Medicaid Work Requirements 2027: Doing the 80 Hours Is Not Enough. You Also Have to Be Seen Doing Them.

On August 1, About 200 Nebraskans Lost Medicaid. The Rest of the Country Starts by January 1.

The new rule asks for 80 hours a month. But the hours are rarely the problem. The proof is. This guide is built around that one fact.

On August 1, 2026, Nebraska became the first state to remove people from Medicaid for not meeting the new federal work rules. Before that day, the state’s Medicaid director said roughly 200 people would lose coverage. About 70,000 Nebraskans fall under the rule. For most of them, nothing happened at all.[1]

Why nothing? Because the state could confirm about three out of four people from records it already had, like payroll data, without sending them a single form. That is the real shape of this law. For most people, it is not a test of whether you work. It is a test of whether the government can see that you work, or see why you are excused.[1]

Starting no later than January 1, 2027, the same rule reaches 43 states and Washington, D.C. About 20 million adults are in the Medicaid group it covers. The federal agency that runs Medicaid, the Centers for Medicare & Medicaid Services (CMS), projects enrollment will fall by 2.3 million in its 2027 fiscal year and by 3.1 to 3.3 million in each year after that.[2, 3]

Here is the number this guide is built on. In the same analysis, CMS estimates that 7 percent of people who are working, in school, or excused will lose coverage anyway, for paperwork reasons. A letter that never arrived. A form sent back late. A document that did not match. The agency wrote that into its own rule. So the goal here is simple: to show you how to be counted, not just how to qualify.[3]

Does This Apply to You? Four Questions Decide It

The rule reaches one Medicaid group: adults who qualify by income under the Affordable Care Act expansion. If you are not in it, the rest of this guide is background.

Answer four questions. Are you 19 through 64? Are you covered in the Medicaid “adult group”, the one created by the Affordable Care Act expansion, or in a state waiver program that covers the same people? Are you not pregnant? Are you not enrolled in Medicare Part A or Part B? If every answer is yes, the rule applies to you, unless one of the exclusions later in this guide fits.[4, 2]

How do you know if you are in the adult group? Mostly by income. In expansion states you can qualify on income alone, up to about 138 percent of the federal poverty level. For a single adult in the 48 contiguous states, the 2026 poverty guideline is $15,960, so 138 percent is roughly $22,025 a year, or about $1,835 a month. Larger households have higher limits.[5, 6]

Who is not in this group? People who get Medicaid because of a disability or Supplemental Security Income, children, people 65 and older, and pregnant women. Nursing home residents qualify through different doors, which our guide to who pays for nursing home care explains. States that never expanded Medicaid are mostly untouched, but a few run waiver programs that count, such as Georgia’s Pathways program. U.S. territories are not covered by the rule at all.[7, 8, 2]

The quickest way to be sure is to look at your last Medicaid approval notice, which names the group you were approved under, or to call your state Medicaid agency. Medicaid.gov keeps a directory of every state agency with its website and toll-free number. Ask one plain question: “Am I subject to the community engagement requirement, and if so, when is my next renewal?”[9]

Five Ways to Reach 80 Hours, and What the Fine Print Actually Allows

For each month the state checks, you meet the rule if you do any one of these: work at least 80 hours; do at least 80 hours of community service; take part in a work program for at least 80 hours; are enrolled in school at least half-time; or mix work, service and a work program to total 80 hours. There is also an income route, which gets its own section next, because for many people it is the easiest.[10, 2]

“Work” is broader than a paycheck. The rule counts work for money, work paid in goods or services, and unpaid work. CMS gives the example of a building superintendent who is paid with free or reduced rent. Self-employment counts too: owning a business, freelancing, or working as an independent contractor all meet the definition of work.[10, 3]

Community service has rules. It must be unpaid work done through a public or nonprofit organization for the direct benefit of the community, and it cannot serve a partisan purpose. The organization has to track the type of activity, the dates and hours, and name a contact person who can confirm them. Court-ordered service counts. So when you volunteer, ask on day one who will confirm your hours, and write that name down.[10]

Work programs are specific. They include job training under the federal Workforce Innovation and Opportunity Act, Trade Act programs, state employment and training programs such as SNAP job training, and training programs for veterans run by the Labor Department or the VA. A job search on its own does not count. Supervised job search can be part of a program, but only as less than half of its hours.[10]

School counts in two ways. If your school says you are enrolled at least half-time, that alone meets the rule, and your status carries through normal breaks. If you are enrolled less than half-time, the hours are converted: each credit hour counts as 3 hours a week, times 4.33 weeks, or about 13 hours a month. Three credits give you about 39 hours, so roughly 41 hours of work would finish the month. Colleges, career and technical programs, high school and high school equivalency programs all count.[10, 11]

The $580 Shortcut: If the Income Is There, the Hours Stop Mattering

The law lets income stand in for hours. The bar is the federal minimum wage times 80, and under the CMS rule it is measured with household income.

