Beginning January 1, 2027, 44 states must tie Medicaid eligibility for adults in the Affordable Care Act expansion group and certain 1115 waiver enrollees to mandatory work requirements under federal legislation. According to the Centers for Medicare and Medicaid Services, implementing these changes requires complex system modifications, targeted enrollee outreach, and extensive communication campaigns across state agencies and managed care plans.
Federal Notice Mandates and Timelines
Federal rules issued by the Centers for Medicare and Medicaid Services establish strict notice requirements for state Medicaid programs. According to the federal guidance, states must send targeted outreach notices to all expansion adults and applicable 1115 waiver enrollees, including individuals who may ultimately qualify for an exemption. This broad notification approach is necessary because state databases often lack sufficient real-time information to determine who is exempt prior to the mailing window, and enrollee circumstances frequently change.
Under the statutory framework, notices must explicitly detail who is subject to the rules, how to comply, and the consequences of noncompliance. States must deliver these notices using at least two different modalities, typically regular mail or an elected electronic format, combined with a secondary method such as phone calls, text messages, or online account alerts. Furthermore, federal regulations mandate that all communications use plain language and remain fully accessible for individuals with limited English proficiency and individuals with disabilities.
Timing depends heavily on state look-back periods. According to a KFF survey fielded between January and March 2026, 36 states plan to look back one month at application to verify compliance, while Idaho and Indiana reported plans to look back three months. For a January 1, 2027 launch date, states using a one-month look-back must deploy notices in September 2026, whereas states with a three-month look-back must begin mailing notices in July 2026.
State Outreach Strategies and Communication Challenges
States are deploying diverse strategies to inform populations while managing operational hurdles. According to state planning documents and Medicaid Advisory Committee meetings, several jurisdictions are experimenting with unique communication formats to prevent confusion.
- Nebraska: Mailed a three-page notice in December 2025 outlining expansion rules, work criteria, and exemptions, though the document omitted the federally required look-back period.
- Montana: Submitted an early state plan amendment requiring notices in April 2026, followed by general letters to all Medicaid enrollees in March and automated text messages during the spring.
- Pennsylvania: Explored using color-coded mailing envelopes—similar to pink renewal envelopes currently in use—to immediately alert enrollment navigators which clients are newly subject to work rules.
- Nevada: Utilized public advisory meetings to test inclusive terminology, discussing alternative phrases like work, school, and volunteer requirements.
Broad public awareness campaigns present significant difficulties. Because work rules apply strictly to adults aged 19 to 64 in expansion and waiver tracks, while exempting pregnant individuals, the medically frail, and parents of young children under age 14, public messaging risks alarming exempt populations. States like New Mexico and Rhode Island are utilizing paid media, radio ads, transit displays, and social media campaigns to reach affected communities without triggering widespread panic among non-affected enrollees.
Call Centers, Digital Tools, and Community Partnerships
As notices land in mailboxes, state call centers face mounting pressure. Existing helplines in states like Nebraska and Delaware operate standard Monday-through-Friday business hours, potentially limiting access for working enrollees. Arkansas has announced plans to conduct proactive outbound calls to remind participants to report changes in circumstance.
To streamline self-service, several states have launched dedicated digital hubs. New Jersey and West Virginia developed unofficial online screening tools to help enrollees check their exemption status, though watchdogs note that tools lacking medical frailty questions may miss certain exemptions. Additionally, states are leaning heavily on community partners.
Illinois launched a comprehensive webinar series for local stakeholders, while Maryland initiated outreach directly to employers to help workers find trusted compliance information. Utah convened a Community Partner Engagement Group to synchronize messaging and establish clear issue-escalation pathways, mirroring collaborative communication networks relied upon during the recent Medicaid unwinding process.
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