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State officials remain uncertain on how to enforce a requirement that many adult Medicaid enrollees show they’re working — even as one state launches its program this week — and they’re taking a variety of approaches to the job, including, in a handful of states, using artificial intelligence.
A KFF survey of Medicaid officials from 42 states and the District of Columbia offers insights into key policy decisions state officials face as the Jan. 1, 2027, deadline for implementing the work requirement nears. Lingering questions include which diseases and illnesses will qualify Medicaid beneficiaries for exemptions and how to automate compliance verification.
Federal guidance is not expected to be released until June. But some states are moving forward with their own definitions of “medical frailty,” which under congressional Republicans’ One Big Beautiful Bill Act will allow Medicaid enrollees to escape the requirement.
The law, President Donald Trump’s signature domestic achievement, revamps Medicaid in more than 40 states that, along with Washington, D.C., fully or partially expanded the program for low-income people to cover adults without children who don’t get insurance through a job. While most adult Medicaid beneficiaries already work or are disabled, caregivers for other people, or in school, many Republicans contend that people enrolled in the program who don’t work sap resources that ought to support low-income children, pregnant women, and disabled people.
About 20 million people gained Medicaid coverage from the expansion, created by the Affordable Care Act — a law that most Republicans still oppose.
The new work rules require that a person be a student at least part-time or work or participate in other qualifying activities, such as community service, for at least 80 hours each month. The requirement could potentially reshape who is eligible for Medicaid and applies to people who are already enrolled.
The Congressional Budget Office estimates that work requirements will reduce federal Medicaid spending by about $326 billion over 10 years. The agency also estimates that 4.8 million more people will be uninsured in 2034 because of the work requirement.
“A lot of states are working on a super-condensed timeline,” said Amaya Diana, a policy analyst at KFF who worked on the survey. They are “still making these big decisions with less than a year before implementation.”
KFF is a health information nonprofit that includes KFF Health News.
The law permits short exemptions from work requirements for enrollees experiencing certain hardships — natural disasters, residing in a county with a high unemployment rate, admission to a hospital or nursing home, or having to travel for an extended period to obtain medical care.
While 28 states and Washington, D.C., will offer hardship exemptions, three of those states won’t adopt all four exemptions allowed by the law and two — Iowa and Indiana — don’t plan to adopt any.
People can also be exempted from the work requirements if they are “medically frail.” But the federal government has not told states how to define that term or how to determine whether an enrollee falls into the category.
The survey showed that 21 states, as of March, had not defined medical frailty. Nebraska, which is implementing its work requirement May 1, recently issued a list of thousands of health conditions that could qualify enrollees as “frail” and exempt them from working.
Some states plan to allow patients to self-attest to medical frailty, while others will require confirmation by a medical professional. The most common way of verifying medical frailty, which will be used in just over 30 states, is by examining Medicaid claims data.
Mehmet Oz, administrator for the federal Centers for Medicare & Medicaid Services, told KFF Health News in an interview this week that “we don’t like self-attesting” and that “documentation is critical.”
Many beneficiaries and their advocates have expressed concerns about losing coverage for administrative reasons. When Arkansas briefly implemented Medicaid work rules, for instance, most lost coverage not because they did not meet the requirements but for failing to correctly submit paperwork in time.
Six states plan to use AI to assist with the work requirement implementation in some way, such as for document processing or comparing beneficiary data from different sources, KFF found. Two states, Maryland and New Mexico, plan to use AI to analyze claims data.
Three states — Arkansas, Missouri, and Oklahoma — plan to use AI to interact directly with people on Medicaid and assist them with identifying and uploading verification documents and data.
Adults on Medicaid will have to reverify that they’re working, or that they’re exempt from the requirement, at least every six months. Some states plan to check quarterly.
When possible, states must use available data sources to verify exemptions or compliance with work requirements.
For example, data from the National Student Clearinghouse will be used by about 10 states to verify school attendance. Some states also plan to tap sources including the Department of Veterans Affairs, AmeriCorps, and service commissions.
But more than half of states told KFF’s researchers that they have insufficient time to add new data sources and cited ongoing costs as a challenge.
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