Beginning January 1, 2027, adults enrolled in Medicaid through the program’s expansion group will have to document at least 80 hours a month of work, schooling, community service or job training to keep their coverage. The Centers for Medicare & Medicaid Services issued the interim final rule implementing that requirement on June 1, 2026, giving states that cover this population roughly seven months to build new verification systems. Pregnant and postpartum enrollees, family caregivers and people CMS classifies as medically frail are excluded from the requirement entirely — but the rule’s narrow definition of who counts as frail has already triggered a lawsuit from two dozen states.
The 80-Hour Standard and Who It Covers
The requirement comes from Section 71119 of the 2025 reconciliation law, the Working Families Tax Cut Act, which the agency implemented through an interim final rule numbered CMS-2454-IFC. The rule applies to what CMS calls an “applicable individual”: a non-pregnant adult between the ages of 19 and 64 who is not entitled to or enrolled in Medicare and who qualifies for Medicaid through the program’s adult expansion group or through certain Section 1115 demonstration waivers that extend comparable coverage. Adults who qualify for Medicaid through disability determinations, age, or other traditional pathways fall outside the new standard entirely.
States must condition eligibility on the requirement beginning January 1, 2027, or sooner if a state opts to move faster. To satisfy the standard for a given month, an applicable individual must complete 80 hours of work, community service or participation in a state work program; enroll in an educational program at least half time; combine those activities to reach 80 hours; or earn monthly income of at least 80 times the federal minimum wage, which comes to $580 in 2026. New applicants generally must show a month of compliance before enrolling, and existing beneficiaries must meet the requirement between renewals.
CMS’s own fact sheet counts 43 states and the District of Columbia as covering the population subject to the new standard. A separate KFF analysis puts the number at 44, once three states that never expanded Medicaid under the Affordable Care Act — Georgia, Tennessee and Wisconsin — are added in for the narrower populations they cover through Medicaid waivers carrying similar eligibility rules. Either count leaves only a handful of states, mostly ones that never adopted the expansion at all, with nothing to implement.
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The Exemptions Written Into the Rule
CMS’s fact sheet lists who is exempt outright: pregnant and postpartum enrollees; people who are medically frail or otherwise have special medical needs; parents, guardians or caregivers of a child 13 or younger or of a person with a disability; former foster care youth; American Indians and Alaska Natives; veterans with a total disability rating; people already meeting TANF work requirements or living in a household meeting SNAP work rules; participants in a drug or alcohol treatment program; and inmates of a public institution. None of these groups has to log hours, enroll in classes or prove income to keep coverage.
States also have the option, not the obligation, to grant short-term hardship exceptions on top of the mandatory exemptions. Where a state chooses to offer them, those exceptions can cover people receiving inpatient hospital or nursing facility care, residents of a county under a presidentially declared disaster or emergency, residents of a county where unemployment sits at 8% or higher or at least 1.5 times the national average, and people who must travel outside their community for medical treatment unavailable at home. Because these are optional, an applicable individual’s practical exposure to the requirement can differ sharply from one state to the next.
A Two-Part Frailty Test Already Facing a Lawsuit
The medically frail exemption is where the rule has drawn the most scrutiny. The underlying statute lists five qualifying categories — being blind or disabled, having a disability that limits daily activities, having a substance use disorder, having a disabling mental disorder, or having a serious or complex medical condition — but CMS’s interim final rule adds a second requirement on top: the condition must also be shown to impair the person’s ability to meet the community engagement requirements. KFF researchers describe that two-part test as a more restrictive reading than states had been led to expect from CMS’s earlier informal guidance.
Operationally, states must build auditable lists of diagnosis codes for each frailty category and revise them as implementation experience accumulates; CMS has warned that a frailty determination with little documented support could expose a state to financial penalties. Self-attestation is allowed as a stopgap through 2027 when no other data exists, but starting January 1, 2028, states may accept an individual’s self-attestation of frailty only once during an entire enrollment period, after which they must rely on claims data, provider documentation or other verification at every renewal, and medically frail status itself must be reverified at least once every 12 months.
States have run into this problem before. In New Hampshire’s earlier work-requirement pilot, enrollees seeking a medical exemption needed a treating provider to certify in writing that they were unable to work, and many struggled to obtain that certification because primary care providers were reluctant to sign forms declaring their own patients incapable of employment. The new federal rule leans on a similar mix of claims data, screening questions and provider input to sort who is protected from the requirement and who is not.
That restrictive reading is now being tested in court. Less than a month after CMS released the rule, Democratic attorneys general from 24 states and the District of Columbia, joined by two governors, sued the administration, arguing the frailty test departs from the statute’s broader exclusion and puts people managing cancer, HIV, diabetes and serious mental illness at risk of losing coverage. The Congressional Budget Office has projected the work requirement will save $326 billion over a decade while leaving 5.3 million more people uninsured, a tradeoff the litigation has not resolved before states must start enforcing it in January.
This article was produced with the assistance of AI and reviewed by The Money Overview editorial team before publication.
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