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Medicaid work requirements

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Work requirements
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• Work requirements by state • Index of articles
• Major arguments
• Reform proposals
•Medicaid work requirements
• Public housing work requirements
• SNAP work requirements
• Child care subsidy work requirements
• Laws
• Court cases
• Scholarly work

What are Medicaid work requirements?
Medicaid work requirements are policies that condition eligibility for Medicaid benefits on participation in work or related activities for certain adult enrollees. These activities may include employment, job training, education, or community service. In 2025, Congress passed the One Big Beautiful Bill Act (OBBBA), which created the first federally mandated Medicaid work requirements. The law requires all states to implement a monthly 80-hour community engagement requirement by January 1, 2027, with the option to apply for a delay through 2029. As of 2025, Georgia was the only state with an active Medicaid work requirement.[1]

Why does it matter?
Medicaid provides health coverage to more than 70 million low-income individuals and families. The enactment of a federal work requirement marks a major shift in how eligibility is determined—replacing a state-by-state waiver process with a national mandate. It highlights ongoing tensions between state autonomy and federal oversight of public assistance—raising questions about how much flexibility states should have in administering federally funded benefit programs. The policy has become a flashpoint between presidential administrations, with the first Trump administration encouraging state adoption and the Biden administration reversing course before Congress established a nationwide standard in 2025.

What is the background?
Before the enactment of the OBBBA in 2025, there were no federally mandated work requirements for Medicaid. States could only implement such policies by applying for a Section 1115 waiver from the Centers for Medicare and Medicaid Services (CMS).[2] During the first Trump administration, 13 states received approval to implement work requirements, but most efforts were blocked by legal challenges. Courts in several states ruled that CMS had not adequately considered the risk of coverage loss, and the Biden administration later withdrew all 13 waivers. Georgia was the only state to successfully defend its waiver in court, and it implemented work requirements in 2023.[3]

What are states doing?
Under the OBBBA, all states must implement work requirements by January 1, 2027, but may apply for early implementation or request a delay through 2029. As of August 12, 2025, six states, Arizona, Arkansas, Iowa, Ohio, South Carolina, and Utah, had submitted waiver requests to CMS to implement Medicaid work requirements. One additional state, Montana, had publicly announced their intent to adopt work requirements but had not yet submitted a formal request. Georgia remained the only state with an active Medicaid work requirement as of that date and had submitted a waiver renewal request to CMS.[4]

What are the arguments?
Proponents of Medicaid work requirements argue that they improve recipient health, ensure benefits are reserved for the truly needy, and help reduce poverty by encouraging employment.

Opponents of Medicaid work requirements argue that they worsen health and employment outcomes, cause people to lose coverage due to administrative burdens, and make it harder for those truly in need to access care.

Dive deeper:

  • Background
    Read more
  • History of Medicaid work requirements
    Read more
  • Timeline of Medicaid work requirements
    Read more
  • Court cases related to Medicaid work requirements
    Read more
  • Noteworthy events
    Read more


Background

See also: Centers for Medicare and Medicaid Services

Medicaid, established by the Social Security Act of 1965, is a nationwide program that provides health coverage for qualifying individuals. The program is jointly funded by the federal government and the states. The states manage Medicaid eligibility, benefits, and administration within federal guidelines.

Medicaid work requirements are mandated work-related activities that Medicaid recipients must complete to qualify for benefits, such as working, pursuing education, participating in a work program, or volunteer activities. As of July 2025, Georgia was the only state with active Medicaid work requirements. The One Big Beautiful Bill Act, which was signed into law on July 4, 2025, requires states to implement a work requirement of at least 80 hours per month by January 1, 2027.[1]

Section 1115 waivers

Section 1115 of the Social Security Act gives the secretary of Health and Human Services (HHS) authority to approve any "experimental, pilot, or demonstration project which, in the judgment of the Secretary, is likely to assist in promoting the objectives of public assistance programs in a State or States." The Centers for Medicare and Medicaid Services (CMS) performs a case-by-case review of Section 1115 applications to determine whether the stated goals are aligned with Medicaid objectives. State applications for Section 1115 waivers must be budget neutral to the federal government, meaning that a state’s experimental project cannot increase federal Medicaid expenditures.[5]

Section 1115 waivers give states flexibility to design and improve programs by implementing state-specific policies to serve Medicaid recipients at the state level. Before the One Big Beautiful Bill Act (OBBB Act) mandated Medicaid work requirements for all states, Section 1115 waivers were the only way states could implement these requirements. The OBBB Act allows states to apply for Section 1115 waivers to implement work requirements for Medicaid ahead of the January 2027 deadline, but does not allow states to use these waivers to waive the work requirements.[5][1]

CMS approved Medicaid work requirement waivers in 13 of the 22 states that applied during the first Trump administration. Of these waivers, only Arkansas fully implemented its program before the Biden administration directed the agency to withdraw all approved waivers.[6] Georgia implemented Medicaid work requirements on July 1, 2023, through the Georgia Pathways program. Click here to learn more.

History of Medicaid work requirements

This section features information about the history of work requirements in the Medicaid program.

