Starting no later than January 1, 2027, states must require many Medicaid adults ages 19 to 64 in the ACA expansion group to show 80 hours a month of work, community service, a work program or half-time school, unless they qualify for an exemption, according to CMS. A November 10, 2026 KFF Health News report on Nebraska, which started in May, found most work-requirement denials there came from paperwork that wasn't returned.
Key facts: The rule applies in 43 states and D.C. to non-pregnant adults 19 to 64 who aren't on Medicare and are covered through the Medicaid adult group or certain waivers, per CMS. · Parents and caregivers of children 13 and under, people who are pregnant or postpartum, people who are medically frail, and several other groups are exempt, per CMS. · If a state can't verify compliance, it must send a notice and give you 30 days to respond before denying or ending coverage, according to CMS.
Seven weeks before a national deadline, one state's head start is getting a close look. On Tuesday, November 10, 2026, KFF Health News published a report by Rachana Pradhan on Nebraska, which began enforcing Medicaid work requirements on May 1, about eight months before most states have to. This week, with most states due to start by January 1, 2027, here's how the rule works and what Nebraska's experience suggests.
What the Federal Rule Requires
The requirement comes from the 2025 budget law. The Centers for Medicare & Medicaid Services (CMS) issued the details in an interim final rule on June 1, 2026, which took effect July 31. Officially it's called "community engagement," which is a gentler name for the same 80 hours.
Per CMS, it applies to non-pregnant adults ages 19 to 64 who aren't on Medicare and who get Medicaid through the adult group (the ACA expansion group) or certain state waivers. That covers 43 states and D.C. Territories are not included.
To meet it for a month, you can:
- work, do community service or join a work program for at least 80 hours,
- be enrolled in school at least half-time,
- combine those activities to reach 80 hours, or
- earn at least 80 times the federal minimum wage, which CMS puts at $580 a month in 2026.
States check at application and at renewal, and can check more often. KFF's analysis notes that at application, states may look back as many as three months, and expansion adults are renewed every six months.
Who Is Exempt
CMS lists several groups who don't have to meet the requirement, including:
- people who are pregnant or postpartum,
- parents, guardians and caregivers of a child 13 or younger, or of a person with a disability,
- people who are medically frail, which KFF says includes people with disabilities, a substance use disorder, a "disabling" mental disorder, or a "serious or complex" medical condition,
- people in a drug or alcohol treatment program,
- American Indians and Alaska Natives, former foster youth, and veterans with a total disability rating,
- people who meet TANF work requirements, or who live in a SNAP household and aren't exempt from SNAP's work rules.
States may also offer short-term hardship exceptions, for example during a hospital stay or in a county with high unemployment or a declared disaster.
What Nebraska's Early Launch Showed
About 70,000 adult Medicaid enrollees in Nebraska are subject to the rule, KFF Health News reports. A state health department spokesperson called the rollout "very successful," pointing to state data that 86% of affected applicants met the requirement or qualified for an exclusion and 93% of existing enrollees kept coverage.
Clinics and advocates told the outlet that many enrollees were confused about whether the rule applied to them. As of August, roughly 1,100 Nebraskans had been denied because of the work requirement, and most of those denials came from people not responding to requests for information. Average call-center waits roughly doubled from about 13 to 26 minutes between May and July before easing, and the state got more than 101,000 calls in August, according to state data cited in the report.
The report also notes that Democrats, who will hold new majorities in Congress in January, have said they plan to try to repeal the Medicaid changes, and that it's unclear whether that would succeed because the president could veto it. For now, the January 1 deadline stands.
The Fine Print: Losing Medicaid over the work requirement can also cost you help on the ACA marketplace. The law makes people who are denied or disenrolled from Medicaid because of work requirements ineligible for marketplace premium tax credits, according to KFF. That makes answering a state notice on time more important than it looks.
What This Means for You
This is general education, not advice:
- Open mail from your state Medicaid agency right away. CMS says that if a state can't verify you meet the rule, it must send a notice and give you 30 calendar days to respond.
- Ask about exemptions. If you're a caregiver, pregnant, in treatment, or have a serious health condition, tell your caseworker. KFF notes some exemptions, such as medical frailty or being in treatment, are harder for states to spot from the data they already have.
- Keep proof handy. Pay stubs, school enrollment records and volunteer hour logs can help if the state asks.
- Make sure the state can reach you. Update your address, phone and email so notices don't go astray.
- If you lose coverage, you can reapply at any time, per CMS, and you'll be checked again then.
Have a question about Medicaid, the marketplace or your coverage options? Ask us, and we may cover it in a future article.
This article is general education, not insurance, legal or financial advice. Medicaid rules vary by state; contact your state Medicaid agency for the rules that apply to you.
Sources:
- KFF Health News: Nebraska Rushed Medicaid Work Rules. Then a Cancer Patient Was Told He'd Lost Coverage. (Nov. 10, 2026)
- CMS: Medicaid Community Engagement Requirement Interim Final Rule fact sheet (June 1, 2026)
- Federal Register: Medicaid Program; Community Engagement Requirement for Certain Individuals (June 3, 2026)
- Medicaid.gov: Community Engagement
- KFF: A Closer Look at the Work Requirement Provisions in the 2025 Federal Budget Reconciliation Law
Frequently asked questions
When do Medicaid work requirements start?
States must start no later than January 1, 2027, and may start earlier, according to CMS. Nebraska began May 1, 2026. Federal law lets HHS give a state more time, until no later than December 31, 2028, if it shows a good-faith effort to comply, KFF reports.
What counts toward the 80 hours?
Per CMS, paid work, community service, a work program, or being enrolled in school at least half-time count, and you can combine them. Earning at least 80 times the federal minimum wage in a month ($580 in 2026) also meets the requirement.
What happens if I get a notice of noncompliance?
CMS says the state must give you 30 calendar days to show you meet the requirement or that you're exempt. If you don't, your application may be denied or your coverage ended, though you can reapply at any time.
