Medicaid Work Requirements, Explained: Who Must Comply and What Counts
The bottom line: If you are enrolled in Medicaid through your state's Expansion population, this new rule applies to you. If you live in Georgia, Tennessee, or Wisconsin, it can apply to you too, even without traditional Expansion, because of how your state's 1115 waiver works.
On June 3, the Centers for Medicare and Medicaid Services released an interim final rule to implement the work requirements, also known as community engagement requirements, under HR 1. The statute exempts this rulemaking from the Administrative Procedures Act and allows CMS to issue the rule without the typical notice and comment process. CMS is still accepting public comments on the rule until July 31, 2026.
Our next series of newsletters will dive into the details of the rule and the questions that remain.
Who Has to Comply
The new requirements apply to the Medicaid Expansion population and to people enrolled through certain Medicaid 1115 waivers.
The Expansion population is easy enough to define, even if it is not always easy to determine whether you yourself are enrolled in it. Every state and the District of Columbia have an Expansion population except for Alabama, Florida, Georgia, Kansas, Mississippi, South Carolina, Tennessee, Texas, Wisconsin, and Wyoming.
The statute also extends the requirements to people enrolled through 1115 waivers that provide Expansion-like coverage. We already knew that Wisconsin and Georgia had programs that would meet this criteria, and Georgia has had a similar work requirement since 2023 through its Pathways to Coverage program. A recent briefing from CMS noted that the agency has identified 13 such populations across 8 states, including Tennessee. That brings us to three states without traditional Expansion that still have people who will need to comply: Georgia, Tennessee, and Wisconsin.
What Activities Qualify
People enrolled in the Expansion population or in similar Medicaid coverage must complete certain activities to maintain their coverage, unless they meet an exclusion or exception, which we will cover in a future newsletter.
Work includes working in exchange for money, goods, or in kind support like room and board. It includes unpaid work such as an internship, and it includes self-employment.
Work programs include job training and preparation programs, such as Job Corps or other services available through the American Job Centers, as well as programs for veterans offered through the Veterans Administration and the Department of Labor. Job search activities alone cannot make up more than half the hours counted toward the program.
Community service must be performed in a structured program run by a public entity or nonprofit for the direct benefit of the community. Court mandated community service qualifies.
Individuals must participate in work, a work program, community service, or some combination of the three for at least 80 hours a month.
Education enrollment at least half time fully satisfies the requirement on its own, regardless of any other work or training. What counts as half time enrollment is determined by the school itself. High school and high school equivalency programs count, though independent self-study toward high school equivalency does not. Education enrollment also covers school breaks, including summer, as long as the individual is enrolled for the following term.
If someone is enrolled less than half time, they can combine their part time enrollment with hours of work, a work program, or community service to reach the 80 hour requirement. To do this, CMS uses a formula that converts credit hour enrollment into equivalent hours of community engagement per month, shown below (pulled directly from the interim final rule):
| Credit Hour(s) | Monthly Hours of Activity for Community Engagement |
|---|---|
| 1 credit hour | 12.99 hours |
| 2 credit hours | 25.98 hours |
| 3 credit hours | 38.97 hours |
| 4 credit hours | 51.96 hours |
| 5 credit hours | 64.95 hours |
| 6 credit hours | 77.94 hours |
For example, a person enrolled in 4 credit hours, which a school considers less than half time, who also works 30 hours a month would have 81.96 hours of community engagement. CMS does not address in the interim final rule whether rounding up is allowed.
Monthly income offers another path to compliance. Individuals can show they meet the requirement by earning an income equivalent to the federal minimum wage for 80 hours a month. At the federal minimum wage of $7.25 an hour, that comes to $580 a month. States with higher minimum wages cannot use their own higher minimum wage to make this calculation. In those states, individuals can work fewer than 80 hours a month as long as they are earning at least $580 a month. States also may not adjust this calculation for anyone earning less than minimum wage, including the tipped minimum wage of $4.25.
Seasonal workers can demonstrate compliance by showing equivalent earnings of $580 a month averaged over the past six months, even in months when they earned less.
Stay tuned for our next newsletter that will cover the exclusions and exceptions.