Survey Reveals State Plans for Work Requirement Implementation in Medicaid

A new survey from KFF¹ reveals how states throughout the country are planning to implement the work requirements for Medicaid eligibility, first introduced in the One Big Beautiful Bill Act in 2025.² States have revealed varying strategies for implementation, as well as a call for more guidance from CMS to implement the requirements effectively.

The findings were based on the annual survey of state Medicaid and Children's Health Insurance Program (CHIP) officials conducted by KFF and the Georgetown University Center for Children and Families.¹ The survey was conducted between January and March of 2026 and included 43 states that need to implement work requirements and featured focus groups with the state officials from Arizona, Indiana, Montana, Nebraska, Ohio, Pennsylvania, Virginia, and Washington. Although all states included in the survey had not made specific policy decisions at the time of the survey, it did provide a glimpse into the priorities of states moving forward.

Iowa, Montana, and Nebraska reported that they were planning to implement work requirements before the January 2027 deadline, including disenrolling those who do not abide by the work requirements. Arkansas reported that they would be doing a soft launch of the work requirements in July, but would not be disenrolling any Medicaid enrollee before the January 2027 deadline. A total of 39 states reported that they would not be implementing the work requirements before January 2027.

Most states reported that they would be verifying compliance every 6 months at renewal (34 states), using a 1-month look-back period for the application (36), and using a 10-month look-back period for renewal; there were 2, 2, and 3 states, respectively, who reported that they would not be doing this and instead requiring more than 1 month for the look-back at both application and renewal. Enrollees may get a short-term hardship exception from these longer-term look-backs if they live in counties with high unemployment rates, have been admitted to either a nursing facility or a hospital, or need to travel outside their communities for medical care. A total of 2 states reported that they would not adopt hardship exceptions at all, and 3 do not plan to adopt all hardship exceptions.

Artificial intelligence (AI) was cited by 6 states as a means of helping with implementing work requirements, although most states are using existing vendors, such as Deloitte, to make the system changes needed in the coming months. However, 21 states had no official plan on whether they would be using AI or another partner to implement the changes, demonstrating the indecision in some areas of the country. About half of the states had not decided whether they would be increasing the capacity of eligibility staff in the coming months, as 14 states reported that they would be expanding and 9 states reported that they would not, indicating a potential influx of work for these staff members.

Many states requested more clarity and guidance from CMS on how to define exceptions and community engagement activities. This includes what qualifies as community service, what is considered a significant relationship when qualifying for the caregiver exception, and what halftime school attendance should be eligible for an exception. Without finalized guidance, states may increase costs by making system changes based on assumptions rather than official recommendations.

Overall, states are approaching implementing the work requirements in different ways, with the lack of federal guidance leaving states to make decisions about how to implement the requirements and how strict those requirements should be from state to state. The survey reveals early decisions on what to expect in January 2027 as the One Big Beautiful Bill Act comes into play for Medicaid eligibility.

References

1. Tolbert J, Diana A, Mudumala A, Brooks T, Yafimenka Y, Lin A. An early look at policy decisions as states get ready to implement work requirements: results from the 2026 Medicaid Eligibility, Enrollment, and Renewal Policies Annual Survey. KFF. April 30, 2026. Accessed April 30, 2026. https://www.kff.org/medicaid/an-early-look-at-policy-decisions-as-states-get-ready-to-implement-work-requirements/
2. Bonavitacola J. Medicaid work requirements set to leave millions without insurance. AJMC. November 4, 2025. Accessed April 30, 2026. https://www.ajmc.com/view/medicaid-work-requirements-set-to-leave-millions-without-insurance