Washington, D.C. — States across the country are scrambling to figure out how to enforce Medicaid work requirements — and many are still making it up as they go, even as the January 2027 deadline for full implementation closes in fast.
A sweeping KFF survey of Medicaid officials in 42 states and Washington, D.C., released Wednesday, lays bare just how unprepared most states are to carry out one of the most significant changes to Medicaid in decades. And for nursing homes that rely heavily on Medicaid — both to fund resident care and, increasingly, to source their workforce — the chaos at the state level could have real consequences.
A Deadline, But No Roadmap
Under the One Big Beautiful Bill Act signed by President Trump, adult Medicaid enrollees in expansion states must prove they’re working, in school, or doing community service for at least 80 hours a month — or lose their coverage. The law kicks in nationally on Jan. 1, 2027.
The problem? Federal guidance isn’t expected until June. States are moving forward anyway, but they’re doing so without the key definitions they need. As of March, 21 states hadn’t even settled on a definition for “medical frailty” — the condition that would exempt a beneficiary from the requirement. That’s a significant gap, because the law’s hardship exemptions include people admitted to a hospital or nursing home. How those exemptions get applied will directly affect who can keep their coverage while receiving long-term care.
“A lot of states are working on a super-condensed timeline,” said KFF policy analyst Amaya Diana. They are “still making these big decisions with less than a year before implementation.”
Dr. Oz Weighs In
CMS Administrator Mehmet Oz told industry reporters this week that he doesn’t want states allowing people to simply self-attest to medical frailty. “We don’t like self-attesting,” he said. “Documentation is critical.”
That’s a stricter standard than many states were planning for — and it has echoes of what happened when Arkansas briefly ran a work requirement program years ago. Most of the people who lost coverage there didn’t fail to meet the requirement. They lost it because they couldn’t navigate the paperwork in time.
What It Means for Nursing Homes
The nursing home connection runs in two directions. On the resident side, the law includes a hardship exemption for people admitted to hospitals or nursing facilities, but it’s up to individual states to decide how broadly to apply it. Two states — Iowa and Indiana — aren’t planning to adopt any hardship exemptions at all.
On the workforce side, Medicaid coverage is essential for many of the lower-income adults who work in nursing homes. If those workers lose coverage due to enrollment errors or verification failures, the churn could ripple into an already tight labor market.
Six states plan to use artificial intelligence to help process work requirement verification — handling documents, comparing beneficiary data, or interacting directly with enrollees to help them submit records. Whether that speeds things up or creates new points of failure remains to be seen.
A National Rollout, but No National Standard
Nebraska launched its program May 1, becoming the first state in the nation to enforce Medicaid work requirements under the new law. It issued a list of thousands of qualifying health conditions that could exempt enrollees as “medically frail.” Most states aren’t that far along.
The Congressional Budget Office projects work requirements will cut federal Medicaid spending by $326 billion over a decade and leave 4.8 million more people uninsured by 2034. For nursing home operators, the stakes are concrete: fewer insured patients, potential coverage gaps during transitions, and more administrative work validating who qualifies for care under a patchwork of state rules.
Providers don’t have long to get ready. Most adults on Medicaid will have to reverify their compliance every six months — some quarterly — starting next year.
