Starting Jan. 1, 2027, most adults ages 19 to 64 who are covered through the Affordable Care Act’s Medicaid expansion and are not on Medicare must show they spend at least 80 hours a month working, volunteering, training, or studying to keep their coverage.
The requirement comes from the 2025 federal budget law, and the Centers for Medicare & Medicaid Services (CMS) fleshed out the details in an interim final rule in 2026. Adults in their 50s and early 60s are where the analyses point to the most trouble.
Who has to prove 80 hours
CMS says about 43 states and Washington, D.C., must implement the requirement. Qualifying activities include employment, certain work programs, community service or at least half-time school. Earning at least $580 a month, which is 80 hours at the federal minimum wage, also counts.
States check at application and at every renewal, which happens at least every six months under the law, according to nonprofit KFF. If a state cannot confirm compliance, the person gets 30 days to respond. If they miss that window, the state denies or ends coverage, though the person can reapply.
The CMS fact sheet lists exemptions for disabled or medically frail adults, parents and caretakers of children younger than 14, pregnant and postpartum women, veterans with total disability ratings and several other groups.
States may start earlier than January 2027, and KFF says states that show good-faith efforts can get extensions through Dec. 31, 2028.
Why adults 50 to 64 face the steepest climb
KFF analyzed 2022 federal survey data on the adults who would be subject to the requirement. Overall, 53% worked at least 80 hours a month.
Among those ages 50 to 64, only 48% did, and they were the least likely of any age group to meet the requirement. Another 24% in that range had health limitations that would likely qualify them for an exemption, and about 29% were at greatest risk of losing coverage because they neither met the hours test nor appeared to qualify for an exemption, KFF found.
The same analysis found that nearly 8 in 10 affected adults either met the requirement or fell short for a reason that would likely earn an exemption. That points to a documentation problem as much as a work problem, although the survey cannot show how many people will actually be dropped.
A KFF Health News report in February 2026 said women in this age group are less likely to be working the required hours because many are family caregivers or have illnesses that limit work.
The same report said Medicaid covers 1 in 5 Americans ages 50 to 64. Some in that age group already skip care until they qualify for Medicare.
The rule goes further than the law, one analysis says
Manatt Health, a health policy and consulting firm, estimated in July 2026 that the CMS rule would add an average of 1.8 million people a year to the coverage losses expected under the statute alone. That would raise average annual losses from 6.4 million to 8.2 million over federal fiscal years 2027 through 2034, Manatt said.
The firm attributes the gap to a narrower medical frailty exemption and limits on self-attestation. Its model assumes a 40% coverage loss rate based largely on New Hampshire’s earlier work requirement experience, so the figures are projections, not counts.
In an earlier estimate of the House-passed version of the bill, the Congressional Budget Office projected that the work requirements would cause about 5.2 million adults to lose federal Medicaid coverage by 2034 and increase the number of uninsured people by 4.8 million.
CMS Administrator Mehmet Oz has described the requirement as a way to help people build skills and independence through work, education, job training or community service.
Losing Medicaid can close the Obamacare door too
People denied or dropped from Medicaid for not meeting the requirement become ineligible for premium tax credits, KFF says, so they cannot buy subsidized marketplace coverage as a fallback.
Unsubsidized plans are getting pricier. Insurers have proposed a median 15% increase for 2027, after a 20% rise in 2026, according to KFF’s review of proposed rates, a trend that has already hit early retirees facing another Obamacare premium jump.
What to do before January
Find out when your state starts enforcing the requirement, because some may begin earlier and others may get extensions. Gather proof now: pay stubs, volunteer hour logs, school enrollment records or a doctor’s letter describing a condition that limits work. States look back one to three months at application, so records from the weeks before you apply matter.
Open every notice from your state Medicaid agency and answer within 30 days. If you have a disabling condition or care for a child younger than 14, ask the agency how to claim an exemption rather than trying to hit 80 hours. People enrolled in Medicare are not subject to the requirement.
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