You also meet the rule for a month if your monthly income is at least the federal minimum wage times 80 hours. At $7.25 an hour, that is $580 a month in 2026. It is the federal minimum wage, even if your state’s is higher, and 30 states plus Washington, D.C. set a higher one. At $15 an hour, about 39 hours of work reach $580. At $20, about 29 hours do.[10, 12, 13]

Here is the part almost nobody explains. CMS’s rule says states must measure this income the same way they measure Medicaid eligibility: using household income under the program’s modified adjusted gross income rules. That includes countable unearned income, and the income of everyone in your Medicaid household. CMS’s own example is a household income of $650 a month, which clears $580. In practice, a household that already reports $580 or more a month in countable income may meet the test even if one adult in it is not working. The rule is new and states are still building systems, so ask your state how it applies this before you rely on it.[3, 10]

Tips, gigs and seasons. CMS uses the regular federal minimum wage, not the lower cash wage employers may pay tipped workers. Gig and freelance income counts as income from work; how to report it for taxes is covered in our 1099-K side income guide. Seasonal workers, such as farm workers or holiday retail staff, can use an average over the prior six months instead. But averages can cut both ways: in a CMS example, two months at $1,500 averaged over six months is $500, which falls short.[3, 14]

Put $580 in perspective. Twelve months of it is $6,960, about 44 percent of the poverty line for one person. Many part-time workers clear it without ever counting hours. And if the state knows your pay but not your hours, the rule lets it estimate hours by dividing your income by $7.25, which helps when you are combining a small job with volunteering or classes. Before your next check, run your own hourly pay through a monthly converter and see which side of $580 you land on.[6, 10]

Ten Groups the Work Rule Does Not Touch

If you fit any one of these, the work rule is not a condition of your coverage at all. The state is supposed to apply the exclusion whenever it has the information.

The first five: former foster youth who qualify for Medicaid’s former foster care group; American Indians and Alaska Natives; parents, guardians, caretaker relatives and family caregivers of a child 13 or younger or of a person with a disability; veterans with a total disability rating from the VA, whether temporary or permanent; and people who are medically frail. If you are a veteran, our VA disability rating guide explains how a total rating is reached.[15, 16, 17]

The next five: people who meet the work rules of TANF, the cash assistance program; members of a SNAP household who are subject to SNAP’s own work rules; people in a drug or alcohol treatment program; people who are incarcerated; and people who are pregnant or in postpartum coverage. SNAP’s work rules changed in 2025, and our grocery budget guide explains who they reach now.[15, 2]

A few more people are treated as meeting the rule for a month even though they are technically in the group: anyone under 19 for part of that month, anyone entitled to or enrolled in Medicare Part A or B, anyone who fits one of Medicaid’s mandatory coverage groups, and anyone who was released from jail or prison within the prior three months. That last one matters. It gives people leaving incarceration a short runway before the hours start counting.[8]

The rule also puts a duty on the state. It must find you excluded whenever it has enough information to do so, even if you also happen to meet the work rule. And if the state can confirm you meet the rule but has only a hint that you are excluded, it must enroll you right away and check the exclusion afterward. The lesson is simple: tell the state early. Report a pregnancy, a caregiving role or a diagnosis on your application or as a change, not after a warning letter.[18]

Parents and Caregivers: The Exclusion Is Wider Than the Headlines Say

The age line is precise: a “dependent child” is 13 or younger. Once your youngest turns 14, the parent exclusion ends, unless you also care for someone with a disability. The exclusion covers a parent or legal guardian, and a caretaker relative who lives with the child and has primary responsibility for the child’s care. That relative can be a grandparent, brother or sister, aunt or uncle, first cousin, niece or nephew, or a step-relative.[15, 2]

