Key Takeaways
- Starting by Jan. 1, 2027, most ACA expansion adults 19 to 64 must show 80 hours a month of work, school or volunteering, or $580 a month in earnings.
- People who are blind or disabled, or who are “medically frail,” are exempt, and so are caregivers of a child 13 or younger or of a person with a disability.
- An Oct. 29 federal court ruling means a qualifying condition alone should now be enough for the medical frailty exemption.
- If you get a notice, you have 30 days to show you meet the rule or are exempt. Missing it can end your coverage.
- Four states have sued, and 42 patient groups and 16 senators want a two-year delay, but for now the Jan. 1 date stands.
Less than seven weeks before Medicaid work requirements take effect across most of the country, millions of adults must prove they work, study, volunteer or qualify for an exemption, and people with disabilities and chronic illnesses are among those most at risk of losing coverage over paperwork, state officials and patient groups warn.
The requirement, created by the 2025 budget reconciliation law (H.R. 1), applies starting Jan. 1, 2027. It is one of the week’s most-watched health stories: West Virginia said Thursday that about 40,000 enrollees have not yet been shown to meet the rule, four states sued to stop it, and patient groups and Senate Democrats asked Congress for a delay.
Who has to meet the new Medicaid work requirements?
According to a CMS fact sheet on the interim final rule issued June 1, the requirement applies to non-pregnant adults ages 19 to 64 who are not enrolled in Medicare and who get Medicaid through the Affordable Care Act’s adult expansion group or certain waiver programs. CMS says 43 states and the District of Columbia must carry it out.
To keep coverage, an affected adult must show, for the months the state checks, one of the following:
- At least 80 hours of work, community service or a work program
- Enrollment in school at least half-time
- Any combination of those activities totaling 80 hours
- Monthly income of at least 80 times the federal minimum wage, or $580 in 2026
States must check at application and at renewal, and may check more often.
Are people with disabilities exempt from Medicaid work requirements?
Many are, but not always automatically. The law lists people who are “medically frail” as exempt, and that category covers five groups, according to a KFF analysis of the rule: people who are blind or disabled; people with a physical, intellectual or developmental disability that limits one or more activities of daily living; people with a substance use disorder; people with a “disabling” mental disorder; and people with a “serious or complex” medical condition.
Other exemptions in the CMS rule include:
- Parents, guardians and caregivers of a child 13 or younger, or of a person with a disability
- Veterans with a total disability rating
- Pregnant and postpartum women, and American Indians and Alaska Natives
- Former foster youth, people in drug or alcohol treatment, and people meeting SNAP or TANF work rules
Many people with disabilities are outside the rule altogether. It does not apply to people enrolled in Medicare, and it covers only the expansion group and certain waiver programs, so people who get Medicaid through another eligibility group, such as coverage tied to Supplemental Security Income, are not subject to it. People with disabilities on expansion coverage, including some waiting out the two-year gap before Medicare starts for SSDI recipients, are the ones who may need to claim an exemption.
What did the court ruling change for the medical frailty exemption?
The June rule set a two-part test: a person had to have a qualifying condition and show that it significantly impaired their ability to work or volunteer. On Oct. 29, a federal judge in Massachusetts v. Oz ruled that CMS exceeded its authority with that second step. According to KFF, the ruling applies nationwide, so people now only need to show a condition that falls into one of the five categories. KFF said HHS had not announced whether it will appeal.
The court upheld other limits. States may use only the past 12 months of claims data to identify medically frail enrollees, and starting in 2028 self-attestation is limited to once per enrollment period. In 2027, states may accept a person’s own statement that they are medically frail.
How many people could lose Medicaid coverage?
In Nebraska, 14% of new applicants and 7% of people renewing coverage who were subject to the rules were denied or lost coverage for not meeting them from May through August, while 57% of those renewing qualified for an exclusion, KFF found in state data.
In West Virginia, about 40,000 of roughly 160,000 people on expanded Medicaid have not been identified as meeting the requirements or qualifying for an exemption, the state Department of Human Services told West Virginia Watch. The state is reviewing more data to find people who qualify for exemptions.