CMS rejection of Medicaid work requirements during the Obama administration

Work requirements came to the forefront of Medicaid policy discussions after President Barack Obama (D) signed the Affordable Care Act (ACA) into law in 2010. The ACA sought to expand Medicaid coverage beyond its original scope (pregnant women and young children with household incomes around the federal poverty level, disabled people, older children, and parents with household incomes below the federal poverty level) to include able-bodied adults without children or people with slightly higher incomes. Each state was allowed to apply for Section 1115 waivers to broaden Medicaid coverage. The following six states submitted Section 1115 waivers proposing to expand Medicaid coverage and adopt work requirements for recipients:

  • Arizona
  • Arkansas
  • Indiana
  • Kentucky
  • New Hampshire
  • Pennsylvania

HHS accepted Section 1115 waivers to expand Medicaid coverage for all six states but rejected the sections establishing work requirements. HHS argued that work requirements for Medicaid undermine access to care and do not support the objectives of Medicaid.[7]

CMS approval of Medicaid work requirements during the first Trump administration

HHS first approved state-based work requirement policies for Medicaid under Section 1115 of the Social Security Act during the first Trump administration.[8]

CMS in January 2018 issued guidance documents inviting states to apply for Section 1115 waivers to create work requirements, reporting requirements, and community engagement conditions for non-elderly, non-pregnant, adult Medicaid beneficiaries without disabilities. CMS guidance documents stated that work requirement provisions would promote the objectives of Medicaid by assisting states "in their efforts to improve Medicaid enrollee health and well-being through incentivizing work and community engagement."[9][10]

CMS approved Section 1115 waivers that conditioned Medicaid coverage on meeting work requirements and reporting requirements in the following 13 states from 2018 to 2020:

  • Arizona
  • Arkansas
  • Georgia
  • Indiana
  • Kentucky
  • Maine
  • Michigan
  • Nebraska
  • New Hampshire
  • Ohio
  • South Carolina
  • Utah
  • Wisconsin

Nine other states submitted Section 1115 waivers but did not receive CMS approval before Biden's administration started withdrawing waivers in 2021:[8]

  • Alabama
  • Idaho
  • Kansas
  • Mississippi
  • Montana
  • Oklahoma
  • South Dakota
  • Tennessee
  • Virginia

Due to litigation, state withdrawals, and the Covid-19 pandemic, only Arkansas fully implemented its approved Section 1115 waiver during the first Trump administration, with the waiver becoming effective in June 2018.

CMS withdrawal of Medicaid work requirements during the Biden administration

CMS later withdrew all approved waivers for Medicaid work requirements during the Biden administration.

President Joe Biden (D) on January 28, 2021, issued Executive Order 14009 and directed HHS to review waivers that risk significant coverage losses.[8]

CMS in February 2021, began issuing final withdrawals for all states that had work requirement approvals under Section 1115 waivers. Though Arkansas filed suit arguing that its work requirements were lawful, the U.S. Supreme Court on March 11, 2023, removed the case from its docket and did not provide reasoning with its cancellation notification.[8][11]

Georgia Medicaid expansion and work requirements

Georgia lawmakers in 2019 passed Senate Bill 106, which created a state-developed protocol—known as Georgia Pathways—to return to historical Medicaid eligibility standards and implement a partial Medicaid expansion to cover adults with households below the poverty level who work at least 80 hours per month.[12]

Georgia submitted its Georgia Pathways plan to CMS in December 2019 and was approved for a Section 1115 waiver in October 2020, effective July 1, 2021. CMS notified Georgia that the work requirement for Medicaid eligibility was being reconsidered in February 2021. Georgia officials replied in March 2021, arguing that work requirements were part of their plan to expand Medicaid coverage, and suspended Medicaid expansion until work requirements were approved.[12]

Georgia filed a lawsuit against CMS and HHS in January 2022 and asked the United States District Court for the Southern District of Georgia to allow the state to proceed with Georgia Pathways as it was initially approved. The U.S. District Court for the Southern District of Georgia ruled in favor of the state on August 19, 2022, and allowed the state to move forward with Georgia Pathways.[12][13]

Georgia became the only state to have a Medicaid work requirement in place when Georgia Pathways took effect on July 1, 2023. The Georgia Department of Community Health (DCH) announced the launch of the Georgia Pathways to Coverage program on July 5, 2023. The program defines employment and training as qualifying work activities.[14][15]

Medicaid work requirements in the One Big Beautiful Bill Act

See also: Work requirements policies in the 2025 budget reconciliation bill (One Big Beautiful Bill Act)

The 2025 budget reconciliation bill that was signed into law on July 4 requires states to adopt community engagement requirements for able-bodied adults without dependents on Medicaid by January 1, 2027. These community engagement requirements can be met by doing any of the following for 80 hours a month:

  • working,
  • doing community service,
  • participating in a work program, or
  • doing a combination of these activities.

An individual could also meet the requirements by enrolling at least part-time in an educational program or by making a monthly income of at least 80 times the federal hourly minimum wage. Failure to comply with the community engagement requirement would result in the denial of an application for Medicaid or disenrollment from the program.[16]

Timeline of Medicaid work requirements

The following timeline features noteworthy events related to the development and implementation of Medicaid work requirements:

  • March 23, 2010

    The Affordable Care Act was signed into law and allowed states to expand Medicaid to cover childless adults earning incomes up to 138 percent of the poverty level.

