By Samantha Liss
April 15, 2026 / 5:00 AM EDT / KFF Health News
New federal rules now require most adults who apply for Medicaid to show at least one month of work, school, or volunteer activity before they can gain or keep benefits. The law, part of the GOP’s One Big Beautiful Bill Act signed by President Trump last July, gives states the option to require one, two, or three months of prior activity — and some Republican-led states are using that flexibility to set stricter standards.
Indiana became the first state to adopt the longest permitted period when Gov. Mike Braun signed a bill in March requiring three consecutive months of work or similar activity. Idaho recently approved a similar three-month requirement that its governor signed into law on April 10. Lawmakers in Arizona, Missouri, and Kentucky have pursued measures to limit how much leniency state agencies can offer when implementing the federal rules.
The Congressional Budget Office estimates about 18.5 million adults will be subject to the new requirements across 42 states and the District of Columbia. In Indiana, the new law would affect roughly one-third of the state’s Medicaid population. The federal rules generally exempt children, people 65 and older, people with disabilities, and those with serious medical conditions; states may also adopt additional exemptions, such as short-term hardship waivers for people temporarily unable to work because of medical care or treatment.
Typically, state Medicaid administrators — not lawmakers — craft implementation details and look to federal regulators for guidance. But the Centers for Medicare & Medicaid Services has not yet provided detailed instructions on many aspects of the law, prompting some state legislators to step in and set strict parameters.
Indiana state Sen. Chris Garten, who introduced the three-month bill, said the change was needed to “align” state law with the federal standard and to curb what he described as waste, fraud, and abuse. “We believe in a safety net for our most vulnerable, not a hammock for able-bodied adults that choose not to work,” Garten said.
Democratic state Sen. Fady Qaddoura questioned whether there is evidence of a widespread enrollment problem that would justify the limits. Mitch Roob, secretary of the Indiana Family and Social Services Administration, told lawmakers he believed only a small number of ineligible people enroll. “It’ll never be none,” he said, noting that some errors occur, but Qaddoura said that did not justify restricting access for vulnerable residents.
Advocates warn the stricter rules and added reporting could lead to coverage losses and harm people who need Medicaid to remain healthy and employed. Adam Mueller, executive director of the Indiana Justice Project, said the tougher documentation requirements will be particularly hard on people with nontraditional, intermittent, or informal work. “If the point is to get people engaged, the one month would do it,” he said. He worries that bureaucratic hurdles will trip up those with the greatest need.
A Center on Budget and Policy Priorities analysis found that how states implement the law — including look-back periods and exemptions — will significantly affect how many people lose coverage. The think tank concluded that shorter look-back periods and broader exemptions will allow more people to enroll, while longer periods and narrower exemptions will impose new barriers.
In Missouri, legislators considered a three-month look-back but later shifted a proposal to require only one month of prior work. Some lawmakers there are also pursuing a constitutional amendment that would prohibit the state from offering optional exemptions such as short-term hardship waivers. The Foundation for Government Accountability, a conservative advocacy group, has testified in support of tougher limits in multiple states, arguing that work requirements move people from dependency and restore dignity and pride through work.
Health providers and patients say the policies risk disrupting care. Jessica Norton, an OB-GYN who treats many Medicaid patients in St. Louis, said coverage churn already forces some new mothers to lose postpartum coverage unexpectedly, even though new mothers are supposed to be exempt. She warned that additional red tape could increase gaps in care. “They are saying, ‘Oh, actually, health care is a privilege, and you have to earn it,’” Norton said.
Nearly two-thirds of adults ages 19 to 64 on Medicaid already work, KFF has found. Many of those who do not work are retired, serving as caregivers, or too sick to work. Patient advocates note that exemptions such as short-term hardship are intended to account for circumstances — for example, a rural cancer patient who must travel for treatment and temporarily cannot meet work-verification rules. Emily Kalmer, a lobbyist for the American Cancer Society’s advocacy arm, told Missouri lawmakers that time is critical for cancer patients and survivors, and removing hardship waivers could cut off needed care.
Opponents of stricter requirements include people who say the rules stigmatize those on Medicaid. Anna Meyer, who owns a small bakery in Columbia, Missouri, and lives with fibromyalgia and food allergies, said the implication that Medicaid recipients are lazy is hurtful. She also described past difficulties submitting information to the state Medicaid agency and fears new reporting requirements could lead to losing coverage even when she meets the rule.
State analyses predict enrollment declines under tighter rules. Indiana’s nonpartisan Legislative Services Agency estimated a drop in Medicaid enrollment from Garten’s measure. Advocates argue that losing coverage undermines people’s ability to stay healthy and work.
The federal law allows states discretion to adopt shorter look-back periods, broader exemptions, and administrative practices designed to reduce coverage losses. How many people ultimately lose coverage will depend on decisions state officials and legislatures make now, and on forthcoming federal guidance from CMS that could clarify compliance and implementation. KFF Health News will continue following how states finalize their approaches and the real-world effects on Medicaid enrollment and access to care.