“Thankfully a court has halted those rules, but that too adds to the chaos and challenges state Medicaid agencies face in implementation and that Medicaid enrollees face in understanding how to comply with new eligibility rules,” said Kelly Allen, director of the West Virginia Center on Budget and Policy.
Missouri, Iowa and Indiana will not adopt any of the optional short-term hardship exceptions, which cover hospital stays, travel for medical care, disasters and high-unemployment counties, the Missouri Independent reported. A Missouri spokesperson said the state will handle medical events through the mandatory medical frailty and caregiver exemptions to “limit the number of separate processes participants must navigate.”
Will the Jan. 1 start date be delayed?
Minnesota, Oregon, New Mexico and Washington filed a lawsuit last week arguing that the threat of losing federal Medicaid funding amounts to “unconstitutional coercion,” MPR News reported. In Minnesota alone, 243,000 residents will be required to meet the rules. CMS told MPR it does not comment on pending litigation.
On Nov. 9, 42 patient organizations, including the American Cancer Society Cancer Action Network, the National Multiple Sclerosis Society, NAMI and Family Voices, urged Congress to enact a two-year delay. A day later, 16 Senate Democrats led by Sens. Raphael Warnock of Georgia and Ben Ray Luján of New Mexico asked Senate leaders to do the same.
CMS says the requirement promotes independence. “This rule helps Americans build skills and independence through work, education, job training, or community service, creating new opportunities for themselves and their families,” CMS Administrator Dr. Mehmet Oz said when the rule was released.
What should people with disabilities do now?
- Find out if the rule applies to you. If you have Medicare, or get Medicaid because of SSI or another disability-based category, it generally does not. Expansion enrollees 19 to 64 should check with their state Medicaid agency.
- Update your contact information with your state Medicaid office so notices reach you.
- Open every letter from Medicaid. If the state cannot verify you, it must give you 30 days to respond.
- Claim your exemption. Ask your doctor or clinic for records showing your diagnosis or disability, and keep copies of any disability determination or VA rating.
- Caregivers count. If you care for a child 13 or younger or a person with a disability, ask about the caregiver exemption.
- If you lose coverage, reapply. CMS says people who are disenrolled can reapply at any time.
Working adults with disabilities who also get SSDI or SSI should know that those programs have their own rules; HNC explained the 2027 SSDI and SSI work rules here. This article is not legal advice.
Frequently Asked Questions
When do Medicaid work requirements start?
States must begin by Jan. 1, 2027, and may start earlier. Nebraska began enforcing them on May 1, 2026.
Who is exempt from Medicaid work requirements?
Exemptions include people who are medically frail (including blind or disabled people), caregivers of a child 13 or younger or of a disabled person, and veterans with a total disability rating, among others.
Do people on SSI or SSDI have to meet Medicaid work requirements?
People enrolled in Medicare are not subject to the rule, and it covers only the expansion group and certain waivers, not other groups such as SSI-linked Medicaid. SSDI recipients on expansion Medicaid before Medicare starts may need to claim the disability exemption.
How many hours do you have to work to keep Medicaid?
80 hours a month of work, volunteering, a work program or half-time school, or monthly earnings of at least $580 in 2026.
What happens if I miss a Medicaid work requirement notice?
The state must give you 30 days to show you meet the rule or are exempt. If you do not respond, your application can be denied or your coverage ended, but you can reapply at any time.
Sources: CMS interim final rule fact sheet; CMS press release; KFF on medical frailty; KFF on the Oct. 29 ruling; KFF on Nebraska data; West Virginia Watch (Nov. 12, 2026); Missouri Independent; MPR News; American Lung Association (Nov. 9, 2026); Office of Sen. Warnock (Nov. 10, 2026).
Top photo: An occupational therapy assistant coaches a patient through hand strength exercises at Landstuhl Regional Medical Center, Germany, March 3, 2020. U.S. Air Force photo by Senior Airman Elizabeth Baker, public domain, via Wikimedia Commons. Illustrative.
