Medicaid expansion adults between 19 and 64 are about to find out what 80 hours a month looks like on paper. States must generally have the new work requirement running no later than January 1, 2027, and in most of them the first month that counts is December 2026, the month before. Nebraska and Montana did not wait for the deadline and have already moved ahead of it.
The new Medicaid work requirement and who is exempt, plus a renewal document checklist. Both sit inside The SNAP & Medicaid Renewal Organizer, built for households sorting out what a state will ask them to prove.
Open the Medicaid work-requirement exemptions and document checklist →
The interim final rule that sets the January 1 date
The federal rule behind all of this is an interim final rule with comment period, published in the Federal Register on June 3, 2026 and effective July 31, 2026. It is in force now, not a proposal. The Centers for Medicare & Medicaid Services says in its fact sheet on the rule that states “must generally implement this requirement no later than January 1, 2027,” or on an earlier date a state picks for itself.
The word “generally” matters. The rule lets states facing implementation trouble ask for temporary relief on timing, so January 1 is the federal default rather than a promise that every state flips the switch that day.
The requirement reaches non-pregnant adults aged 19 to 64 who are not entitled to or enrolled in Medicare and who are covered through Medicaid expansion. The measure is 80 hours per month of qualifying activity, and CMS says an individual may combine activities to reach it.
Why December 2026 is the first month on the calendar
The December claim does not come from the rule text itself. It comes from timing that Anna Mudumala and Jennifer Tolbert of KFF worked out from state plans in a July 24, 2026 fact sheet. Federal law requires outreach notices to go out three months before the first lookback month. For states using a one-month lookback, KFF writes, “the first lookback month is December 2026; therefore, outreach notices must be sent in September.”
That describes most states, though not all. KFF counted 36 states that had made a decision and planned to look back one month when verifying compliance at an application. Idaho and Indiana planned a three-month lookback instead, which pushes their first counted month earlier and their notices earlier too. Under the CMS fact sheet, states check compliance at application and at renewal, and may check more often if they choose.
So a household in a one-month-lookback state that applies or renews in January 2027 is, in practice, being asked about December. Hours worked or volunteered that month are the ones a caseworker will look for.
Which states are already running it
Nebraska and Montana have implemented ahead of the federal date. KFF notes that Nebraska sent its notice in December 2025, and Montana filed a state plan amendment to start early. Colorado, Idaho, Missouri, Louisiana and Wisconsin have launched pages about the requirement, and New Jersey, West Virginia, Louisiana and Wisconsin have put screening tools online, according to the same KFF fact sheet.
Outreach is also getting loud in places. KFF lists paid media planned in New Mexico, social media and paid media in Rhode Island, and transit advertising and health fairs in the District of Columbia. A household that has not heard anything by autumn is likely to hear soon, since the notices must name who is subject, how to comply and what happens on noncompliance, and must arrive by regular mail plus at least one other channel.
What counts toward the 80 hours a month
CMS lists four qualifying routes: employment, participation in certain work programs, community service, or enrollment in an educational program at least half time. Hours from different routes can be added together, so 50 hours of work and 30 hours of volunteering meet the same bar as 80 hours on a job.
Pay can substitute for hours. CMS says an individual can instead earn at least 80 times the federal hourly minimum wage, which it puts at $580 per month in 2026. KFF found that Colorado’s and Idaho’s websites both say earning at least $580 from paid work verifies compliance, which spares a worker with a steady paycheck from tracking a time sheet.
Who is exempt from the work requirement
The CMS fact sheet names several groups outside the rule:
- people who are pregnant or in a postpartum period;
- people who are disabled or medically frail;
- parents and caretakers of children under 14, or of people with disabilities;
- American Indians and Alaska Natives.
The Federal Register text carries the full set of exempt categories, including the definitions a state uses to decide who is medically frail. The exemptions are a status the state has to recognize, which is why the notice and screening tools matter: an exempt person who never responds can still be flagged as out of compliance.
What a household has to produce, and the 30-day cure window
When a state cannot confirm compliance from its own data, CMS says it must “provide the individual with 30 calendar days to demonstrate compliance” before coverage is cut. That is the cure period, and it starts only after the state has told the household it could not verify the hours.
The proof is concrete: pay records reaching the $580 mark, an employer or program letter showing hours, a volunteer coordinator’s sign-off, a school enrollment record, or documentation of an exemption such as a medical-frailty finding or a child’s age. The federal sources do not give a single national document list, so each state’s notice is the controlling instruction.
One-month and three-month lookbacks, state-by-state proof rules and a 30-day clock
The friction is that the same federal rule becomes different paperwork depending on the state. A one-month lookback in most states means a single month, December 2026, decides an application filed in January. A three-month lookback in Idaho and Indiana means three months of records. KFF found state websites already differ on the shortcut, with Colorado and Idaho pointing to the $580 earnings figure.
Two clocks can also overlap. A state notice arrives in September or later, the first lookback month passes in December, a renewal or application follows, and if the state cannot verify compliance the 30 calendar days to cure begin. A household holding a mix of part-time work, volunteer hours and a possible exemption has to decide which proof answers which request.
The official route costs nothing. Each state Medicaid agency sends the notice and takes the documents directly, and a household can respond without paid help.
Sorting December hours and exemptions before a state asks
The 80-hour rule, the January 1 start and the 30-day cure window leave a household with a documentation job: working out which activities count, whether an exemption applies, and which proof to hold for the lookback month. That job differs by state and is the part the federal rule leaves to each Medicaid agency.
The SNAP & Medicaid Renewal Organizer includes the new Medicaid work requirement and who is exempt, a renewal document checklist, 51 state packs and a renewal and reporting calendar for keeping dates and records in one place.
Line up the proof for a lookback month and the 30-day cure window →
This piece was drafted with AI assistance; the dates, hours and exemptions were checked against the CMS fact sheet, the Federal Register rule and KFF’s state tracker.
