Most Medicaid adults ages 50 to 64 who face the new work rules are already working or could qualify for an exemption, nonprofit KFF found. They still have to prove it, and that is where coverage is at risk.
The same analysis found that fewer than half of Medicaid adults 50 to 64 would meet the requirement through a job or school alone, compared with 72% of those ages 19 to 27 and 66% of those 27 to 49.
The Congressional Budget Office estimated the work requirements would cause nearly 5 million people to become uninsured.
States must generally start enforcing the rules by Jan. 1, 2027, according to the Centers for Medicare & Medicaid Services. The requirement covers 43 states and Washington, D.C.
What counts and who is exempt
The rule applies to adults ages 19 to 64 in the Medicaid expansion group who are not pregnant and not on Medicare. That group is low-income adults who became eligible when their state expanded Medicaid under the Affordable Care Act.
They need 80 hours a month of work, community service or a work program. Enrolling at least half-time in school counts, as does earning at least 80 times the federal minimum wage, which CMS sets at $580 a month in 2026.
Exemptions include:
- Parents or caregivers of a child 13 or younger or of a person with a disability
- Veterans with a total disability rating
- People considered medically frail (their health keeps them from working)
- People in substance use treatment
- People who already meet SNAP (Supplemental Nutrition Assistance Program) or TANF (Temporary Assistance for Needy Families) work rules
States may add short-term hardship exceptions, such as living in a disaster area or a high-unemployment county.
Where the paperwork can sink you
States must check compliance at application and at renewal. If a state cannot verify it, the enrollee gets a notice and 30 calendar days to show compliance or an exemption.
CMS says someone who does not respond might be denied or disenrolled but can reapply at any time.
States are supposed to start with data they already hold, such as unemployment and education records. Health policy researchers told KFF Health News that enrollees may be allowed to attest to their hours in 2027 when the data falls short, with proof such as pay stubs, medical records or doctors’ notes likely required later.
Morgan Henderson of the Hilltop Institute warned that the higher the manual reporting burden, the fewer people will complete it.
Definitions also differ. Carolyn Sheridan of the National Organization for Rare Disorders noted that someone could be medically frail in Nebraska but not in Delaware, because states set their own severity standards.
Losing Medicaid this way does not hand you a fallback. KFF reports that adults who lose Medicaid for not meeting the requirements are ineligible for premium tax credits, which are the subsidies that lower the cost of Marketplace plans.
What to do before January
Check with your state Medicaid agency on its start date. Nebraska began enforcing in May, and Montana started in July and began denying or disenrolling people who do not comply in October.
Keep a monthly log with pay stubs, volunteer letters, school enrollment records, and a doctor’s note if you are medically frail. Unpaid family caregiving may qualify you for an exemption, and caregivers may also qualify for tax breaks.
If you need qualifying hours quickly, consider jobs for a career change, which include options with or without a degree.
Open every state notice the day it arrives. The 30-day clock is already ticking.
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