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    Medicaid changes from the 2025 law: work requirements and timeline

    The 2025 reconciliation law (Public Law 119-21) requires most states to make adults in the Medicaid expansion group show 80 hours a month of work or similar activity, generally starting by 1 January 2027.[1][2] It also adds six-month renewals, limits retroactive coverage, and phases in cost sharing and financing limits through 2032. CBO estimated the law will leave 10 million more people uninsured in 2034.[3][4][5]

    Editor reviewedStrict sourcingUpdated ExplainerHealth and medicine, Tech policy

    Medicaid is a joint federal and state program that provides free or low-cost coverage to some low-income people, families, children, pregnant women, older adults and people with disabilities.[6] The 2025 budget reconciliation law, signed on 4 July 2025, changes who keeps Medicaid and how states pay for it.[1] This explainer sets out the main changes and their dates. It is not legal or medical advice. If you are on Medicaid, your state Medicaid agency can tell you whether and how the new rules apply to you.

    Work requirements

    Starting in 2027, many adults who got Medicaid through the ACA expansion will need to show 80 hours a month of work, volunteering, job training or school to get or keep coverage.[2][7] Earning at least 80 times the federal minimum wage, about $580 a month in 2026, also counts.[7] Many people are exempt. They include pregnant people, people who are medically frail, parents of children 13 and under, and some veterans.[8]

    Section 71119 requires states to apply the requirement no later than the first quarter beginning after 31 December 2026, or earlier at state option through a section 1115 waiver or state plan.[9] HHS may exempt states making a good-faith effort, but exemptions must expire by 31 December 2028.[10] CMS’s interim final rule of 1 June 2026 applies the requirement to non-pregnant adults aged 19-64 in the expansion group or certain 1115 demonstrations who are not on Medicare. Forty-three states and DC are covered, and the territories are not.[11] States verify compliance at application and renewal. If they cannot verify it, they must allow 30 days to respond before denying or ending coverage.[12]

    Nebraska and Montana implemented work requirements early. KFF says most states must send outreach notices in September 2026 for a January 2027 start.[13]

    Renewals, retroactive coverage and cost sharing

    Expansion adults will have to renew their Medicaid every six months. This applies to renewals scheduled from 1 January 2027, the first quarter after 31 December 2026.[3] Medicaid will also cover fewer past medical bills from before someone applied.[4] From October 2028, some expansion adults will pay up to $35 per service, though primary care and mental health care are exempt.[14]

    Retroactive coverage is limited to one month before application for expansion enrollees and two months for traditional enrollees.[4] From 1 October 2028, states must impose cost sharing of up to $35 per service on expansion adults with incomes of 100-138% FPL. Primary care, mental health, substance use services and some clinic services are exempt.[14]

    State financing

    The law bars all states from creating new provider taxes or raising existing ones. Provider taxes are one way states fund their share of Medicaid. For expansion states, the safe-harbor limit falls by 0.5 percentage points a year from fiscal 2028 until it reaches 3.5% in FY 2032.[15] The financing changes start in fiscal 2028, after the work requirement (January 2027) and six-month renewals (from 1 January 2027).[15][2][3]

    Coverage estimates

    CBO estimated the law will reduce federal health spending by over $1 trillion and increase the number of uninsured people by 10 million in 2034. Of that, 7.5 million comes from the Medicaid changes.[5] CBO attributed 5.3 million more uninsured people in 2034 to the work requirement alone, before interactions with other provisions.[16] Combined with the expired ACA credits, the estimated increase in the uninsured by 2034 tops 14 million.[17] These are projections.

    For coverage bought on the individual market, see the ACA Marketplace explainer. Follow implementation in the health care changes tracker, and see how CMS fits in at CMS.

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    Questions readers ask

    When do Medicaid work requirements start?

    The law requires states to start no later than the first quarter beginning after 31 December 2026, which CMS describes as generally by 1 January 2027. States may start earlier, and HHS can grant good-faith exemptions that must end by 31 December 2028.[9][2][10]

    Who has to meet the Medicaid work requirement?

    Non-pregnant adults aged 19 to 64 in the Medicaid expansion group or certain section 1115 demonstrations who are not on Medicare. Forty-three states and DC must implement it.[11]

    How many hours do you need, and what counts?

    80 hours a month of work, community service or a work program, half-time school, a mix of these, or monthly income of at least 80 times the federal minimum wage ($580 a month in 2026).[7]

    Who is exempt?

    Exempt groups include pregnant and postpartum people, medically frail or disabled people, parents and caretakers of children 13 and under or of disabled people, American Indians and Alaska Natives, former foster youth, veterans with a total disability rating, and people meeting SNAP or TANF work rules.[8]

    What happens if a state cannot verify that someone meets the requirement?

