Medicaid work requirement

What is a Medicaid work requirement?

A Medicaid work requirement is a provision that requires certain Medicaid enrollees to participate in “community engagement” activities (work, school, job training, volunteering, etc.) in order to maintain their health coverage.

Do any states have Medicaid work requirements?

As of late 2024, Georgia is the only state in the country that has a Medicaid work requirement. It took effect in July 2023, for people who want to enroll in the state’s partial Medicaid expansion, which is called Georgia Pathways to Coverage. This program is available to adults under age 65 with household income below the poverty level, but only if they’re working at least 80 hours per month and reporting their work to the state.

But by mid-2024, a year after the program began, only 4,231 people had enrolled in Georgia Pathways.¹ This extremely low enrollment is due in large part to the work requirement and associated paperwork.²

The Trump administration approved Georgia’s Medicaid work requirement in 2020, but the Biden administration subsequently revoked the approval. In 2022, however, a U.S. District Judge ruled that HHS acted in an “arbitrary and capricious” manner when they revoked Georgia’s Medicaid work requirement approval, thus clearing the way for Georgia to implement its Medicaid work requirement in conjunction with a partial expansion of Medicaid, starting in mid-2023.

Which states previously implemented Medicaid work requirements?

In addition to Georgia, five other states previously implemented Medicaid work requirements, although none of them are currently in effect. Arkansas, Indiana, Michigan, New Hampshire, and Utah implemented Medicaid work requirements between 2018 and 2020.

Arkansas was the only state in which people lost their coverage as a result of the work requirement. In the other four states where work requirements did become effective, they weren’t in effect long enough to result in coverage losses.

Utah and Michigan were the only states where Medicaid work requirements were in effect as of early 2020, and both had suspended their work requirements by the spring of 2020. In Michigan, this was due to a court ruling; in Utah, it was due to the COVID pandemic. And in 2021, the Biden administration officially withdrew federal approval for all of the previously-approved Medicaid work requirement waivers.

How do states get approval for Medicaid work requirements?

Medicaid work requirements need approval from HHS under an 1115 waiver. (Legislation introduced in Congress in September 2024 would allow states to implement Medicaid work requirements for adult enrollees who aren’t pregnant, disabled, or elderly, without the need to obtain specific federal permission.³ But until if and when this sort of legislation were to be enacted, a state has to obtain an approved waiver from CMS in order to implement a Medicaid work requirement.)

The concept of a work requirement had previously been a non-starter throughout the Medicaid program’s history, but the Trump administration encouraged states to submit waiver proposals for work requirements. Numerous states submitted waiver proposals. Ultimately, 13 states received approval from the Trump administration to implement Medicaid work requirements for at least some of their adult Medicaid enrollees (see chart below).