  • February 12, 2016 - August 24, 2016

    Arizona, Arkansas, Indiana, Kentucky, New Hampshire, and Pennsylvania submitted Section 1115 waivers to expand Medicaid and create work requirements for beneficiaries.[17][18][19][20]

  • September 30, 2016 - July 3, 2017

    CMS accepted portions of Section 1115 waivers from Arizona, Arkansas, Indiana, Kentucky, New Hampshire, and Pennsylvania expanding Medicaid coverage, but rejected portions establishing work requirements for eligibility.[21]

  • January 11, 2018

    CMS issued guidance inviting states to request Section 1115 waivers for work requirements and reporting requirements as a condition of Medicaid eligibility for non-elderly, non-pregnant, able-bodied adult beneficiaries.[22]

  • January 12, 2018 - November 15, 2020

    CMS approved Section 1115 waiver implementing work requirements for Medicaid for Arizona, Arkansas, Georgia, Indiana, Kentucky, Maine, Michigan, Nebraska, New Hampshire, Ohio, South Carolina, Utah, and Wisconsin.[23][24][25][26][27][23][28][29][30][31][32][33][34]

  • December 16, 2019

    Gov. Andy Beshear (D) withdrew Kentucky's Medicaid work requirement waiver.[35]

  • March 17, 2021 - December 27, 2021

    CMS revoked work requirements for Medicaid eligibility in Arizona, Arkansas, Georgia, Indiana, Maine, Michigan, Nebraska, New Hampshire, Ohio, South Carolina, Utah, and Wisconsin.[36][37][38][39][40][41][42][43]

  • August 19, 2022

    The U.S. District Court for the Southern District of Georgia ruled that the state of Georgia could lawfully implement the Georgia Pathways program as part of its Medicaid expansion with work requirements as a standard for eligibility.[12]

  • July 1, 2023

    Georgia implemented Medicaid work requirements through the Georgia Pathways program.[14]

  • July 4, 2025

    The One Big Beautiful Bill Act was signed into law, requiring states to implement a work requirement for able-bodied Medicaid recipients of at least 80 hours per month.

Court cases related to Medicaid work requirements

See also: Medicaid work requirements pros and cons

The following six states challenged CMS' withdrawal of Medicaid work requirements under the Biden administration:

Georgia

Georgia v. Lasure (2022)

Georgia filed a lawsuit against CMS and HHS in January 2022 after CMS notified Georgia that its previously approved work requirement for Medicaid eligibility was being reconsidered. Georgia asked the United States District Court for the Southern District of Georgia to allow the state to proceed with Georgia Pathways as it was initially approved. The U.S. District Court for the Southern District of Georgia ruled in favor of the state on August 19, 2022, arguing that "CMS’s decision to rescind approval for Pathways was arbitrary and capricious, and the appropriate course is to set it aside." The court allowed Georgia to move forward with Georgia Pathways effective July 2023.[12][13]

Indiana

Azar v. Rose (2021)

Indiana submitted a Section 1115 waiver to establish work requirements for Medicaid eligibility on July 20, 2017. CMS approved Indiana's Section 1115 waiver on February 1, 2018. A group of Indiana residents enrolled in Medicaid filed a lawsuit against HHS Secretary Alex Azar in the United States District Court for the District of Columbia, asking the court to place a stay on Indiana work requirements until Stewart v. Azar, and Gresham v. Azar were resolved. The United States District Court for the District of Columbia on July 8, 2021, ordered the parties to file a status report within two weeks of the end of the Covid-19 public health emergency or within two weeks of CMS' review of Indiana's waiver approval, depending on which occurred first. HHS later revoked Indiana's work requirement for Medicaid beneficiaries on June 25, 2021, arguing that the Covid-19 pandemic and loss of Medicaid coverage for vulnerable individuals undermined the goals of Medicaid. The district court did not issue a ruling in the case Azar v. Rose due to HHS's revocation of the state's Medicaid work requirements.[44][45][46]

Michigan

Young v. Azar (2020)

Michigan submitted a Section 1115 waiver to amend the state Medicaid program and institute work requirements for eligibility on September 10, 2018. CMS approved Michigan's Medicaid work requirement on December 21, 2018. A group of Medicaid recipients from Michigan sued HHS Secretary Alex Azar in the United States Court of Appeals for the District of Columbia on November 22, 2019. A three-judge panel on March 3, 2020, ruled that the approval of work requirements for Medicaid in Michigan were unlawful, citing Azar v. Gresham.[47][48]

Arkansas

Azar v. Gresham (2020)