    The state must send a notice and give the person 30 days to show compliance or an exemption. Coverage can then be denied or ended, but people can reapply.[12]

    Sources

    · 17 claims from 8 publishers

    Each numbered claim is a statement we checked against the sources listed with it. Tap a number in the text to see its sources in place.

    1. [1]

      The 2025 budget reconciliation law (H.R. 1, formerly called the "One Big Beautiful Bill Act") became Public Law 119-21 when President Trump signed it on 4 July 2025. confirmedas of 2025-07-04

    2. [2]

      CMS issued an interim final rule on 1 June 2026 implementing the requirement of 80 hours a month of qualifying activity; states must generally implement it by 1 January 2027. confirmedas of 2026-06-01

    3. [3]

      The law requires states to redetermine eligibility every six months for Medicaid expansion adults, for renewals scheduled from the first quarter beginning after 31 December 2026 (that is, from 1 January 2027). confirmedas of 2025-08-22

    4. [4]

      The law limits retroactive Medicaid coverage to one month before application for expansion enrollees and two months for traditional enrollees. confirmedas of 2025-08-22

    5. [5]

      CBO estimated the 2025 reconciliation law will cut federal health spending by over $1 trillion and increase the number of uninsured people in 2034 by 10 million (7.5 million from Medicaid changes, 2.1 million from ACA Marketplace changes). confirmedas of 2025-08-22· forecast

    6. [6]

      Medicaid is a joint federal and state program that provides free or low-cost coverage to some low-income people, families, children, pregnant women, older adults and people with disabilities. confirmedas of 2026-10-11

    7. [7]

      Adults can meet the requirement with 80 hours a month of work, community service or a work program, half-time education, a combination, or monthly income of at least 80 times the federal minimum wage ($580 a month in 2026). confirmedas of 2026-06-01

    8. [8]

      Exempt groups include pregnant and postpartum people, medically frail or disabled people, parents and caretakers of children 13 and under or of disabled people, American Indians and Alaska Natives, former foster youth, veterans with a total disability rating, and people meeting SNAP or TANF work rules. confirmedas of 2026-06-01

    9. [9]

      The law requires states to apply Medicaid community engagement (work) requirements to applicable individuals beginning no later than the first quarter starting after 31 December 2026, or earlier at state option. confirmedas of 2025-07-04

    10. [10]

      HHS may exempt a state making a good-faith effort to comply, but any such exemption must expire by 31 December 2028. confirmedas of 2025-07-04

    11. [11]

      The requirement applies to non-pregnant adults aged 19 to 64 in the Medicaid expansion group or certain section 1115 demonstrations who are not on Medicare; 43 states and DC must implement it, and US territories are not covered. confirmedas of 2026-06-01

    12. [12]

      States must verify compliance at application and renewal; if they cannot, they must give the person 30 days to show compliance or an exemption before denying or ending coverage, and people who are disenrolled may reapply. confirmedas of 2026-06-01

    13. [13]

      Nebraska and Montana had already implemented Medicaid work requirements by mid-2026, and most states must send outreach notices in September 2026 ahead of a 1 January 2027 start. confirmedas of 2026-07-24

    14. [14]

      From 1 October 2028 states must charge expansion adults with incomes of 100-138% of poverty cost sharing of up to $35 per service, with exemptions for primary care, mental health and some other services. confirmedas of 2025-08-22

    15. [15]

      States may fund their share of Medicaid partly through provider taxes; the law bars states from creating new provider taxes or raising existing ones, and cuts the safe-harbor limit for expansion states from 6% to 5.5% in fiscal 2028, then by 0.5 percentage points a year until it reaches 3.5% in FY 2032. confirmedas of 2025-08-22

    16. [16]

      CBO estimated the work requirement provision will increase the number of uninsured people by 5.3 million in 2034, before interactions with other provisions, making it the largest single source of the law's coverage losses. confirmedas of 2025-08-22· forecast

    17. [17]

      CBO's earlier estimates found extending the enhanced premium tax credits would have kept another 4.2 million people insured in 2034; combined with the 2025 law, KFF puts the total increase in the uninsured by 2034 above 14 million and Georgetown's Center for Children and Families at about 15 million. confirmedas of 2026-10-06· forecast

    Revision history (1)
    1. Page created.

    Created Oct 11, 2026. Last reviewed by an editor on Oct 11, 2026. Next scheduled review: Jan 4, 2027.

    Cite this page

    "Medicaid changes from the 2025 law: work requirements and timeline." ContentLora, updated Oct 11, 2026. https://contentlora.com/explain/medicaid-changes-2025-law-explained

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