The bigger surprise is the second half: caring for a “disabled individual” also qualifies, and that phrase uses the broad definition from the Americans with Disabilities Act. The rule says outright that the person you care for does not need to be on Medicaid or any other program because of a disability. An adult son helping a mother with advanced multiple sclerosis can qualify, even if she has never applied for disability benefits.[15, 19]

Family caregivers get three separate paths. You qualify if you live with the child or disabled person and give regular help that is not just occasional. You qualify if you are a relative who does not live with them but gives regular help. And you qualify if you are not a relative and do not live with them, as long as you give at least 80 hours of help a month. More than one person in the same home can qualify at once.[15]

The catch is that caregiving is almost invisible in government data. Payroll records show a job; nothing shows that you drive your father to dialysis three times a week. That is why Nebraska’s declaration form lists caring for a person with a disability as one of the things people must declare themselves. Say it on your application or renewal form. Name the person you care for, describe the help, and keep a simple weekly log in case the state asks.[20]

Medically Frail: Under the CMS Rule, a Diagnosis Alone Is Not Enough

The five health categories come from Congress. The extra test, whether your condition significantly impairs your ability to meet the rule, comes from CMS, and it is being fought in court.

The law lists five kinds of people as medically frail: someone who is blind or disabled under Social Security’s definition; someone with a substance use disorder; someone with a disabling mental disorder; someone with a physical, intellectual or developmental disability that significantly limits at least one activity of daily living, such as bathing or dressing; and someone with a serious or complex medical condition. For substance use, CMS excludes people in “stable recovery,” which it defines as five years or more.[15]

Then CMS added a condition. Under its rule, you are medically frail only if your condition significantly impairs your ability to comply with the work requirement. Each state must build a list of qualifying conditions that is “auditable” and “justifiable,” update it over time, and give people whose condition is not on the list a reasonable way to ask for the exclusion anyway. KFF notes that states found too generous in audits could face financial penalties, which pushes states toward caution.[15, 7]

CMS’s own training deck, posted September 8, 2026, shows how this plays out. A man with diabetes who has had a leg amputated, uses a wheelchair and has stage 4 kidney disease can be excluded straight from his medical claims. A woman treated for breast cancer ten years ago, now seen once a year with no active disease, lands in a manual review where the state may ask for records. So does a woman whose mild anxiety is managed by her regular doctor. Same diagnosis on paper, different answer in practice.[21]

How it gets checked: the state must first look at your medical claims from the past 12 months. If that is not enough, then until January 1, 2028, the state may accept your own statement signed under penalty of perjury. From 2028 on, such a statement can be used only once per stretch of continuous enrollment, and must be backed by data or documents at your next renewal. After the state confirms you are medically frail, it must recheck at least every 12 months.[18, 21]

What to do now: at your next appointment, ask your doctor to write down how your condition limits your ability to work, study or volunteer, not just what the condition is. Ask for a copy. If your state’s list does not include your condition, use the request process the rule requires. And keep an eye on the courts: two lawsuits, described later in this guide, target exactly this “significantly impairs” test.[15]

Short-Term Hardship: Four Bad Months the Rule Can Forgive, If Your State Opts In

States may choose to treat you as meeting the rule for any month in which, for all or part of the month, one of four things happens. You receive inpatient-level care in a hospital, nursing facility or psychiatric hospital, or care of similar intensity. You live in a county under a presidential disaster or emergency declaration. You live in a county where unemployment is at or above 8 percent, or 1.5 times the national rate if that is lower. Or you, or a dependent, must travel away from your community for an extended time to get care for a serious condition that is not available nearby.[22, 2]

Two of these are automatic. For a disaster or a high-unemployment county, the state must apply the exception without asking you for anything. The hospital and travel exceptions work differently: you, or someone acting for you, must request them. The state has to tell you how to ask, by when, how it will decide, and how to appeal a no.[22, 18]

Not every state offers these. In a KFF survey fielded from January to March 2026, 29 states planned to adopt at least one hardship exception, and all but three of those planned to adopt all four. Indiana and Iowa planned to adopt none. Oklahoma was skipping the disaster and unemployment exceptions, Missouri the unemployment one, and New York the travel one. Policies can change, so check your state’s notice, which must say whether it offers them.[23, 24]

If you are admitted to a hospital, keep your admission and discharge papers, and ask the hospital’s social worker to help you file the hardship request before you leave. Those two dates are what the state needs, and they are hardest to find months later.[22]

