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Two states, Montana and Nebraska, have begun implementing new federal work requirements for certain Medicaid recipients, far earlier than the national implementation date in 2027.
Under the new federal policy, Medicaid expansion recipients across 44 states will be required to work, volunteer, attend school or take part in job training for at least 80 hours each month to retain coverage. Exemptions apply to certain groups, including people with disabilities or serious health conditions, parents of young children and caregivers.
The requirements were established under President Donald Trump’s sweeping budget law, the One Big Beautiful Bill Act, which was signed into law in July 2025. Although states have until January 1, 2027 to introduce the rules, Montana and Nebraska chose to begin several months ahead of schedule.
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Medicaid is a government health insurance program for eligible low-income Americans, including children, pregnant women, older adults and people with disabilities. It is jointly funded by the federal government and individual states, which set many of their own eligibility rules and benefits within federal guidelines. The program helps cover the cost of services such as doctor visits, hospital care, prescription drugs and long-term care.
Supporters argue that tying Medicaid eligibility to work status could help lift people out of poverty while reducing federal spending. Critics, however, cite research into earlier Medicaid work requirements that found they did not significantly increase employment and could penalize vulnerable Americans. A coalition of 25 states and the District of Columbia is suing the Trump administration over the new requirements.
According to analysis by the Robert Wood Johnson Foundation (RWJF), a health philanthropy organization, between 4.9 and 10.1 million Americans could lose their Medicaid coverage due to work requirements and eligibility checks.
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What Are the New Work Requirements?
The rule applies to adults covered through Medicaid expansion. It generally affects people ages 19 to 64 who are not eligible for or enrolled in Medicare and who receive Medicaid under the adult expansion category or certain demonstration programs offering minimum essential coverage.
Affected recipients must complete at least 80 hours of qualifying activities each month to maintain their benefits. They can meet the requirement through paid work, community service, participation in an approved employment program, attendance in an educational program at least half-time, or a combination of those activities.
The requirements do not apply to:
- Pregnant people and those eligible for postpartum Medicaid coverage
- Former foster care recipients
- American Indians and Alaska Natives
- Veterans with a total disability rating
- Parents, guardians, caregiver relatives or family caregivers responsible for a child age 13 or younger
- People caring for an individual with a disability
- People considered medically frail or whose health substantially limits their ability to comply
- Individuals who already meet Temporary Assistance for Needy Families (TANF) work requirements
- Members of households receiving SNAP benefits who are subject to that program’s work requirements
- People participating in drug or alcohol rehabilitation or treatment programs
- People incarcerated in public institutions
Why Have States Implemented Rules Early?
Nebraska Governor Jim Pillen, a Republican, advocated that the requirements will encourage work and "promote long-term independence and stronger community ties."
"These requirements will help Nebraskans achieve greater self-sufficiency through employment and other meaningful activities," he said in a December 2025 statement. "Working not only provides purpose but helps people become active, productive members of their communities."
"Montana has made a strong, sustained commitment to implementing community engagement requirements, and we are proud to be among the first states to move forward in close partnership with CMS [Centers for Medicare and Medicaid Services]," Montana's Department of Public Health and Human Services director Charlie Brereton said.
When Do the New Rules Start?
Despite Nebraska and Montana making an early start on implementing the new rules, states are not actually required to enforce work requirements until January 1, 2027.
Iowa plans to begin applying them to new applicants on December 1, although most existing recipients will not face the requirements until renewals beginning in February 2027.
Arkansas also began checking recipients’ compliance in July as part of a "soft implementation," but the state has confirmed nobody will lose coverage for failing to meet the rules before the nationwide January 1 deadline.
Contact Newsweek editors for this story: Ben Kelly and Robert Greenall
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