Medicaid Work Requirements: What the CMS Interim Final Rule Actually Says
Medicaid work requirements are now federal policy for expansion populations, following a new interim final rule issued by the Centers for Medicare & Medicaid Services (CMS). The rule directs states that expanded Medicaid under the Affordable Care Act (ACA) to impose "community engagement" conditions on certain adult enrollees — meaning some people may need to work, volunteer, attend school, or participate in job training to maintain their Medicaid coverage. This does not mean your coverage ends tomorrow, but it does mean the rules governing Medicaid eligibility for expansion adults are changing in ways that could affect millions of households.
---
Data Snapshot
As of the most recent federal reporting, approximately 21.7 million adults gained Medicaid coverage through ACA expansion, according to CMS enrollment data published at CMS.gov. The new interim final rule targets the non-exempt portion of this expansion population — a group that policy analysts at the Center on Budget and Policy Priorities estimate could represent tens of millions of enrollees across the 40 states (plus D.C.) that have adopted expansion. Historically, when Arkansas implemented a similar work requirement in 2018, approximately 18,000 people lost coverage within months before a federal court blocked enforcement — a figure that underscores the real-world stakes of these policy changes.
---
Who Is Affected by the New Rule
The interim final rule applies specifically to Medicaid expansion adults — generally, individuals between the ages of 19 and 64 who are enrolled in Medicaid because their state expanded eligibility up to 138% of the Federal Poverty Level (FPL) under the ACA.
Who May Be Required to Meet Work Requirements
Under the rule's framework, states seeking to implement work requirements must target able-bodied, non-elderly adults who are not already covered by an exemption category. This generally includes:
- Adults ages 19–55 (the specific age ceiling may vary by state waiver)
- People who are not pregnant
- People who are not receiving Supplemental Security Income (SSI) or Social Security Disability Insurance (SSDI)
- People who are not the primary caregiver of a dependent child under a certain age
- People who are not enrolled in a substance use disorder treatment program
Who Is Likely Exempt
The rule includes — and states are expected to honor — exemptions for:
- Individuals with a documented physical or mental disability
- Pregnant and recently postpartum individuals
- Primary caregivers of young children or adults with disabilities
- People already working at least a minimum number of hours per week (typically 80 hours per month)
- Full-time students
- People participating in approved job training or vocational rehabilitation programs
If you fall into any of these categories, you may not be required to meet community engagement criteria — but you will likely need to document your exempt status with your state Medicaid agency.
---
How Work Requirements Would Actually Be Enforced
This is where the process gets important to understand: CMS cannot simply flip a switch and impose work requirements nationwide. States must go through a formal process.
The Section 1115 Waiver Process
To implement work requirements, a state must:
- Apply for a Section 1115 demonstration waiver from CMS, which allows states to test policy changes that deviate from standard Medicaid rules.
- Receive CMS approval — which, under this administration, is expected to move faster than in prior years, but is not guaranteed or automatic.
- Publish a state implementation plan that outlines how requirements will be tracked, how exemptions will be processed, and how enrollees will be notified.
- Provide a notice period before enforcement begins, so enrollees have time to respond.
This means the timeline for when — or whether — work requirements take effect in your state will vary significantly. Some states may move quickly; others may not apply at all or may face legal challenges that delay implementation.
What "Community Engagement" Can Include
Under most waiver frameworks, qualifying activities have included:
- Paid employment (full-time or part-time)
- Job search activities
- Vocational education or job skills training
- Community service or volunteering
- Participation in a GED or adult education program
- Enrollment in substance use disorder treatment
The specific hours required and what counts as a qualifying activity will depend on your state's approved waiver terms.
---
What You Should Do Right Now
Even if your state has not yet implemented work requirements, there are practical steps you can take today to protect your coverage.
Step 1: Confirm Your Current Medicaid Status
Log in to your state's Medicaid portal or contact your state Medicaid agency directly to confirm your enrollment is active and your contact information is current. Notices about new requirements will be mailed or sent electronically — if your address is outdated, you could miss critical deadlines.
