KFF survey: Many states seek clearer federal guidance on Medicaid work requirements

KFF said on April 30 that states are making early decisions on how to run new Medicaid work requirements while still waiting for key federal instructions on exemptions, verification and reporting. The survey covers the 43 states that will have to apply the rules under the 2025 reconciliation law, including the 41 states and Washington, D.C., that expanded Medicaid under the Affordable Care Act, plus Georgia and Wisconsin’s partial expansion programs. The law requires implementation starting January 1, 2027, but allows states to move sooner. KFF said the combination of a fixed deadline, delayed guidance and limited time for system changes is already shaping how states design the rules. ### Which states are covered, and when do the rules start? The 2025 reconciliation law, signed by President Donald Trump on July 4, 2025, conditions Medicaid eligibility for certain adults on meeting work requirements starting January 1, 2027. KFF said the requirement applies to adults in the Affordable Care Act expansion group and to enrollees in partial expansion waiver programs in Georgia and Wisconsin. As of June 2025, about 20 million people were enrolled in Medicaid expansion, representing 30% of total enrollment in expansion states. (kff.org) KFF said states can begin enforcing the rules before 2027, and three states — Iowa, Montana and Nebraska — reported plans to do that. Arkansas told KFF it plans a “soft implementation” in 2026 without disenrollments before the official January 2027 start date. (kff.org) ### What are states still waiting to hear from Washington? KFF said states reported uncertainty about how to define and verify some exemptions because federal guidance has been delayed. Governing, summarizing the KFF findings on May 14, said states want more direction from the Centers for Medicare and Medicaid Services on acceptable verification methods, exemptions and what counts as community service. (kff.org) CMS guidance matters because states must decide how to connect data sources, write eligibility rules and train staff before the deadline. KFF said states are trying to answer policy and operational questions while also making system upgrades, developing outreach plans and hiring or training workers within a relatively short timeframe. ### How different are the state approaches already? (kff.org) Seven states told KFF they plan either stricter verification rules or earlier implementation than the federal minimum requires. KFF identified Arkansas, Idaho, Indiana and New Hampshire as states planning longer look-back periods at application or renewal, and said Indiana and New Hampshire also plan quarterly compliance checks instead of the minimum semiannual schedule. (kff.org) KFF’s tracker said 33 states, as of March 2026, planned to look back one month at application and renewal to verify work or exemption status. The law requires states to verify compliance or exemption status at application and every six months at renewal, with the option to check more often between renewals. ### How are states trying to verify work and exemptions? (kff.org) Eighteen states told KFF they plan to use new data sources to automate more of the verification process, including checks for school attendance, community service, veteran status and recent release from incarceration. KFF said half of the states had not yet decided whether to adopt those additional automated data sources. (kff.org) Most states also said they are exploring ways to identify medically frail people who may be exempt, with Medicaid claims data and other records among the tools under review. KFF said many states would like to allow self-attestation by applicants and enrollees for some exemptions. (kff.org) ### Why are state officials focused on administration, not just policy? KFF said work requirements will require new system changes, new outreach and new data links, and it pointed to Medicaid “unwinding” after the pandemic as a recent example of how difficult eligibility operations can be. In that process, states had to redetermine eligibility for all enrollees and disenrolled people who were no longer eligible or who did not complete renewal paperwork. (kff.org) KFF said the unwinding showed that outcomes can turn on policy choices, system design and how well states communicate with enrollees. The group said automated renewals and streamlined processes helped preserve coverage for eligible people and reduce burden on agencies, but work requirements will add new complications because states must collect different information and target outreach more narrowly. (kff.org) ### What should readers watch next? KFF said its Medicaid work-requirements tracker will be updated as CMS releases guidance and as states make more implementation decisions. The tracker also includes state-by-state information on verification rules, hardship exceptions, enrollment and renewal outcomes that can serve as a baseline ahead of the January 1, 2027 deadline. (kff.org 1) (kff.org 2)