Overview of the KFF Survey
A new survey from KFF and the Georgetown University Center for Children and Families reveals how states plan to implement Medicaid work requirements. Researchers surveyed Medicaid officials from 43 states and conducted focus groups with officials from nine states. Together, these findings offer one of the clearest pictures yet of state-level preparations for this major policy shift.
Most states favor less restrictive approaches to verify compliance. However, a few states are moving faster than required. Additionally, some plan to check beneficiary eligibility more frequently than the minimum standard.
What the Big Beautiful Bill Requires
The Core Mandate
The Big Beautiful Bill, signed into law last summer, introduced significant changes to Medicaid. One key provision mandates work requirements for roughly 20 million beneficiaries enrolled under Medicaid expansion. Under the law, enrollees must report at least 80 hours of work, education, or volunteer activity each month to maintain coverage.
A Historic Policy Shift
This requirement marks one of the most sweeping changes to Medicaid in recent history. Previously, only two states had fully adopted a Medicaid work policy. Furthermore, research shows those earlier mandates were costly to implement. Studies also found they did not meaningfully increase employment among beneficiaries.
How States Are Choosing to Verify Compliance
Compliance Check Frequency
States must decide how often to verify that enrollees meet work requirements. According to the survey, 34 states plan to check compliance every six months at renewal. In contrast, Indiana and New Hampshire will verify compliance quarterly — a notably stricter approach. Meanwhile, seven states have yet to finalize their decision.
Lookback Periods for Data Verification
States must also decide how far back to look when reviewing enrollee data. Most states — specifically 36 — will review one month of data at application or renewal. However, Indiana and Idaho will look back three months. This approach gives those states a longer view of each enrollee’s activity history.
Application and Renewal Updates
Most states plan to add new questions to Medicaid applications and renewals. These questions help confirm whether beneficiaries meet work requirements. Moreover, states will continue using existing data sources — such as wage records, food assistance data, and state unemployment data — to verify compliance. This dual approach reduces the administrative burden on both programs and enrollees.
Hardship Exemptions: What States Are Offering
Optional Exemptions Widely Adopted
Twenty-nine states confirmed they will use at least one optional hardship exemption. These exemptions offer flexibility for enrollees who face difficult circumstances. For example, some states will exempt people living in counties with high unemployment rates. Others will grant exceptions for residents in areas recovering from natural disasters. Notably, only two states said they would offer no optional exemptions at all.
Timeline Pressures and CMS Guidance
A Tight January 2026 Deadline
The law requires most states to implement work requirements by January 1. In fact, 39 states confirm they will meet that target. Yet some states are moving even sooner. Iowa and Montana plan to adopt the policies before year-end. Furthermore, Nebraska has already launched its program, becoming the first state to do so.
CMS Guidance Still Pending
States are currently awaiting additional guidance from the Centers for Medicare and Medicaid Services, expected in June. That timing concerns many program officials. Jennifer Tolbert, deputy director of KFF’s Medicaid and uninsured program, flagged the challenge during a recent webinar. She noted the late release of guidance leaves states with very little time to build fully working systems by January 1.
Technology, AI, and Staffing Solutions
AI Tools and Existing Vendor Relationships
Despite the complexity, states are finding practical paths forward. Most plan to work with existing vendors to update their eligibility systems, since the implementation timeline is too short for new contracts. Notably, six states plan to use artificial intelligence during this transition. AI applications include improving data matching and providing direct support to eligibility staff.
Workforce Capacity Building
Staffing capacity is a top concern across many states. Fourteen states plan to expand their eligibility workforce. Among them, nine aim to hire new workers, and seven plan to bring on contractors. Kate McEvoy, executive director of the National Association of Medicaid Directors, noted during the webinar that state legislatures must first appropriate funds before hiring can begin. She added that states clearly recognize the need to build capacity so they can respond to people seeking help.
Key Takeaways
The KFF and Georgetown survey reveals wide variation in how states approach Medicaid work requirement implementation. Most favor a less restrictive path. Nevertheless, a few are moving early or adopting tighter verification schedules. All face pressure from a firm deadline and limited federal guidance. Going forward, how each state balances compliance demands with enrollee access will shape Medicaid coverage outcomes for millions of Americans.