Arkansas submitted a Section 1115 waiver to establish work requirements for Medicaid eligibility on June 30, 2017. CMS approved Arkansas' waiver on March 5, 2018. Arkansas implemented work requirements for Medicaid eligibility on June 1, 2018. Charles Gresham and nine other Arkansas citizens sued HHS Secretary Alex Azar in the United States District Court for the District of Columbia on August 14, 2018. The court on March 27, 2019, ruled that CMS approval of Arkansas' work requirements for Medicaid coverage was unlawful because the secretary acted in an "arbitrary and capricious manner because he failed to analyze whether the demonstrations would promote the primary objective of Medicaid—to furnish medical assistance." A three-judge panel from the United States Court of Appeals for the District of Columbia, on February 14, 2020, unanimously affirmed the United States District Court for the District of Columbia’s decision ruling that the Arkansas Medicaid work requirement program was unlawful because it failed to consider the impact on coverage. The U.S. Supreme Court, on April 18, 2022, dismissed Azar v. Gresham as moot after CMS withdrew the waiver.[49][50][51]

New Hampshire

Philbrick v. Azar (2020)

New Hampshire submitted a Section 1115 waiver on July 23, 2018, to create work requirements for non-disabled Medicaid beneficiaries ages 19 to 64. HHS Secretary Alex Azar approved New Hampshire's Section 1115 waiver on November 30, 2018. Samuel Philbrick sued Azar in the United States District Court for the District of Columbia, which ruled in 2019 that approval of New Hampshire work requirements for Medicaid was unlawful because CMS failed to consider the impact of work requirements on coverage. The court argued that New Hampshire's work requirements did not advance the purposes of Medicaid. New Hampshire appealed and the United States Court of Appeals for the District of Columbia Circuit on May 20, 2020, affirmed the lower court’s ruling, citing the reasoning in Azar v. Gresham. The U.S. Supreme Court on April 18, 2022, remanded the case to HHS following CMS' withdrawal of New Hampshire's work requirements for Medicaid.[52][53][54]

Kentucky

Azar v. Stewart (2018)

Kentucky submitted a Section 1115 waiver to establish work requirements for Medicaid eligibility on September 8, 2016. CMS approved Kentucky's Section 1115 waiver on January 12, 2018. A group of Medicaid recipients in Kentucky sued HHS Secretary Alex Azar in the United States District Court for the District of Columbia, arguing that HHS' approval of Kentucky's work requirements was unlawful because they impeded the goals of Medicaid to promote medical assistance for low-income citizens. The United States District Court for the District of Columbia on June 29, 2018, ruled that Kentucky’s work requirements were unlawful because CMS failed to consider the impact on coverage. The court vacated Kentucky’s waiver and remanded it to CMS, which reapproved Kentucky’s work requirement for Medicaid. The United States District Court for the District of Columbia on March 27, 2019, again found that the approval of work requirements was unlawful because HHS Secretary Alex Azar "never adequately considered whether Kentucky HEALTH would in fact help the state furnish medical assistance to its citizens, a central objective of Medicaid." The United States Court of Appeals for the District of Columbia Circuit on January 8, 2020, dismissed the appeal from the United States District Court for the District of Columbia because Kentucky Governor Andy Beshear (D) withdrew Medicaid work requirements.[55] [56][57]

Noteworthy events

Noteworthy events at the federal level

Medicaid work requirement provisions included in the One Big Beautiful Bill Act (2025): The 2025 budget reconciliation bill that was signed into law on July 4 requires states to adopt community engagement requirements for able-bodied adults without dependents on Medicaid by January 1, 2027. These community engagement requirements can be met by doing any of the following for 80 hours a month:

  • working,
  • doing community service,
  • participating in a work program, or
  • doing a combination of these activities.

An individual could also meet the requirements by enrolling at least part-time in an educational program or by making a monthly income of at least 80 times the federal hourly minimum wage. Failure to comply with the community engagement requirement would result in the denial of an application for Medicaid or disenrollment from the program.[58]

Robert F. Kennedy Jr., Mehmet Oz, Brooke Rollins, and Scott Turner on work requirements for public assistance programs (2025): Secretary of Health and Human Services Robert F. Kennedy Jr., Administrator of the Centers for Medicare & Medicaid Services, Mehmet Oz, Secretary of Agriculture Brooke Rollins, and Secretary of Housing and Urban Development Scott Turner cowrote a New York Times opinion piece, that was published on May 14, 2025. The secretaries and administrator expressed their feelings on work requirements for public assistance and support for a 20 hour/week work requirement across programs.[59]

They wrote:

“

Establishing universal work requirements for able-bodied adults across the welfare programs we manage will prioritize the vulnerable, empower able-bodied individuals, help rebuild thriving communities and protect the taxpayers.[60]

”
“

Our agencies are united in a very straightforward policy approach: Able-bodied adults receiving benefits must work, participate in job training or volunteer in their communities at least 20 hours a week. Limited exceptions will be made for good cause, like caring for young children and health issues, but the principle is clear — those who can work, should.[60]

”

Medicaid work requirements proposal included in debt ceiling bill (2023):The U.S. House of Representatives on April 26, 2023, voted 219-210 to pass H.R. 2811, the Limit, Save, Grow Act of 2023, which aims to raise the federal government’s debt ceiling and includes provisions related to work requirements for certain able-bodied adults receiving Medicaid, Temporary Assistance for Needy Families (TANF) and Supplemental Nutrition Assistance Program (SNAP) assistance.