Step 2: Identify Whether You May Be Exempt
Review the exemption categories listed above. If you believe you qualify for an exemption — due to disability, caregiving responsibilities, or another qualifying circumstance — start gathering documentation now. This may include:
- A letter from a physician documenting a disability or medical condition
- Birth certificates or custody documents for dependent children
- Proof of current employment or school enrollment
- Documentation of participation in a job training program
Step 3: Track Your State's Waiver Status
Visit your state Medicaid agency's website and search for "Section 1115 waiver" or "community engagement requirements." CMS also maintains a list of approved and pending waivers at Medicaid.gov. Knowing where your state stands gives you time to prepare.
Step 4: Connect With a Benefits Navigator or Legal Aid Organization
If you are concerned about how this rule may affect your coverage, a certified application counselor or legal aid attorney can help you understand your rights at no cost. Many states have federally funded navigator programs through the ACA marketplace that can assist with Medicaid questions as well.
Step 5: Keep Records of Your Activities
If your state does implement work requirements, you will likely need to self-report qualifying hours on a monthly or quarterly basis through an online portal or paper form. Start keeping a simple log of your work hours, volunteer activities, or training participation now — even before requirements are formally in place.
---
The Legal Landscape: This Rule Will Likely Be Challenged
It is worth knowing that Medicaid work requirements have a complicated legal history. The Trump administration's first-term attempts to implement work requirements through Section 1115 waivers were blocked by federal courts, with judges ruling that CMS had not adequately considered the impact on coverage. The current interim final rule takes a different regulatory approach — issuing requirements through rulemaking rather than solely through waiver approvals — but legal challenges are widely anticipated.
This does not mean you should assume the rule will be blocked. It means the situation is fluid, and staying informed through your state Medicaid agency and reputable policy sources is the most practical thing you can do.
---
If You Lose Coverage: Other Programs That May Be Available
If work requirements are implemented in your state and you are unable to meet them or document an exemption, you may have other options worth exploring:
- ACA Marketplace coverage: If your income is between 100% and 400% FPL, you may be eligible for premium tax credits through Healthcare.gov.
- CHIP: If you have children in your household, they may remain eligible for the Children's Health Insurance Program (CHIP) regardless of your Medicaid status.
- Community health centers: Federally Qualified Health Centers (FQHCs) provide sliding-scale care regardless of insurance status. Find one at findahealthcenter.hrsa.gov.
- State-specific programs: Some states have their own health coverage programs for low-income adults that operate separately from federal Medicaid expansion.
---
People Also Ask
Does the new CMS rule mean I will lose my Medicaid right away? No. The interim final rule sets a federal framework, but states must apply for and receive CMS approval through a Section 1115 waiver before enforcing work requirements. Your coverage is not automatically terminated. You should monitor communications from your state Medicaid agency and keep your contact information current to receive any notices about changes in your state.
What counts as a qualifying work activity under Medicaid work requirements? Qualifying activities typically include paid employment, job search, vocational training, community service, adult education, and approved treatment programs. The specific activities and minimum hours — usually around 80 hours per month — depend on your state's approved waiver terms. Not all states will define qualifying activities the same way.
What if I have a disability or health condition — am I exempt? Individuals with documented physical or mental disabilities are generally exempt from work requirements under most waiver frameworks. However, you may need to provide documentation from a licensed medical provider to your state Medicaid agency to establish your exempt status. Contact your state agency or a benefits navigator for guidance specific to your situation.
Which states are most likely to implement Medicaid work requirements? States that previously applied for or expressed interest in Section 1115 work requirement waivers — including Georgia, which has an active partial-expansion program with work requirements — are most likely to move quickly. States with Democratic-led administrations are less likely to apply. Check your state Medicaid agency's website or CMS's waiver tracker at Medicaid.gov for current status.
Where can I get free help understanding how this affects my Medicaid coverage? You can contact your state Medicaid agency directly, reach out to a certified application counselor through Healthcare.gov's navigator program, or connect with a local legal aid organization. Benefits.gov also maintains a benefits finder tool that may help you learn about programs that may be available to you based on your household situation.
---
Program eligibility and availability vary by state. Not affiliated with any government agency.
Last reviewed: July 2026