The implementation of new Medicaid operate requirements is gaining momentum as states begin to chart their paths under the 2025 federal reconciliation law. Signed into law on July 4, 2025, the law—often referred to as the “One Big Beautiful Bill”—conditions Medicaid eligibility for adults participating in the Affordable Care Act (ACA) Medicaid expansion, and those in partial expansion waiver programs, on demonstrating work activity starting January 1, 2027. Although, states aren’t waiting until then, with some proactively moving to implement these requirements sooner.
The shift towards work requirements represents a significant change in the landscape of Medicaid eligibility. Currently, 41 states and the District of Columbia have expanded their Medicaid programs to cover adults with incomes up to 138% of the federal poverty level (FPL), which was $21,597 for an individual in 2025, according to the KFF. The upcoming changes necessitate substantial policy adjustments, system upgrades, and outreach efforts from states to ensure a smooth transition and minimize disruption for beneficiaries.
Nebraska Leads the Way with Early Implementation
Nebraska has emerged as the first state to announce it will enforce the federal work requirements ahead of the January 2027 deadline. The state plans to begin enforcement on May 1, 2026, utilizing a state plan amendment (SPA) to expedite the process. This approach allows Nebraska to align its Medicaid policies with the new federal guidelines sooner than required.
Navigating 1115 Waivers and Federal Alignment
States also have the option of implementing work requirements early through 1115 waivers, which allow states to test innovative approaches to Medicaid. Several states submitted waiver requests during the second Trump administration, but the passage of the 2025 reconciliation law has prompted some to reconsider these applications, opting instead for the SPA route. A key question remains regarding how the Centers for Medicare & Medicaid Services (CMS) will handle pending 1115 waivers that propose implementation strategies differing from the federal requirements outlined in the law before the January 1, 2027 deadline.
Currently, Georgia stands as the sole state with an active Medicaid work requirement waiver, following legal challenges to the Biden administration’s attempts to halt it. CMS recently approved a temporary extension of Georgia’s waiver, incorporating new exemptions from the work requirements. However, this waiver is set to expire on December 31, 2026, after which Georgia will be obligated to fully comply with the new federal requirements beginning January 1, 2027.
The KFF is actively tracking the implementation of these Medicaid provisions, providing resources to understand state options and assess readiness.
State-by-State Implementation Status
The implementation of Medicaid work requirements is unfolding at different paces across the country. Even as Nebraska is taking the lead with an early SPA, other states are exploring various approaches, including pursuing 1115 waivers or preparing for full compliance by the January 1, 2027 deadline. The Congressional Research Service (CRS) provides a comprehensive overview of the health provisions within the 2025 reconciliation law, including those impacting Medicaid.
The Georgetown University Center for Children and Families highlights that the budget reconciliation law includes “deep, damaging cuts” to Medicaid, CHIP, and the Affordable Care Act’s Marketplaces, as detailed in their analysis.
Looking ahead, the coming months will be critical as states finalize their implementation plans and prepare for the changes to Medicaid eligibility. The success of these efforts will depend on effective communication, robust outreach, and a commitment to ensuring that eligible individuals retain access to essential healthcare coverage. Continued monitoring of state actions and federal guidance will be essential to understanding the full impact of these new requirements.
Disclaimer: This article provides informational content about healthcare policy and is not intended to be a substitute for professional medical or legal advice. Always consult with a qualified healthcare provider or legal professional for personalized guidance.
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