The Application Clock: The Months That Count Can Start Before You Apply

When you apply, the state does not look at the month you apply. It looks back at one to three consecutive months right before it, and each state picks the number. In the KFF survey, 36 states planned to look back one month. Indiana and Idaho planned three.[25, 23]

CMS spelled out what that means in its December 2025 guidance. Someone applying in January 2027 in a state that looks back three months must show community engagement in October, November and December 2026. In a two-month state, November and December. October 2026 begins this week. If you might need Medicaid early next year and live in a three-month state, the months that count are already about to start.[26]

The flip side is in the rule itself. An application is judged under the rules in place on the day it is submitted. CMS’s example: an application filed December 15, 2026 and decided January 15, 2027 must not be checked for November activity, because the requirement was not yet in force when it was filed. The work rule then applies at that person’s next renewal. If you are eligible today and need coverage, there is no reason to wait.[3]

And if you are turned down because a look-back month came up short, it is not a lockout. The rule forbids states from restricting your ability to reapply or to be covered once you qualify. You can apply again as soon as you have the months.[27]

The Renewal Clock: Every Six Months, and the First Check Can Start Early

If you are already enrolled, you are not cut off on your state’s start date. The state first checks you at your first renewal that begins on or after that date. “Begins” matters: CMS notes that most states take 60 to 90 days to work through a renewal, so the review of your data can start well before your coverage period ends.[28, 3]

Renewals also speed up. For the adult group, renewals scheduled on or after January 1, 2027 happen every six months instead of every twelve. American Indians and Alaska Natives stay on a 12-month cycle. Some states are pulling renewals forward to line up. Montana, for example, says a member whose last renewal was in August 2026 will be renewed in February 2027, not August 2027.[29, 30]

At each renewal you must show you met the rule, or were excused, for at least one month since your last one. States may demand more. In the KFF survey, Arkansas planned to look back three months at renewal, and Indiana and New Hampshire planned quarterly checks between renewals. Nebraska, which started before six-month renewals, gives current members a 12-month window: at least one calendar month since the last renewal.[25, 23, 20]

CMS itself points out the squeeze: on a six-month cycle, with 60 to 90 days of processing, you may be only about three months into a new period when the next review starts. So learn your renewal month now. Put a reminder on your calendar three months before it, and treat every month in between as one that might be checked.[3]

Where Your State Stands: Early Starters, January Starters, and Possible Delays

Nebraska went live on May 1, 2026, and began checking members whose coverage periods end on or after July 31, 2026. Its first terminations came on August 1. Montana started July 1, 2026, with a “hold harmless” period: from July through September it reviewed people but did not deny or remove anyone for this reason. Starting in October 2026, Montana says noncompliance is enforced with denial and disenrollment.[20, 1, 31, 11]

Iowa says certain members of its expansion program must meet the requirements by December 1, 2026. Arkansas began a soft launch on July 1, 2026, but said it would not remove anyone before January 1, 2027. Georgia has run its own work-linked program, Pathways to Coverage, since July 2023. Every other affected state must start by January 1, 2027.[32, 33, 34, 35]

A state that is struggling can ask CMS for a good-faith exemption. The first one lasts up to six months, extensions are possible, and none can run past December 31, 2028. In its December 2025 guidance, CMS said it expected approvals to be limited to states making meaningful efforts that run into severe or unexpected problems. As of this writing we have not seen a public approval, so plan on your state starting on time.[36, 26]

You should have heard from your state already. Outreach must start months ahead: for a January 1 start, by September 2026 in states that look back one month, by August in two-month states and by July in three-month states. The Massachusetts attorney general put the one-month deadline at August 31, 2026. The notice must come by regular mail, or electronically if you chose that, plus at least one other way, such as your online account, a phone call or a text. If you have seen nothing, call your state and update your address today.[26, 24, 37]

The State Has to Look Before It Asks You

Before asking you for anything, the state must check every reliable source it has or should have: payroll data, other state and local agencies, a federal data service, its own eligibility system, your case file, and your medical claims from the past 12 months. It cannot stop after checking one kind of activity. It has to keep looking until it confirms that you met the rule, were excused, or are excluded. Only then may it ask you for more.[18]

How often will that work? CMS estimates that 56 percent of people due for renewal will be confirmed automatically, and that the other 44 percent, about 8.8 million people, will have to send something, at roughly two hours each time, twice a year. Nebraska, a small state that runs its own eligibility system, says it can confirm about three-quarters of its members without contacting them. CMS is also funding system upgrades, including $200 million in grants to states.[3, 1, 38]

