 under federal law.
Non-expansion states (Texas, Florida, Wisconsin, Kansas, Tennessee, Wyoming, Mississippi, Alabama, South Carolina, Georgia before Pathways) are not affected by the expansion work requirement, since they do not have an expansion population.
What Counts as Qualifying Activity?
The 80-hour monthly requirement can be met through a combination of activities. The federal law and most state proposals recognize the following:
- Paid employment (full-time, part-time, or self-employment)
- Job search activities (in some states, for a limited number of hours)
- Job training and workforce development programs
- Vocational education or GED/skills training
- College enrollment (at least half-time)
- Community service or volunteering
- Substance use disorder treatment (in some state plans)
- Caregiving (meeting the exemption criteria removes the requirement entirely)
States have some flexibility in how they define and verify qualifying activities, so the specific documentation requirements will vary.
How Work Requirements Are Enforced
Under the Georgia Pathways model, participants log their activities through an online portal. Noncompliance results in loss of Medicaid coverage. Under the 2026 reporting change, Georgia shifted from monthly to annual reporting, reducing the administrative burden on enrollees.
Under the new federal framework, enforcement details are left partly to states, but the core mechanism is the same: failure to report 80 qualifying hours in a month can trigger a loss of coverage. Individuals who are disenrolled due to noncompliance can reapply once they demonstrate compliance.
Advocates and health policy researchers have raised concern that administrative burden, not actual lack of work activity, will be the primary cause of coverage loss. Research on the 2019 Arkansas program found that roughly 18,000 people lost coverage in a matter of months, largely due to reporting failures rather than actual unemployment.
Projected Impact
The Congressional Budget Office estimated that the work requirement provisions in the 2025 reconciliation law would cause approximately 8.6 million people to lose Medicaid coverage by 2034. The KFF (Kaiser Family Foundation) and the Center on Budget and Policy Priorities have noted that the vast majority of Medicaid expansion adults who work are already working, but many may lose coverage due to difficulty navigating reporting requirements.
Research from the Georgia Pathways program illustrates the enrollment challenge. Despite being eligible, the program enrolled only about 5% of the projected population in its first three years.
What to Do If You Receive a Work Requirement Notice
If you are enrolled in Medicaid and receive a notice about work requirements, take these steps:
- Read the notice carefully. Check whether your state has implemented early requirements or whether the notice is informational ahead of the January 2027 deadline.
- Confirm your exemption status. If you are a parent of a child under 13, pregnant, disabled, or otherwise exempt, document that status and submit it to your state Medicaid agency.
- Register for the reporting portal. Most states will require online activity reporting. Set up an account early and document your qualifying hours.
- Contact your state Medicaid office. If you have questions about your specific situation, contact your state agency directly.
- Check if you qualify for other coverage. If you lose Medicaid due to work requirements, you may qualify for ACA Marketplace coverage with income-based subsidies. Use our free benefits screener to check eligibility across multiple programs.
Medicaid Work Requirements and the 1115 Waiver Process
Section 1115 of the Social Security Act gives the federal government authority to waive normal Medicaid rules for states running approved demonstration projects. For years, work requirements existed only through this waiver process, and they required CMS approval.
The 2025 reconciliation law changed that structure. Work requirements are now a federal mandate, not a waiver option. States can still use a Section 1115 waiver to go beyond the federal requirements (for example, to add additional qualifying activities, require more than 80 hours, or expand exemptions), but the baseline requirement is now statutory.
This matters because the waiver pathway was frequently challenged in court. The Biden administration revoked several approved waivers. The statutory mandate makes legal challenges more difficult.
Frequently Asked Questions
Who has to meet Medicaid work requirements?
The requirement applies to adults ages 19 to 64 who are enrolled in Medicaid through the ACA expansion. People on traditional Medicaid, including children, pregnant women, seniors (65+), and people with disabilities, are not subject to work requirements.
How many hours per month is required?
The federal minimum is 80 hours per month of qualifying activity. Some states may propose higher thresholds through 1115 waiver requests, though most early-implementing states are using the 80-hour federal floor.
What if I am already working but lose Medicaid due to a reporting problem?
You have the right to appeal. Contact your state Medicaid agency and request a hearing. Document your work activity and submit it as part of the appeal. Several advocacy organizations also offer free legal help for Medicaid appeals.
Does working affect my Medicaid eligibility based on income?
Yes, separately from work requirements. Medicaid eligibility is income-based. If your income rises above the eligibility threshold, you may no longer qualify regardless of work requirements. In expansion states, the income limit for adults is 138% of the Federal Poverty Level (FPL), which is approximately $20,783 per year for a single adult in 2026. Use our benefits screener to check current income limits for your state.
When do work requirements take effect in my state?
If you live in Nebraska, they are already in effect (May 2026). Montana and Arkansas begin July 2026. Iowa begins December 2026. All other expansion states are required to implement by January 1, 2027. Check with your state Medicaid agency for the most current timeline.
Can I lose Medicaid if I am unemployed but looking for work?
It depends on your state's rules. Some states count job search activities toward the 80-hour requirement. Others do not. If you are unemployed and actively looking for work, contact your state Medicaid office to understand what documentation you can submit to maintain coverage.
What is Georgia Pathways?
Georgia Pathways to Coverage is Georgia's Section 1115 waiver program, launched in July 2023. It is the only active Medicaid work requirement program currently operating. It covers adults ages 19 to 64 who meet work or community engagement requirements. The program is set to expire December 31, 2026, after which Georgia will transition to the federal framework.
Does my state have to implement work requirements if it did not expand Medicaid?
No. The work requirement mandate only applies to states that expanded Medicaid under the ACA. States that have not expanded Medicaid, such as Texas, Florida, and Mississippi, do not have an expansion population subject to these rules.
Where can I check my current Medicaid eligibility?
Use the Benefits Navigator free screener to check Medicaid eligibility, income limits, and other benefit programs for your state. You can also contact your state Medicaid agency directly or visit benefits.gov.
