On May 22, 2025, the US House of Representatives advanced a comprehensive legislative package that includes expansive changes to healthcare spending and tax policies. The One Big Beautiful Bill Act, H.R. 1, will be subject to further revision in the Senate – and potentially again in the House – before it can be sent to the president for his signature. If enacted, the legislation would have significant implications for the Medicaid program, including a nationwide work and community engagement requirement. The House-passed bill establishes a deadline of December 31, 2026, for implementation, but individual states could move earlier.
As state legislatures pass work requirement bills, governors consider executive actions, and Congress contemplates revisions to the Medicaid work mandate, vetting key implementation issues may significantly affect the direction of related policies. Even before implementation, states must test operations, enable systems, and establish connections to beneficiaries to reduce potential implementation missteps, inappropriate disenrollments, and litigation risks.
If the goal of Medicaid work requirement policies is to stimulate connections between health benefits and employment/workforce, building state and federal capacities to support these approaches is critical to effectuating that change. In the remainder of this article, Health Management Associates (HMA), experts focus on the operational dynamics that need to be discussed, tested, and built as states begin introducing work and community engagement initiatives.
Federal Policies and Early State Actions on Work Requirements
The House bill would require all states to implement work and community engagement requirements for adults without dependents for at least 80 hours per month.[1] Employment, work programs, education, or community service (or a combination of those activities) would satisfy the requirement.
The work requirements in the House-passed legislation would apply only to individuals between the ages of 19 and 64 without dependents, and the following groups are exempted:
- Women who are pregnant or entitled to postpartum medical assistance
- Members of Tribes
- Individuals who are medically frail (i.e., people who are blind, disabled, with chronic substance use disorder, has serious or complex medical conditions, or others as approved by the Secretary of the US Department of Health and Human Services)
- Parents of dependent children or family caregivers to individuals with disabilities
- Veterans
- People who are participating in a drug or alcoholic treatment and rehabilitation program
- Individuals who are incarcerated or have been released from incarceration in the past 90 days
In addition, individuals who already meet work requirements through other programs, such as Temporary Assistance for Needy Families (TANF) or the Supplemental Nutrition Assistance Program (SNAP), would be exempt. However, the House-passed version would make the eligibility verification and work requirements for SNAP more stringent and shift program costs to these states, which would affect cross-functional eligibility. The legislation also includes temporary hardship waivers for natural disasters and areas with an unemployment rate greater than 8 percent (150 percent of the national average).
Though the federal budget package has received a great deal of attention, at least 14 states already have moved forward (see Table 1) in advance of the current federal debate by passing laws and submitting work requirement demonstration requests to the Centers for Medicare & Medicaid Services (CMS).
Table 1. A Review of 2025 States’ Approaches to Work Requirements in Medicaid
| Status | State | Population Criteria | Requirements | Exemptions/ Notes | Public Comment |
| Work Requirement Request Submitted | Arizona | Ages 19−55 | 80 hours/month | Multiple exemptions; 5-year lifetime limit | Closed |
| Work Requirement Request Submitted | Arkansas | Ages 19−64; covered by a qualified health plan (QHP) | Data matching to assess whether on track/not on track | No exemptions | Closed |
| Work Requirement Amendment Request Submitted | Georgia | Ages 19−64; 0-100% FPL | 80 hours/month | Already has approval but is requesting reporting be changed from monthly to annually and adding more qualifying activities | Federal comment period open through June 1, 2025 |
| Work Requirement Request Submitted | Ohio | Ages 19−54; expansion adults | Unspecified hours | Limited list of exemptions | Closed |
| Legislation Passed | Idaho | Ages 19−64 | 20 hours/week required | Limited list of exemptions | — |
| Legislation Passed | Indiana | Ages 19−64; expansion adults | 20 hours/week required | Limited list of exemptions | — |
| Legislation Passed | Montana | Ages 19−55 | 80 hours/month required | Multiple exemptions | — |
| Ballot Initiative Passed | South Dakota | Expansion adults | — | 2024 ballot initiative asking voters for approval for state to impose work requirements for expansion adults passed | — |
| Legislation Pending | North Carolina | — | — | Pursue requirements that are CMS approvable | — |
| Work Requirement Request Draft | Iowa | Ages 19−64; expansion adults | 100 hours/month required | Limited list of exemptions Separate bill would end expansion if work requirements are withdrawn/ prohibited (80 hr./mo.) | Closed |