Nebraska puts the practical rule plainly: if the state does not send you a request, you do not have to send anything. Your job is to watch your mail, email and text messages, because that is how a request arrives. Missing a request is the single most common way a working person ends up in the 7 percent.[20]

Where are the data weakest? Nebraska’s own declaration form is a good map. It is meant only for things people must declare themselves: volunteering, education or work programs, caring for a person with a disability, previous incarceration, medical exemptions, and VA disability ratings. If your situation is on that list, expect a request, and get your proof ready before it comes.[20]

What Counts as Proof, and How to Send It

Match the proof to the path. For work: pay stubs or a letter from your employer showing hours or pay, and for self-employment, records of what you earned. For school: an enrollment verification from the registrar. For community service: the organization’s record of your dates and hours, with the name and phone number of the person who can confirm them. For medical frailty: health records, a provider’s documentation or certification, or a care manager’s notes from your health plan.[10, 21]

The documentation rules tighten over time. Before January 1, 2028, a state may ask for documents or accept other information when its data come up empty. Starting January 1, 2028, it must require documents whenever they are reasonably available. But at every stage the state must accept other information when no documents exist, and it may not deny or end your coverage just because you cannot produce a document that does not exist.[18]

You can send information any way you could apply: online, by phone, by mail, or in person, and states must also accept other commonly available electronic methods. You do not have to do it alone. An adult in your household, a family member, or an authorized representative can submit it for you.[18, 39]

The habit that protects you most is boring. Keep a monthly folder, on paper or as photos on your phone, with that month’s pay stubs, class schedule or volunteer hours. Write down your volunteer supervisor’s name and number. Every time you send something to the state, note the date and how you sent it, and keep a copy. When a request comes, you answer in a day instead of a month.

The 30-Day Letter: What It Must Say and What Happens Next

If the state cannot confirm you, it must send a notice of noncompliance. The rule spells out what it must say: which months are being checked; how to show you met the rule or were excused; how to show you are excluded; the deadline; the ways you can send information; what happens to your Medicaid and to your eligibility for Marketplace tax credits if you do not respond; and how to reapply if you are denied.[27]

You get 30 calendar days from the day you receive the letter, and the rule treats it as received 5 days after the date printed on it unless you show it came later. Your coverage continues during that time. CMS’s fact sheet puts it simply: 30 days to show you met the requirement, or that it does not apply to you.[27, 2]

If the 30 days pass without a satisfactory answer, the state still has duties. It must first consider every other way you might qualify for Medicaid. If none works, it must send a written notice with your appeal rights, give at least 10 days’ advance notice, and end coverage no later than the end of the month after the month the 30 days ran out.[27, 40]

Here is how the dates can fall. A letter dated March 2 is treated as received March 7. The 30-day window runs out in early April, on April 5 or 6 depending on how your state counts. Coverage can then end no later than May 31. That sounds like a lot of time. It is not, because the whole point is to answer inside the first window, while your coverage is safe and nothing has to be undone. Answer in the first week.[27]

If You Are Cut Off: Three Doors Back In

Door one: a fair hearing. This is Medicaid’s appeal. States must give you a reasonable time to ask for one, up to 90 days from the date the notice is mailed. The timing matters: if you ask for a hearing before the date the action takes effect, the state generally must keep your coverage going until the hearing decision. If you lose, the state can try to recover what it paid for your care during that time, so ask the agency or legal aid about that risk.[41, 42]

Door two: reconsideration. If you were cut off because you did not send requested information, and you send it within 90 days after your coverage ended, the state must reconsider your eligibility without making you file a new application. Some states allow longer. This door is built for exactly the person the 7 percent describes: someone who qualified all along but missed the paperwork.[43, 27]

Door three: apply again. The rule forbids any restriction on reapplying, which is a real change from Arkansas in 2018, where three months of noncompliance locked people out until the next year. But move fast. For applications made on or after January 1, 2027, Medicaid can reach back only one month before the application month for adults in the expansion group, down from three. Every week you wait can be a week of bills that are yours alone.[27, 44, 45]

You do not have to do any of this alone. Legal aid offices, funded in part by the federal Legal Services Corporation, help with Medicaid appeals at no cost to people who qualify. And if bills pile up during a gap, our guide to medical bills and medical debt explains how to check them, dispute them and ask for financial assistance.[46]

