Medicaid Work Requirements: State Implementation & Waiver Updates (2025)

The landscape of Medicaid eligibility is undergoing significant changes as states navigate the implementation of operate requirements mandated by the 2025 reconciliation law, often referred to as the “One Big Gorgeous Bill.” This legislation 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 beginning January 1, 2027. While the federal requirement doesn’t take effect until 2027, several states are already moving to implement these changes, utilizing both state plan amendments and 1115 waivers.

Early Implementation Pathways: SPAs and Waivers

States have two primary avenues for implementing work requirements before the federal deadline: through a state plan amendment (SPA) or via an approved 1115 waiver. A state plan amendment allows for quicker implementation, aligning directly with federal guidelines. Nebraska has taken the lead, announcing plans to enforce these federal work requirements starting May 1, 2026. KFF’s Medicaid Work Requirements Tracker provides ongoing updates on state-level activity.

The 1115 waiver process, traditionally used for broader Medicaid program changes, offers states more flexibility, but also requires approval from the Centers for Medicare & Medicaid Services (CMS). Several states submitted waivers seeking to implement work requirements prior to the federal mandate, but the passage of the 2025 reconciliation law has prompted some to reconsider these approaches, opting instead for the more streamlined SPA route.

Georgia’s Waiver and the Path to Full Compliance

Currently, Georgia stands as the sole state with an active Medicaid work requirement waiver, a result of litigation surrounding the Biden administration’s initial attempts to halt its implementation. CMS recently approved a temporary extension of Georgia’s waiver, incorporating new exemptions from the work requirements. Although, this waiver is set to expire on December 31, 2026, after which Georgia will be required to fully align with the new federal requirements taking effect on January 1, 2027. Details of the temporary extension are available on the Medicaid.gov website.

Navigating the Waiver Landscape: Pending Applications and CMS Review

The implementation of work requirements isn’t without its complexities. A key question remains regarding how CMS will handle pending 1115 waivers that seek to implement requirements earlier than the federal deadline, particularly those that deviate from the specifications outlined in the 2025 reconciliation law. The law itself, signed into law on July 4, 2025 (Public Law 119-21), includes provisions restricting states’ ability to employ provider taxes to finance their Medicaid programs, alongside the new administrative requirements and eligibility conditions. The American Medical Association provides an overview of the key provisions within the One Big Beautiful Bill Act of 2025.

The map and data table compiled by KFF (available in the source material) visually represent the current status of states pursuing work requirement waivers and those opting for early implementation through state plan amendments. This information serves as a valuable resource for understanding the evolving landscape of Medicaid eligibility across the nation.

What These Changes Mean for Medicaid Enrollees

The introduction of work requirements represents a significant shift in Medicaid policy, potentially impacting access to coverage for individuals who are unable to meet the requirements. While exemptions are anticipated – and Georgia’s recent waiver extension demonstrates a willingness to incorporate them – the process of verifying work activity and navigating potential barriers to compliance could create challenges for enrollees. The KFF issue brief, “A Closer Look at the Medicaid Work Requirement Provisions in the Big Beautiful Bill”, delves into the potential implications of these requirements.

States will need to invest in robust outreach and education strategies to inform enrollees about the new requirements, as well as system upgrades to efficiently track and verify work activity. Hiring and training staff to manage these processes will also be crucial. The success of these implementations will depend heavily on states’ ability to address potential logistical hurdles and ensure that eligible individuals are not inadvertently disenrolled.

Looking Ahead: Implementation and Ongoing Monitoring

As states move forward with implementing work requirements, ongoing monitoring and evaluation will be essential. Tracking enrollment trends, renewal outcomes, and application processing times will provide valuable data for assessing the impact of these policies. This data will also facilitate identify potential areas for improvement and inform future policy decisions. The 2025 reconciliation law has initiated a period of significant change for Medicaid, and careful observation of these developments will be critical for understanding the long-term effects on access to care and health outcomes. The Johns Hopkins Bloomberg School of Public Health offers further context on the broader changes coming to the ACA, Medicaid, and Medicare. Read their analysis here.

For individuals with questions about their Medicaid eligibility or the new work requirements, it is recommended to consult with their state’s Medicaid agency or a qualified healthcare navigator.