Medicaid Work Requirements Take Shape as States Set Implementation Plans

Key Takeaways

• H.R. 1 Medicaid work requirements mandate that states implement work, education, or community engagement requirements of at least 80 hours per month for the expansion population starting July 1, 2027.
• Indiana, Utah, New Hampshire, Idaho, and Kentucky have advanced state Medicaid work requirement implementation through legislation this session, with key debates focusing on look-back periods and self-attestation policies.
• The Medicaid work requirement look-back period has emerged as a central policy question, with states split between one-month windows (Utah, New Hampshire, Kentucky) and three-month periods (Indiana, Idaho) for verifying compliance prior to application.
• Nebraska, Montana, and Arkansas are positioning themselves as early adopters, with implementation timelines ranging from May 2026 to January 2027 that will likely inform other states' approaches.
• States are awaiting additional guidance from CMS, which is required to issue a final interim rule on H.R. 1 Medicaid work requirements by June 1, 2026.

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Under H.R. 1, states will be required to implement Medicaid work requirements as a condition of eligibility for the expansion population starting July 1, 2027. The policy requires enrollees to have at least 80 hours per month of work, education, or community engagement, with exemptions for specific populations, and outlines the verification and enrollment process while giving states certain flexibility on implementing requirements early. This year, states are evaluating and pursuing pathways for implementation.

State Legislative Actions on Medicaid Work Requirements

This session, legislatures have advanced work requirement policies with Indiana, Utah, and New Hampshire enacting legislation, and Idaho and Kentucky enrolling similar measures.

Look-Back Period Debates and State Approaches

A key policy debate has centered on “look-back” periods. Under H.R. 1, states are required to conduct a look-back review of at least one and up to three months prior to application to verify compliance with work requirements. Some lawmakers argue that longer windows promote consistent work participation, while others warn that extending the period creates administrative barriers that could lead to coverage losses. Utah, New Hampshire, and Kentucky opted for a one-month look-back period at application in their legislation, while Indiana and Idaho included a three-month period.

Self-Attestation Policy Variations Across States

Self-attestation has also been a key consideration for states, with Indiana, Utah, and New Hampshire including provisions to prohibit self-attestation of work requirements or exemptions. Kentucky’s bill originally included a ban on self-attestation, but it was removed from the version that passed the legislature.

Early Implementation Plans by Pioneer States

Some states are aiming to be early adopters and have already set forth implementation plans. In December, Nebraska Governor Jim Pillen (R) announced his intent to implement work requirements as early as May, while the Montana Department of Public Health and Human Services announced development of a State Plan Amendment with a target effective date of July 1, 2026. Similarly, Arkansas unveiled plans to “soft launch” Medicaid work requirement verification procedures in July, with the goal of piloting procedures prior to full enforcement in January 2027. These early-adopter states are likely to provide key insights into operational and administrative challenges associated with implementation that could inform the approach in other states.

Federal Guidance and CMS Rulemaking Timeline

Finally, states are also waiting for additional guidance from the Centers for Medicare & Medicaid Services (CMS). CMS released initial guidance in December 2025 and is required to promulgate a final interim rule by June 1, 2026. The forthcoming rulemaking is expected to provide further clarity and additional direction for states as they continue to design policies.

Track Health Care Policy

The ever-evolving state health policy landscape will continue to influence how health care organizations make business decisions. MultiState’s team pulls from decades of expertise to help you effectively navigate and engage. MultiState’s team understands the issues, knows the key players and organizations, and we harness that expertise to help our clients effectively navigate and engage on their policy priorities. We offer customized strategic solutions to help you develop and execute a proactive multistate agenda focused on your company’s goals. Learn more about our Health Care Policy Practice.