The Marketplace Trap: Losing Medicaid This Way Also Blocks the Tax Credit

Normally, when people lose Medicaid, they can turn to a HealthCare.gov plan, where a premium tax credit lowers the monthly price. Not this time. The law says that for any month you would have been eligible for Medicaid but for the work requirement, you are treated as eligible for Medicaid for tax-credit purposes. And people eligible for government coverage like Medicaid cannot get the premium tax credit. So a work-requirement denial also shuts the door to subsidized Marketplace coverage.[47, 3, 48]

That makes this kind of loss very different from losing Medicaid because your income went up. If a raise pushes you above the Medicaid limit, Marketplace savings may still be available, and our guides to 2026 Marketplace premiums and to health insurance after a job loss walk through those choices. The state’s notice must tell you about the tax-credit consequence, so read that paragraph closely.[49, 27]

What does going without coverage actually cost? For most people it is not the premium they save. It is one emergency room visit, one hospital stay, or a year of prescriptions at full price. Before you decide that a lapse is survivable, put numbers on what your own health care could cost over the years ahead.

What Happened the Last Time: Arkansas, Georgia, and Who Is Actually on Medicaid

Arkansas tried a work requirement starting in June 2018. A court halted it in March 2019. Before that, according to the state’s own reports, more than 18,000 people lost coverage for not complying. In a 2021 letter, CMS wrote that even people who were working, or who had serious health needs, lost coverage or were at risk because of complicated administrative and paperwork requirements. That program also required monthly reporting and locked people out until the next year.[44]

Georgia opened its Pathways program in July 2023. The Government Accountability Office later found that $54.2 million of the $80.3 million spent on the program had gone to administration, not health care, and that federal dollars paid about 88 percent of those administrative costs.[35, 34]

Who is actually on Medicaid? KFF’s analysis of 2023 Census survey data found that among adults under 65 on Medicaid who do not get disability benefits or Medicare, 64 percent were working, and 92 percent were either working or not working because of caregiving, illness or disability, or school. The remaining 8 percent were retired, could not find work, or gave another reason.[50]

MACPAC, the commission that advises Congress on Medicaid, summed up the earlier experiments in April 2026: where they were carried out, coverage losses were substantial, and lack of awareness, barriers to work and administrative problems were common reasons people did not report. CMS’s own rule says much the same. The lesson for you is practical. Awareness is the protection. People who know the months, the letters and the deadlines are the ones who stay counted.[51, 3]

The Court Fight: What Is Being Challenged, and What Is Not

CMS issued its rule on June 1, 2026. It was published in the Federal Register on June 3 and took effect on July 31, the same day public comments closed. The lawsuits so far target how CMS wrote the rule, especially its medical frailty test, not the 80-hour requirement Congress passed. Whatever the courts decide, the basic requirement is law.[3]

The states’ case. On June 29, 2026, a coalition led by Massachusetts, California and New Jersey sued in federal court in Massachusetts, in Commonwealth of Massachusetts v. Oz. Reporting counts 25 states and Washington, D.C.; the Massachusetts attorney general calls it a coalition of 26. On July 29, the judge denied their request to pause the rule, noting that the tight timeline was set by Congress. The case continues: the states moved for partial summary judgment on September 1, the government filed its own motion on September 18, and a hearing is set for October 20, 2026.[52, 37, 53]

The doctors’ case. On September 18, 2026, the American Academy of Pediatrics, the American College of Physicians, Doctors for America and other groups, joined by individual Medicaid enrollees, sued in federal court in Maryland in Taylor v. Kennedy. They argue the CMS rule narrows the medically frail exclusion that Congress wrote, by making sick people prove their condition keeps them from meeting the work requirement, and they ask the court to stay that policy.[54, 55]

What this means for you: as of today, the CMS rule is in force, and no court has paused it. Plan as if it applies. If a court later changes the medical frailty test, states will have to adjust their lists and letters, and people who were denied may get another look. Until then, the advice in this guide stands.[53]

The Other Medicaid Clocks Running Through 2028

The work rule arrives with a package of other changes from the same 2025 law. Each has its own date.