The proposal would require applicable Medicaid and SNAP recipients to complete 80 hours a month of community engagement or work-related activity. Applicable individuals under the proposal generally include adults between the ages of 19 and 55 who are physically able to work, not pregnant, and not serving as a caregiver to a dependent or incapacitated person. The proposal also includes provisions aimed at reducing TANF caseloads by modifying certain reporting and performance measures for the program’s existing work requirements.

In his April 19 remarks on the House floor, Speaker Kevin McCarthy (R-Calif.) argued, "Our plan ensures adults without dependents earn a paycheck and learn new skills. By restoring these commonsense measures, we can help more Americans earn a paycheck, learn new skills, reduce childhood poverty and rebuild the workforce."

Democrats, including House Agriculture Committee ranking member David Scott (D-Ga.), have argued against the work requirements. Scott stated in a press release, “Holding food assistance hostage for those who depend on it—including 15.3 million of our children, 5.8 million of our seniors and 1.2 million of our veterans—in exchange for increasing the debt limit is a nonstarter.” President Joe Biden (D) stated that he would veto the legislation if reached his desk.

President Joe Biden (D) signed the final version of the debt ceiling legislation—the Fiscal Responsibility Act of 2023—on June 3, 2023. The bill included modified SNAP and TANF work requirements but did not include Medicaid work requirements.[61]

Noteworthy events at the state level

South Dakota Health and Human Services to revoke section 1115 waiver amendment request for work requirements (2025): South Dakota Health and Human Services applied to CMS for a section 1115 demonstration waiver to implement work requirements for Medicaid. The proposal would have made it necessary for individuals to be employed, to be meeting other public assistance work requirements, to be pursuing education, or to be caring for a child, elderly person, or a disabled person in order to maintain eligibility, but did not set a specific number of hours that would have to met to maintain eligiblity.[62] The state announced its intention to withdraw the application in late July after the passage of the 2025 budget reconciliation bill, which requires states to enact more stringent Medicaid work requirements by 2027.[63]

The Montana Department of Public Health and Human Services (DPHHS) opens comment period for section 1115 waiver (2025): On July 7, Montana's DPHHS announced the opening of a 60-day public comment period on the state's proposed section 1115 waiver application. The draft of the waiver was scheduled to be made publicly available on July 18. The press release stated that the section 1115 waiver would be used to implement community engagement and cost-sharing requirements that are required under state and federal law. The community engagement requirement would condition Medicaid benefits on full or part-time work.[64]


Iowa Health and Human Services submits section 1115 waiver amendment request for work requirements (2025): On June 6, Iowa submitted their section 1115 waiver request to implement work requirements to the federal Centers for Medicare and Medicaid Services (CMS).[65] If approved, the Iowa Health and Wellness Plan would require able-bodied adults to work 100 hours per month or prove that they earn 100 times the state hourly minimum wage every month. Iowa Senate File 615, which would institute the work requirement upon CMS approval, was signed into law on June 6.[66]


Iowa SF615 is signed into law, which would enact work requirements for Medicaid upon federal approval (2025): On June 6, Governor Kim Reynolds (R) signed Iowa SF615. The law would require individuals who do not qualify for exemption to work 80 hours a month to maintain eligibility for Medicaid.[67] As of June 6, Iowa had applied to the federal CMS for permission to implement work requirements.[68]

Indiana SB2, which contains Medicaid work requirement provisions, is signed into law (2025): On May 1, Governor Mike Braun (R) signed SB2 into law. The bill lays out provisions related to the Healthy Indiana Plan, which would require able-bodied adults to attend school full-time or work, volunteer, or participate in a work program for 20 hours a week in order to maintain eligibility.[69] The work requirement cannot be enacted without a section 1115 waiver from the federal CMS. As of May 2, 2025, Indiana had not yet applied for a waiver.[70]

South Carolina Health and Human Services to submit section 1115 waiver amendment request for work requirements (2025): On April 30, South Carolina Health and Human Services gave public notice of intent to apply to CMS for a section 1115 demonstration waiver to implement work requirements for Medicaid. The community engagement requirement would make it necessary for individuals to be employed 80 hours per month, to be meeting unemployment insurance job search requirements, to be pursuing education, or to be in substance abuse treatment in order to maintain eligibility.[71]

Utah to submit section 1115 waiver amendment request for work requirements (2025): The public comment period for Utah's proposed section 1115 waiver amendment request opened on April 22 and was scheduled to end on May 22, 2025.[72] The amendment proposal would institute a community engagement requirement to maintain eligibility for Medicaid for individuals who aren't granted an exemption. Reasons an individual would be exempt from the requirement include being over the age of 60, being pregnant or 12 months or less postpartum, complying with SNAP work requirements, working 30 hours or more per week, and others.[73]

Arizona applies to CMS for amendment to section 1115 waiver to implement work requirements for Medicaid (2025): On March 28, Arizona submitted a waiver amendment request to implement work requirements for expansion adults aged 19-55.[74] These individuals would be required to work 20 hours a week to maintain eligibility. There would be a 6-month grace period for individuals to seek exemptions or demonstrate compliance.[75]


Kentucky legislature overrides governor's veto, enacting HB 695, which requires the state to apply to implement Medicaid work requirements (2025): On March 27th, the Kentucky Legislature voted to override Governor Andy Beshear's(D) veto of House Bill 695, which requires the state to seek work requirements for able-bodied adult Medicaid recipients.[76]

