The federal reconciliation bill known as the One Big Beautiful Bill Act or the Working Families Tax Cuts Act, passed last year, mandates that states must enforce work requirements for specific Medicaid recipients by January 1, 2027.
This new rule is set to impact adults in 43 states, including Washington, D.C., who qualify under the Affordable Care Act’s Medicaid expansion and certain waiver programs, like those in Georgia and Wisconsin. According to KFF, the health policy nonprofit, these individuals must begin meeting work criteria starting in 2027.
States like Iowa, Montana, and Nebraska are already planning to implement these work requirements for eligible union members this year. In contrast, most states, Ohio included, are looking towards a 2027 start date. Arkansas intends to “softly implement” guidelines in 2026, but won’t disqualify anyone until the official requirements kick in in January 2027, as noted by KFF.
“This is a big endeavor for the state and will significantly affect both enrollees and the healthcare providers they rely on,” commented Larry Levitt, KFF’s executive VP of health policy. The Congressional Budget Office estimates that these work mandates could reduce federal Medicaid spending by more than $300 billion over the next decade, potentially leaving over 5 million more people without insurance.
Who Will Be Affected?
Ohio is already on the path to implementing work requirements for Medicaid expansion recipients. The state submitted a proposal to the Centers for Medicare and Medicaid Services back in February 2025 to initiate these rules for expansion enrollees.
Governor Mike DeWine mentioned, “In our efforts to help individuals achieve full potential, we have a duty to ensure as many Ohioans as possible are moving towards economic independence.” Although the proposal has yet to materialize and remains “pending” with CMS, the starting date is set for January 1, 2027, consistent with most states that have adopted Medicaid expansion under the ACA.
This requirement typically applies to adults aged 19 to 64 who receive Medicaid because their income is at or below 138% of the federal poverty level and are not pregnant, disabled, or otherwise exempt.
Exemptions from the work mandate include individuals under 19 or over 65, pregnant or postpartum individuals, those eligible for Medicare, caregivers of young children or dependents with disabilities, individuals who have met work requirements for SNAP or TANF, those with disabilities or serious medical conditions, participants in substance abuse treatment programs, recently released prisoners, and members of American Indian tribes or certain specified groups.
Ohio Medicaid plans to match postpartum eligibility to current coverage, which grants 12 months of postpartum benefits. An updated directive from CMS is anticipated in June with further updates to follow.
To keep Medicaid eligibility, those not exempt in the expansion group must show that each month they either:
- Work a minimum of 80 hours
- Complete 80 hours of community service
- Engage in an 80-hour work program
- Take at least half-time education courses
- Participate in any combination of these tasks for a total of 80 hours or more
How Does Ohio Compare to Other States?
States have the authority to adapt certain rules and exceptions, and KFF recently surveyed states about their plans regarding work requirements.
Ohio, similar to many other states, has chosen a less stringent approach in implementing these requirements compared to the options the federal government has allowed.
For instance, Ohio Medicaid verifies only the last month of a Medicaid member’s job history, including schooling and community service, when applying or renewing services. It won’t require looking back over several months.
“Many states adopt the least restrictive policies when verifying compliance,” stated Jennifer Tolbert, KFF’s director of state health policy and analysis.
Another area of flexibility involves hardship exceptions. The federal government permits states to set hardship exceptions for work requirements, and Ohio, like most states, plans to adopt all four permitted exceptions:
- Living in areas with high unemployment
- Experiencing natural disasters
- Hospitalization
- Extended travel for treatment
KFF’s research indicates Ohio will also adopt additional hardship exceptions as they appear.
States like Indiana and Iowa intend to apply strict requirements without such exceptions. Others, like Missouri, have no plans to grant exceptions for high-unemployment areas, while New York won’t provide leeway for necessary medical travel.
Roughly half of the states have defined “medically frail” status, a category that can exempt individuals from work requirements. Ohio’s definition includes adults with significant chronic illnesses or disabilities limiting daily activities, extending to those recovering from substance abuse issues. When verifying such conditions, Ohio Medicaid aims to use various sources, including medical claims data and self-certification, pending permission from CMS.
Most states, Ohio included, are considering working with vendors, like Accenture, to implement required changes swiftly. While some states are thinking of increasing their available personnel, Ohio does not plan to expand its team of qualified workers.
Verification of Work and Community Engagement
States can adopt different methods to verify engagement and work requirements. Early proposals suggested that individuals reporting household incomes above a specified threshold would be assumed to have stable employment. Additionally, enrollment in programs using disability as the foundation could exempt someone from work requirements.
According to KFF, Ohio plans to use diverse data sources for verification, including information from education systems, veterans’ affairs, and corrections data.
Ohio Medicaid is reviewing methods for knowledge verification, and once established, members will receive clear guidelines on documenting their activities. More instructions from CMS, including updated directives, are also expected in June.
