Work requirements for certain Medicaid beneficiaries will begin in January 2026, following changes in federal policy. These changes stem from legislation associated with President Donald Trump's 2025 tax cut and policy law. Several Republican-led states are adopting stricter rules than those mandated by federal law regarding how individuals can prove they are medically unable to work.
Federal regulations allow states to accept a recipient's self-attestation for the first year, but at least six states are requiring immediate documentation. Advocates have raised concerns that this could create barriers for new applicants to the Medicaid program. Jennifer Tolbert, director of state health policy and data at KFF, noted that individuals who cannot afford to see a doctor may struggle to provide the necessary documentation when applying for Medicaid.
As some states impose stricter requirements, Democrats in 25 states are filing lawsuits, claiming the new rules are excessively harsh. According to the Congressional Budget Office's 2025 estimate, the changes are expected to save the federal government $887 billion over the next decade but could lead to 7.5 million fewer individuals having health insurance.
The Foundation for Government Accountability has been advocating for states to enforce stricter compliance with work requirements, arguing that self-attestation can lead to fraud. Jonathan Ingram, vice president of research and policy at the organization, criticized self-attestation as a policy that prioritizes enrollment over program integrity.
States such as Arkansas, Idaho, Indiana, New Hampshire, North Carolina, and Ohio have enacted laws that prohibit self-attestation for qualifying for work requirement exemptions starting next year. Missouri state Rep. Darin Chappell has proposed an amendment to enshrine Medicaid work requirements in the state constitution, requiring documentary evidence for exemptions.
The new requirements will affect up to 20 million lower-income adults without children at home who are enrolled in Medicaid through an optional expansion in 40 states and the District of Columbia. Beneficiaries will need to work or volunteer at least 80 hours each month or be enrolled in school at least half-time to maintain eligibility, with exceptions for medical frailty.
The Centers for Medicare and Medicaid Services has defined medically frail individuals as those with substance use disorders, disabilities, or serious medical conditions. However, a recent rule stated that a condition must significantly impair an individual's ability to work, volunteer, or attend school to qualify for an exemption.
States will now be required to reassess Medicaid recipients' eligibility twice a year instead of once. Starting in 2028, states can accept self-attestation only once upon enrollment, and documentation will be required at least every 12 months thereafter.
States are expected to increasingly rely on third-party data to make eligibility determinations, which may include workers' compensation claims or prescription information. However, many states will need to invest significantly in updating their computer systems to accommodate these changes.
In Arizona, for instance, enrollment in Medicaid dropped by 55% from April 2025 to April 2026, attributed to challenges in implementing new federal requirements. Ingram argued that concerns over ending self-attestation are exaggerated, as individuals can obtain diagnoses from various healthcare providers.
Patient advocates, however, contend that the additional paperwork and requirements could lead to coverage loss. Nate Crippes, a lawyer at the Disability Law Center in Utah, emphasized that many individuals in the Medicaid expansion group have mental health or substance use disorders, complicating their ability to provide documentation.
Lucy Dagneau, senior director at the American Cancer Society Cancer Action Network, expressed concern that banning self-attestation could result in more people losing coverage, as diagnosis codes do not reflect the severity of conditions. Advocates fear that the stricter requirements will disproportionately impact those with serious health issues.