October 1, 2026. Federal Medicaid funding for noncitizens narrows to U.S. citizens and nationals, lawful permanent residents, Cuban and Haitian entrants, and people from the Compact of Free Association nations. Many other lawfully present immigrants, including refugees and asylees, lose federally funded full Medicaid, as Montana’s notice to members spells out. Emergency Medicaid is not affected.[45, 30]

January 1, 2027. Six-month renewals begin for the adult group. For applications made on or after this date, retroactive coverage shrinks to one month before the application month for the adult group and two months for everyone else, down from three. That second change matters most for families facing a sudden hospital or nursing home bill, which our nursing home guide covers in detail.[29, 45]

January 1, 2028. The paperwork rules tighten: states must require documents whenever they are reasonably available, and a signed statement can support a medical frailty exclusion only once per stretch of enrollment. October 1, 2028. States must charge cost sharing of up to $35 per service to adult-group members with income above 100 percent of the poverty line. Primary care, behavioral health, and visits to community health centers and rural health clinics are exempt, and a family’s total cost sharing cannot exceed 5 percent of its income. December 31, 2028 is the last possible day of any good-faith delay.[18, 45, 36]

Two of these rules turn on percentages of the poverty line: whether your income is above 100 percent, and whether your costs stay under 5 percent of income. Both are simple divisions, and they are worth doing once for your own household.

Your 90-Day Plan: Six Moves That Keep You Counted

1. Fix your contact details this week. Update your mailing address, phone number and email with your state Medicaid agency, turn on text or email alerts if your state offers them, and set up your online account. Requests arrive by mail plus at least one other channel, and a request you never see is the one that ends coverage.[24, 20]

2. Pick your lane. If an exclusion fits, such as a child 13 or younger, a disability, pregnancy or a 100 percent VA rating, report it now. If your household income is at least $580 a month, make sure the state can see it. If you are counting hours, decide which mix of work, school, volunteering or a work program gets you to 80.[15, 10]

3. Learn your two clock settings. Ask your state how many months it looks back at application and at renewal, and when your next renewal is due. Put a reminder three months before that date. 4. Start the monthly folder today, even if you are sure the state can see your job.[25]

5. When a letter comes, circle the date. Add 5 days for delivery and 30 days to answer, but aim to reply in the first week, keep a copy, and call if anything is unclear. 6. If you are cut off, use the doors in order of speed: ask for a fair hearing before the action date to keep coverage, send missing information within 90 days, or reapply the same day.[27, 42, 43]

Where to get help: your state Medicaid agency, listed with phone numbers on Medicaid.gov; your health plan’s member services line; and legal aid, which you can find through the Legal Services Corporation. CMS posts new guidance for states on its community engagement page, which is where any change after the court cases will show up first.[9, 46, 56]

Frequently Asked Questions

Short answers to the questions people ask first. Where a date or a number decides the answer, it is stated, because those are the places where a guess can cost you your coverage.

Key Takeaways

The test is proof, not just work. CMS’s own analysis expects 7 percent of people who are working, studying or excused to lose coverage for paperwork reasons. Most people will be confirmed from data the state already has. Your job is to make sure the rest of your situation is visible, and to answer any request fast.

Check the four questions first. The rule reaches adults 19 through 64 in the expansion adult group or an equivalent waiver, who are not pregnant and not on Medicare. Ten exclusions, including parents of children 13 or younger, caregivers, and medically frail people, take you out entirely.

Income can replace hours. Monthly income of at least $580, the federal minimum wage times 80, meets the rule, and CMS measures it with household income. In a state with a $15 minimum wage, that is about 39 hours of work. Confirm with your state how it counts household income.

Two clocks run. At application the state looks back one to three months, so a January 2027 applicant in a three-month state needs October through December 2026. Enrolled members are checked at the first renewal that begins after the start date, then every six months. Know your renewal month and set a reminder three months before it.

The 30-day letter is the moment that matters. You get 30 days from receipt, counted as 5 days after the date on the letter, and coverage continues while you answer. Answer in the first week. If you are cut off, ask for a fair hearing before the action date, send missing information within 90 days, or reapply the same day. There is no lockout, but retroactive coverage shrinks to one month in 2027.

Losing Medicaid this way costs more than Medicaid. A work-requirement denial also blocks the Marketplace premium tax credit, which makes this loss different from losing coverage because your income rose. And the rules are still moving: two lawsuits target CMS’s medical frailty test, with a hearing set for October 20, 2026. Until a court says otherwise, plan as if the rule applies to you.