Kentucky is a divided government, with a Republican-controlled legislature and a Democratic governor. The veto was overridden with a 29-7 vote in the Senate and an 80-20 vote in the House.[77] The vote was along party lines in the Senate and almost along party lines in the House, with only one Democrat, Rep. Matthew Lehman (D), voting in favor.[78][79]

Kentucky's program under HB 695, should CMS approve the waiver, will require able-bodied adults without dependents who have been enrolled in Medicaid for 12 or more months to complete minimum community engagement or work activities that qualify under federal code, including:

  • working a job for 20 hours per week,
  • participating in a work program for 20 hours per week,
  • doing a combination of these for 20 hours per week, and
  • participating in a workfare program for 20 hours per week.[76]


Idaho H0345 becomes law, requiring the state to apply to implement Medicaid work requirements (2025): On March 19th, Governor Brad Little (R) of Idaho signed a bill into law that requires the state to submit a waiver request to CMS. Upon approval, the state will institute work requirements for able-bodied adult Medicaid recipients. The bill passed along party lines with a 29-6 vote in the Senate and 61-9 vote in the House. Idaho is a Republican trifecta, meaning that its executive branch and both houses of its legislature are Republican-controlled. Activities that will fulfill the work requirement, should CMS approve the program, include: working a job, participating in a work, doing a combination of these, participating in a workfare program, or volunteering for 20 hours a week.[80]


Ohio applies to CMS for waiver to implement work requirements for Medicaid (2025): On March 7, the state submitted its waiver request to the Centers for Medicare and Medicaid Services.[81] The proposal conditions Medicaid expansion on work requirements. If the waiver is approved, Medicaid recipients in the state will be required to meet at least one of the following criteria:[82]

  • be employed,
  • be over age 55,
  • be enrolled in school or a job training program,
  • be participating in alcohol/drug addiction treatment program, or
  • have intensive physical health care needs or serious mental illness.


Arkansas Governor applies to CMS for waiver to implement work requirements for Medicaid (2025): On January 28, 2025, Arkansas Governor Sarah Huckabee Sanders (R) submitted a request to the Centers for Medicare and Medicaid Services (CMS) for a section 1115 waiver in order to implement a program that requires able-bodied Medicaid recipients aged 19-64 to work in order to receive benefits. The proposed amendment does not set a minimum number of hours that individuals must work per month in order to receive benefits and instead focuses on personal development plans to increase individuals’ wages and hours worked.[83]


South Dakota Constitutional Amendment F Ballot Measure (2024): South Dakota Constitutional Amendment F was on the ballot on November 5, 2024 and was approved by voters. The measure amended the South Dakota Constitution to provide that the state may impose a work requirement on eligible individuals in order to receive Medicaid benefits. The state requires a Section 1115 waiver to put any work requirements in place. On January 25, the South Dakota State Senate voted 28-4 to approve Senate Joint Resolution 501 (SJR 501) putting the amendment on the ballot. On February 27, the South Dakota House of Representatives voted 63-7 to pass SJR 501. In both chambers, Republicans were in favor of the amendment, and Democrats were opposed.

Both South Dakota and North Carolina expanded Medicaid in 2023. Neither state implemented work requirements at that time, with Georgia remaining the only state with Medicaid work requirements as of the fourth quarter of 2024.


Georgia implements Medicaid work requirements, Ohio seeks waiver (2023): Georgia and Ohio took action concerning Medicaid work requirements. Georgia became the only state to have Medicaid work requirements in place when the Georgia Pathways program took effect on July 1, 2023. Ohio Governor Mike DeWine (R) later signed a two-year state budget on July 4, 2023, that seeks to implement work requirements for Medicaid recipients.

Georgia lawmakers in 2019 created Georgia Pathways through the passage of Senate Bill 106. The program aims to expand Medicaid coverage to qualifying adults with households below the poverty level who work at least 80 hours per month. The Centers for Medicare and Medicaid Services (CMS) approved Georgia’s plan under the first Trump administration but later rescinded the plan under the Biden administration—resulting in a legal challenge that culminated in favor of Georgia.

The Ohio state budget requires the director of the Ohio Department of Medicaid to apply for a Section 1115 waiver from the Centers for Medicare and Medicaid Services (CMS) in February 2025. The waiver, if approved by CMS, would allow the state to establish Medicaid work requirements for able-bodied residents ages 55 and younger. Able-bodied adults without dependents under the policy would be required to work or study 20 hours per week to qualify for Medicaid benefits.[84][85]


North Carolina's ACA Medicaid expansion includes a section requiring the pursuit of work requirements (2023): North Carolina's HB76, which expanded Medicaid under the Affordable Care Act included a section requiring the Department of Health and Human Services, Division of Health Benefits (DHB) to negotiate with Centers for Medicare and Medicaid Services (CMS) to develop a plan to implement work requirements if there is ever any indication that CMS would approve such a plan.[86]