| Work Requirement Request Draft | Kentucky | Ages 19−60; no dependents; enrolled more than 12 months | Connected to employment resources | Multiple exemptions | State comment period open through June 12, 2025 |
| Work Requirement Request Draft | South Carolina | Ages 19−64; 67%−100% FPL | Specified activities (work specific is 80 hours/month) | Limiting participation to 11,400 individuals based upon available state funding | State comment period open through May 31, 2025 |
| Work Requirement Request Draft | Utah | Expansion adults ages 19−59 | Register for work, complete an employment training assessment and assigned job training, and apply to jobs with at least 48 employers within 3 months of enrollment | Several exemptions, largely aligned with federal SNAP exemptions | State comment period open through May 22, 2025 |
| Anticipated Waiver Request | Alabama | Non-expansion population | — | Potential to resubmit previous work requirement demonstration request | — |
Key Questions to Guide State Policy Decisions
Considerable research and findings from previous Medicaid work requirement initiatives can help prepare policymakers to implement a potential new phase of Medicaid work requirement policies. Some previous findings include the high cost of administration relative to potential savings, the importance of systems that support foundational items like logging an enrollee’s compliance activities and exemptions, as well as developing an efficient appeals process. The Medicaid and CHIP Payment and Access Commission (MACPAC), General Accounting Office, National Institutes for Health, and multiple researchers have published assessments regarding previous experiences that could prove useful in policy making.
HMA experts have experience identifying key issues and considerations, analyzing options, and implementing critical issues and for state leaders and stakeholders who will be responsible for implementing work requirements. Several of these issues are described below and in more detail in the HMA blog, Building State Capacities for Medicaid Work and Community Engagement Requirements.
- Exemptions, particularly medical frailty definitions and assessments. The federal government and states will need to identify individuals classified as “medically frail” and make them exempt from the mandates. Medically frail individuals include those with chronic, serious, or complex medical conditions. Various methods can be employed to identify these people.
- Developing and streamlining systems and processes to promote continued coverage for eligible individuals. The Medicaid unwinding from the COVID public health emergency taught policymakers lessons about the complexities of Medicaid systems, patient engagement, and reliable methods of member outreach. State Workforce Commissions and Departments of Labor are clear partners, as they manage integrated eligibility systems and data-sharing agreements across programs like SNAP and TANF, which also serve many Medicaid participants. These and other partnerships will need further exploration.
- Clinical and utilization data that promote eligibility assessment. Many, but not all, individuals with chronic diseases may be exempt from the requirements. Knowing the health status and chronic conditions of the populations affected and the conditions that qualify people for exemption are variables as implementation questions, like the definition of medically frail, are addressed.
- Anticipated need for effective Medicaid managed care engagement in work requirements/community engagement initiatives. Approximately 80 percent of Medicaid expansion enrollees are members of comprehensive managed care organizations (MCOs). States will need to review the scope of existing vendor contracts as well as determine the need for new services, roles, third-party reporting, oversight, and potential exemptions for emergencies. Work requirements can disrupt MCO risk pool stability and care coordination. MCOs have a financial incentive to drive down inappropriate disenrollments and are uniquely positioned to support state responsibilities, including maintenance of up-to-date contact information.
- Measuring impact and adapting policies as needed. Dynamic metrics that provide actionable information to federal and state policy makers will support effective oversight and monitoring.
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HMA helps stakeholders—including state agencies and their partners—manage the challenges of implementing new Medicaid or CHIP initiatives, with a focus on ensuring efficient integration and improvements in outcomes. Our teams are adept at developing materials for and supporting stakeholder engagement from design to implementation, which is a critical aspect for work and community engagement initiatives and other potential new eligibility and renewal requirements.
For support tracking federal and state level developments and enhancing your organization’s strategy and preparations for new Medicaid requirements, contact our featured experts below.
[1] U.S. Congress. House. One Big Beautiful Bill Act. H.R.1. 119th Cong., 1st sess. Introduced May 20, 2025. https://www.congress.gov/bill/119th-congress/house-bill/1/text.
