Millions of Americans on Medicaid will soon be required to work, volunteer, or go to school to keep their health insurance.
New federal rules under the One Big Beautiful Bill Act of 2025 will force most adults on Medicaid to complete at least 80 hours per month of approved activities starting in late 2026. If they don’t, they could lose coverage entirely.
The law applies to adults aged 19 to 64 who are enrolled in Medicaid expansion. States must begin notifying people by summer 2026, and enforcement will begin by December 31, 2026 in most places.
Some states may start even sooner. Nebraska plans to begin enforcement on May 1, 2026, according to state officials.
What Counts as “Work”
To stay eligible, enrollees must do one of the following for at least 80 hours each month:
- Work a paid job or be self-employed earning around $580 or more per month
- Enroll at least half-time in college or a job training program
- Volunteer at nonprofits, food banks, or community organizations
- Join a work program approved under federal nutrition or employment laws
“This is about encouraging able-bodied adults to engage with their communities,” said a spokesperson for the U.S. Department of Health and Human Services in a statement released in early 2025.
Who Is Exempt
Not everyone will be required to work. The law includes several exemptions:
- Parents or guardians caring for children 13 years old or younger
- Pregnant women or people who are medically frail
- People in substance abuse treatment programs
- Disabled veterans and former foster youth under 26
- American Indians and Alaska Natives
Caregivers of disabled family members are also exempt, according to the federal guidance issued under the new law.
Timeline: What Happens in 2026
The rollout will happen in stages throughout the year.
By June 1, 2026, the Secretary of Health and Human Services must release official rules and guidelines for states to follow.
Between June 30 and August 31, 2026, all states must contact Medicaid enrollees by mail and at least one other method—such as text message, phone call, or a state website—to explain the new requirements.
Starting in October 2026, some states may begin tracking compliance during a “look-back period” before full enforcement begins in January 2027.
What Happens If You Don’t Comply
States will check eligibility every six months starting December 31, 2026.
If someone doesn’t meet the 80-hour requirement and isn’t exempt, the state will send a notice. The person will have 30 days to prove they qualify or meet an exemption. If they don’t respond, they will be disenrolled.
People who lose Medicaid for not working also cannot get subsidies to buy insurance on the Affordable Care Act marketplace, according to the law. That means they may be left with no affordable health coverage options.
Why This Matters Now
An estimated 20 million adults are enrolled in Medicaid expansion nationwide, according to data from the Centers for Medicare & Medicaid Services (CMS). Many of them may not know the rules are changing.
Advocates worry that confusing paperwork or lack of outreach could lead to coverage losses—even for people who are working or exempt.
“People could lose coverage simply because they didn’t understand the new rules or didn’t get the notice in time,” said a policy analyst at the Center on Budget and Policy Priorities in a recent interview.
States are now racing to prepare systems, train staff, and reach millions of people before the deadline.