“ PURSUIT OF MEDICAID WORK REQUIREMENTS

SECTION 2.4. If there is any indication that work requirements as a condition of participation in the Medicaid program may be authorized by the Centers for Medicare and Medicaid Services (CMS), then the Department of Health and Human Services, Division of Health Benefits (DHB), shall enter into negotiations with CMS to develop a plan for those work requirements and to obtain approval of that plan...[60]

”


See also

External links

Footnotes

  1. ↑ 1.0 1.1 1.2 Congress.gov, "H.R.1 - 119th congress (2025 - 2026)," July 4, 2025 Cite error: Invalid <ref> tag; name "obbba" defined multiple times with different content
  2. ↑ Social Security, Demonstration Projects, accessed May 15, 2023
  3. ↑ Kaiser Family Foundation, An Overview of Medicaid Work Requirements, accessed May 8, 2023
  4. ↑ KFF, "Medicaid Waiver Tracker: Approved and Pending Section 1115 Waivers by State," updated August 12, 2025
  5. ↑ 5.0 5.1 Medicaid, Section 1115 Demonstrations, May 5, 2023
  6. ↑ Kaiser Family Foundation, An Overview of Medicaid Work Requirements, accessed May 8, 2023
  7. ↑ Pinal Central, Feds reject Arizona plan to impose limits, accessed May 25, 2023
  8. ↑ 8.0 8.1 8.2 8.3 Kaiser Family Foundation, Overview of Medicaid Work Requirements, accessed May 5, 2023
  9. ↑ Affordable Care Act Litigation, Opportunities to Promote Work and Community Engagement Among Medicaid Beneficiaries, accessed May 5, 2023
  10. ↑ Kaiser Family Foundation, Medicaid and Work Requirements, accessed May 5, 2023
  11. ↑ JD Supra, Supreme Court Cancels Arguments on Medicaid Work Requirements, accessed May 25, 2023
  12. ↑ 12.0 12.1 12.2 12.3 12.4 Health Insurance, Georgia Medicaid, accessed May 26, 2023
  13. ↑ 13.0 13.1 Court Listener, Georgia v. Lasure, accessed May 26, 2023
  14. ↑ 14.0 14.1 The Hill, Georgia Medicaid Work Requirements, accessed July 13, 2023
  15. ↑ [file:///C:/Users/samue/Downloads/GA%20Pathways%20Release_FINAL%207.5.23.pdf Georgia DCH, Georgia Pathways, accessed July 13, 2023]
  16. ↑ Congress.gov, "H.R.1 - 119th Congress (2025 - 2026)," accessed July 10, 2025
  17. ↑ Mac Pac, Work as a condition of Medicaid eligibility, accessed May 25, 2023
  18. ↑ AHCCCS, Arizona Section 1115 Waiver, accessed May 25, 2023
  19. ↑ Medicaid, Arkansas waiver, accessed May 25, 2023
  20. ↑ Medicaid, Kentucky Section 1115 Waiver, accessed May 25, 2023
  21. ↑ Medicaid, Kentucky Waiver, accessed May 25, 2023
  22. ↑ Affordable Care Act Litigation, HHS letter to state Medicaid Directors, accessed May 8, 2023
  23. ↑ 23.0 23.1 Kaiser Family Foundation, Re-approval of Kentucky Medicaid demonstration waiver, accessed May 8, 2023
  24. ↑ Essential Hospitals, CMS Approves Indiana Medicaid work requirements, accessed May 8, 2023
  25. ↑ Essential Hospitals, CMS Approves Arkansas Medicaid Work Requirements, accessed May 8, 2023
  26. ↑ CMS, State innovation Waivers, accessed May 8, 2023
  27. ↑ Medicaid, CMS letter to Wisconsin approving Medicaid work requirements, accessed May 8, 2023
  28. ↑ American Health Association, CMS approves Michigan Medicaid waiver, accessed May 8, 2023
  29. ↑ Urban Institute, New Hampshire Medicaid Work Requirements, accessed May 8, 2023
  30. ↑ CMS, CMS Approves Arizona’s Medicaid Community Engagement Demonstration Amendment, accessed May 8, 2023
  31. ↑ McDermott plus, Ohio Medicaid work requirements, accessed May 8, 2023
  32. ↑ State of Reform, Utah work requirements, accessed May 8, 2023
  33. ↑ Medicaid, South Carolina approval letter, accessed May 8, 2023
  34. ↑ CMS, CMS Approves Nebraska Medicaid Demonstration to Provide Pathway to Enhanced Benefits for Eligible Adults, accessed May 8, 2023
  35. ↑ Kentucky.gov, Governor Beshear Ends Medicaid Waiver, accessed May 17, 2023
  36. ↑ JD Supra, HHS Revokes Arkansas and New Hampshire Medicaid Work Requirements, accessed May 8, 2023
  37. ↑ MHA, Michigan’s Medicaid Work Requirement Rescinded, accessed May 8, 2023
  38. ↑ JD Supra, CMS Withdraws Prior Approval for “Must-Work” Requirements in State Medicaid Programs, accessed May 8, 2023
  39. ↑ Columbus Dispatch, Biden administration withdraws approval for Ohio's Medicaid work requirement, accessed May 8, 2023
