New federal rules now require most adults applying for Medicaid to document at least one month of work, schooling, or volunteer activity before gaining or keeping benefits. The law, part of the GOP One Big Beautiful Bill Act signed last July, lets states choose a one-, two- or three-month look-back period — and several Republican-led states are using that flexibility to adopt the strictest option.
Indiana was the first to enact the maximum three-month requirement when Gov. Mike Braun signed the bill in March; Idaho followed with a similar law in April. Legislators in Arizona, Missouri and Kentucky have pushed measures that would limit the ability of state agencies to grant leniency when implementing the new federal standard.
The Congressional Budget Office estimates roughly 18.5 million adults will be subject to the requirements across 42 states and the District of Columbia. In Indiana, officials say the change would affect about one-third of the state’s Medicaid enrollees. Federal rules exempt children, people 65 and older, people with disabilities and those with serious medical conditions; states may also add exemptions, such as short-term hardship waivers for people temporarily unable to work because of medical treatment.
Typically, state Medicaid agencies design implementation details and await guidance from the Centers for Medicare and Medicaid Services. Because CMS has not yet issued detailed instructions on many aspects of the policy, some state lawmakers have stepped in to set firm parameters.
Supporters say stricter state rules are needed to align law with the federal standard and to curb waste. Indiana state Sen. Chris Garten, who sponsored the three-month bill, argued the change restores the program’s intent as a safety net rather than a long-term alternative to work. Democratic lawmakers and some agency officials counter that evidence of widespread improper enrollment is limited, and that a small number of errors does not justify restricting access for vulnerable people.
Advocates, providers and policy analysts warn that tougher documentation and longer look-back periods could trigger significant coverage losses and disrupt care. Legal and community groups say the new paperwork will be particularly burdensome for people with irregular, informal or gig work, and for those who must travel or pause employment for medical treatment. An Indiana advocate said the one-month standard would be sufficient to encourage engagement and that additional bureaucratic hurdles risk tripping up people with the greatest needs.
A Center on Budget and Policy Priorities analysis found that how states apply the rules — including the chosen look-back period, the breadth of exemptions and administrative practices — will determine how many people lose coverage. Shorter look-back windows and broader exemptions, the report said, will allow more people to enroll; longer windows and narrower exceptions will create new barriers.
In Missouri, lawmakers discussed a three-month look-back before settling on a proposal that would require only one month. Some state legislators there are also pursuing a constitutional amendment to bar the state from offering optional exemptions such as short-term hardship waivers. Conservative advocacy groups, including the Foundation for Government Accountability, have urged tougher limits, arguing that work requirements move people away from dependency and toward employment.
Health providers say the policies risk interrupting care. An OB-GYN in St. Louis noted that coverage churn already causes some new mothers to lose postpartum coverage despite existing exemptions, and warned that additional red tape could widen gaps in care. Patient advocates point out that nearly two-thirds of adults ages 19 to 64 on Medicaid already work, and many of those who do not are retired, serving as caregivers, or too sick to work. Cancer and other serious illness advocates have told lawmakers that removing hardship waivers could cut off time-sensitive treatment.
Opponents also say the rules stigmatize people who rely on Medicaid. One small-business owner with chronic illness described past difficulties submitting documentation to the state and fears new reporting requirements could cause her to lose coverage even when she meets the standard.
State budget and policy analyses predict enrollment declines under stricter rules. Indiana’s nonpartisan Legislative Services Agency estimated a drop in Medicaid rolls tied to the three-month measure, and advocates caution that losing coverage undermines people’s ability to stay healthy and maintain employment.
The federal law allows states discretion to adopt shorter look-back windows, broader exemptions and administrative processes designed to limit coverage losses. How many people ultimately lose benefits will depend on decisions state officials make now and on forthcoming CMS guidance that could clarify compliance and implementation. KFF Health News will continue tracking how states finalize policies and the effects on Medicaid enrollment and access to care.