Georgia, Tennessee and Wisconsin have spent more than a decade as three of the states that refused to expand Medicaid under the Affordable Care Act. That decision does not shield either state’s Medicaid program from the newest federal mandate. Starting January 2027, all three have to run the same 80-hour-a-month work test that expansion states do, because a meaningful share of their own adult enrollees are covered through a different pathway that Washington now treats exactly the same way for this purpose.
How Three States That Never Expanded Medicaid Got Pulled In Anyway
The work requirement created by the 2025 federal reconciliation law was written to apply to the Affordable Care Act’s Medicaid expansion group, the population of low-income adults that 40 states and the District of Columbia added coverage for after 2014. Georgia, Tennessee and Wisconsin are not among them; all three declined to expand Medicaid under the ACA. But CMS’s interim final rule, issued June 1, 2026 and published in the Federal Register on June 3, defines who counts as an “applicable individual” to include not just the expansion group but also enrollees in certain Section 1115 demonstration waivers that CMS says provide the same kind of minimum essential coverage to adult beneficiaries. According to CMS’s own fact sheet on the rule, that combination brings the total to 43 states and the District of Columbia, a count KFF’s July 2026 outreach-requirements brief rounds to 44 states when it lists Georgia, Tennessee and Wisconsin by name as the non-expansion states caught by the waiver pathway. Neither source treats the discrepancy as a dispute over the underlying count; it reflects only whether the District of Columbia is spoken of as a “state” for the purpose of a quick headline number.
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The 1115 Waiver Pathway That Doesn’t Care About Expansion Status
Section 1115 of the Social Security Act lets states run demonstration programs that go beyond standard Medicaid rules, and several non-expansion states have used that authority to cover working-age adults who would otherwise fall into a coverage gap, without ever formally adopting the ACA’s expansion group. CMS’s rule treats a demonstration that provides that kind of adult coverage as functionally equivalent to expansion coverage for work-requirement purposes, regardless of whether the state ever expanded Medicaid in the way most people mean that term. That is the mechanism that pulls Georgia, Tennessee and Wisconsin enrollees into the same 80-hour standard as someone covered under a traditional expansion group in California or New York.
It also means a state’s political decision to reject ACA expansion did not shield its Medicaid program from this particular federal requirement. The work requirement rides in through whichever coverage pathway a state actually used to cover adults, not through the label the state gave that pathway.
This is a distinction with real consequences for how each state now has to build its notice and verification systems. A state that expanded Medicaid in the conventional way already has years of experience running an expansion-group eligibility system, including the data infrastructure to track income and enrollment for that population. A state that instead relied on an 1115 waiver to cover a narrower slice of adults built that infrastructure for a different, often smaller and more specialized population, which means Georgia, Tennessee and Wisconsin are adapting waiver-specific systems that were never designed with a nationwide work-requirement mandate in mind.
Eighty Hours a Month, No Matter How a State Reached the Coverage
Once someone is swept into the applicable-individual definition, the standard itself doesn’t vary by state or by pathway. CMS’s fact sheet describes the same test everywhere it applies: 80 hours a month of work, community service, or a qualifying work program; half-time enrollment in an educational program; a combination of activities that adds up to 80 hours; or monthly income of at least 80 times the federal minimum wage, which comes to $580 in 2026. The same mandatory exemptions apply too, covering people who are pregnant or postpartum, medically frail, caregivers of a young child or a disabled family member, veterans with a total disability rating, American Indians and Alaska Natives, and several other specified groups. A 1115 waiver enrollee in Tennessee who is exempt for one of those reasons is exempt on exactly the same terms as an expansion enrollee in Ohio. If a state cannot verify that a non-exempt enrollee met the standard, the rule requires a notice of noncompliance and gives that person 30 calendar days to show they qualify or that an exemption applies before coverage is denied or ended, the same cure period that applies in every other covered state.
What Georgia, Tennessee and Wisconsin Enrollees Should Watch For
Enrollees covered through a waiver program in a non-expansion state have less reason to expect this notice than someone in a state where expansion, and the debate around it, has been front-page news for a decade. That is exactly the gap KFF’s outreach research flags as a communication risk nationally, and it applies with extra force here: a waiver enrollee who has never heard the phrase “Medicaid expansion” applied to their own coverage may not connect a work-requirement notice to their own case at all. The requirement starts January 1, 2027, the same date as everywhere else, and the same outreach notice rules apply regardless of the pathway that got someone covered. Reading the notice’s fine print on which specific waiver or eligibility group it references, rather than assuming a state’s non-expansion status settles the question, is the only reliable way for someone in one of these three states to know where they actually stand.
This article was produced with AI assistance and reviewed by a human editor. Figures are linked to their primary sources; where a claim could not be verified from the public record, we say so.
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