  40. ↑ Medicaid, UT primary care, accessed May 8, 2023
  41. ↑ CMS, Maine enforcement letter, accessed May 8, 2023
  42. ↑ CMS, CMS Takes Steps to Protect Georgians from Harmful Effects of Work Requirements and Premiums in the Medicaid Program, accessed May 8, 2023
  43. ↑ CMS, Enforcement letter for Nebraska, accessed May 8, 2023
  44. ↑ Court Listener, Rose v. Azar, accessed May 8, 2023
  45. ↑ Medicaid, Healthy Indiana Plan, accessed May 26, 2023
  46. ↑ Aimed Alliance, Medicaid Work Requirement Cases, accessed June 22, 2023
  47. ↑ Affordable Care Act Litigation, 1115 waivers, accessed May 8, 2023
  48. ↑ Affordable Care Act Litigation, Young v. Azar, accessed May 29, 2023
  49. ↑ Affordable Care Act Litigation, Gresham v. Azar Memorandum, accessed May 5, 2023
  50. ↑ Affordable Care Act Litigation, U.S. Supreme Court certiorari, accessed May 5, 2023
  51. ↑ Affordable Care Act Litigation, Gresham v. Azar, accessed May 5, 2023
  52. ↑ United States Supreme Court, Certiori, Azar v. Philbrick, accessed May 5, 2023
  53. ↑ Affordable Care Act Litigation, Azar v. Philbrick, accessed May 5, 2023
  54. ↑ Affordable Care Act Litigation, Azar v. Philbrick, accessed May 5, 2023
  55. ↑ U.S. Supreme Court, Azar v. Stewart, accessed May 5, 2023
  56. ↑ Affordable Care Act Litigation, Azar v. Stewart, accessed May 5, 2023
  57. ↑ Affordable Care Act Litigation, Azar v. Stewart, accessed May 5, 2023
  58. ↑ Congress.gov, "H.R.1 - 119th Congress (2025 - 2026)," accessed July 10, 2025
  59. ↑ New York Times, "Trump Leadership: If You Want Welfare and Can Work, You Must," May 14, 2025
  60. ↑ 60.0 60.1 60.2 Note: This text is quoted verbatim from the original source. Any inconsistencies are attributable to the original source.
  61. ↑ CNN, "Here’s who would have to work for government benefits – and who wouldn’t – under the debt ceiling package," June 2, 2023
  62. ↑ dss.sd.gov, "SDCareerLink A South Dakota 1115 Demonstration Proposal," accessed June 11, 2025
  63. ↑ South Dakota Searchlight, "Passage of federal Medicaid work requirements leads SD to withdraw its own proposal," accessed August 6, 2025
  64. ↑ Montana DPHHS, "DPHHS Seeks Public Comment on Proposed Community Engagement, Cost Sharing," accessed July 9, 2025
  65. ↑ Medicaid.gov, "Iowa Health and Wellness Plan Section 1115 Demonstration Amendment," accessed June 25, 2025
  66. ↑ Iowa Legislature, "Bill History for Senate File 615 - Status: Passed House," accessed April 27, 2025
  67. ↑ Iowa Legislature, "SF615_GovLetter.pdf," accessed June 11, 2025
  68. ↑ KFF, "Section 1115 waiver tracker - work requirements," accessed June 25
  69. ↑ Indiana General Assembly, "Senate Bill 2 - Medicaid matters." accessed May 7, 2025
  70. ↑ KFF, "Medicaid Waiver Tracker: Approved and Pending Section 1115 Waivers by State," accessed May 7, 2025
  71. ↑ SCDHHS, "Public Notice for South Carolina Department of Health and Human Services Palmetto Pathways to Independence Demonstration Waiver," accessed May 7, 2025
  72. ↑ Utah Medicaid, "Public hearings," accessed May 7, 2025
  73. ↑ Utah DHHS, "State of Utah Section 1115 Demonstration Amendment Community Engagement," accessed May 7, 2025
  74. ↑ Medicaid.gov, "RE: AHCCCS Works Amendment Request," accessed April 23, 2025
  75. ↑ KFF, "Section 1115 waiver tracker work requirements," accessed April 23, 2025
  76. ↑ 76.0 76.1 Kentucky Legislature, "25RS HB 695," March 27, 2025
  77. ↑ Kentucky Legislature, "vote history.pdf," March 27, 2025
  78. ↑ Kentucky Legislature, "House of Representatives," April 2, 2025
  79. ↑ Kentucky Legislature, "Senate," April 2, 2025
  80. ↑ Legiscan, "ID H0345 | 2025 | Regular Session," March 19, 2025
  81. ↑ Medicaid.gov, "Ohio Group VIII 1115 Demonstration," accessed April 23, 2025
  82. ↑ KFF, "Section 1115 waiver tracker work requirements," accessed April 23, 2025
  83. ↑ Governor of Arkansas, "Pathway to Prosperity Waiver," February 3, 2025
  84. ↑ CNN, "Georgia is now the only state with work requirements in Medicaid," August 9, 2023
  85. ↑ Cleveland.com, "Ohio to seek work requirement (again) for Medicaid enrollees," July 6, 2023
  86. ↑ North Carolina Legislature, "House Bill 76," December 5, 2024
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