By Jan. 1, 2027, states must require many adults on Medicaid expansion to prove they work, volunteer or study for 80 hours a month. The rule comes from the 2025 federal budget reconciliation law, and an interim final rule spells out how it works. The requirement runs through age 64, and age alone does not exempt anyone.
That puts adults ages 50 to 64 under the requirement in 43 states and D.C. Covered adults must show compliance when they apply and renew, and states may check more often.
What counts and who is exempt
The 80 hours can come from work, community service, a work program or half-time school, and hours can be combined. Earning at least $580 a month in 2026, the federal minimum wage times 80 hours, also meets the requirement.
Exemptions include people who are medically frail or disabled, parents or caretakers of a child 13 or younger or of a person with a disability, veterans with a total disability rating, and people who already meet Supplemental Nutrition Assistance Program (SNAP) or Temporary Assistance for Needy Families (TANF) work rules.
Adults on Medicare are not covered by the requirement, and neither are people who qualify for Medicaid through disability.
Why older enrollees are the ones to watch
In 2023, among Medicaid adults ages 50 to 64 who did not receive Supplemental Security Income (SSI) or Social Security Disability Insurance (SSDI) and did not have Medicare, KFF reported that 37% worked full time and 15% worked part time.
Another 20% cited illness or disability, and 9% cited caregiving. Many of them would meet the rule or qualify for an exemption. The risk is proving it on time.
Arkansas offers the closest precedent. About 18,000 people lost coverage under its 2018 work requirement, and the Congressional Budget Office (CBO), citing Arkansas research, found many participants did not know about the requirement or found it too burdensome to document, according to KFF.
KFF’s brief also says that Georgia’s interim evaluation found its work requirement significantly lowered enrollment, particularly among adults 50 to 64.
Projections for the national rule vary. The CBO estimated that work requirements in the House-passed version of the law would add 4.8 million people to the uninsured in 2034, and KFF notes the agency has not published an updated estimate for the enacted law.
An Urban Institute analysis projected that extending the requirement from age 55 to age 64 would cost an additional 1 million adults their federally funded Medicaid coverage in 2026. These are modeled estimates, not counts.
What to do before January
If a state cannot verify compliance, it sends a notice, and the enrollee has 30 calendar days to show compliance or an exemption.
Keep pay stubs, volunteer hour logs, school enrollment records and caregiving documentation in one folder. Anyone who may qualify as medically frail can ask a doctor about documenting it now rather than during a 30-day window.
Applicants must meet the requirement for at least one month before applying, and existing enrollees must meet it for one or more months between renewals.
The requirement ends at 65. The Medicare enrollment windows set when Medicare coverage can start, and some programs that help pay Medicare costs are income-based.
Nebraska began enforcing the requirement May 1; other states can start before Jan. 1. Federal officials can let a state delay as late as Dec. 31, 2028, so a state agency notice may set the date that matters.
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