Medicaid Work Requirements: State Implementation and Waiver Status

Medicaid Work Requirements: Navigating the 2027 Federal Mandate

The landscape of healthcare access in the United States is undergoing a significant transition. Following the passage of the 2025 reconciliation law, states are now preparing for a major shift in how Medicaid eligibility is determined for adults within the ACA Medicaid expansion group. The new federal mandate requires these individuals to meet specific work requirements to maintain their coverage.

While the federal deadline for full alignment is January 1, 2027, the rollout is already beginning in several states through alternative regulatory pathways. Understanding these mechanisms is essential for patients and providers navigating the evolving requirements of the Medicaid program.

The Dual Pathways to Implementation: SPAs and 1115 Waivers

States have two primary methods to implement work requirements before the 2027 federal deadline: State Plan Amendments (SPAs) and 1115 waivers.

State Plan Amendments (SPAs)

A State Plan Amendment allows a state to change how it administers its Medicaid program. Several states have opted for this route to begin enforcing work requirements ahead of schedule:

• Nebraska: The first state to announce early enforcement, with requirements having gone into effect on May 1, 2026.
• Montana: Indicated it will begin enforcing requirements on July 1, 2026.
• Iowa: Scheduled to implement its requirements on December 1, 2026.

1115 Waivers

States may also seek to implement work requirements through an 1115 waiver. Since the beginning of the second Trump administration, multiple states have submitted waiver requests to facilitate this transition. However, the regulatory landscape remains complex. Some states are pivoting away from 1115 waivers in favor of SPAs, or because the passage of the federal law has rendered certain proposed waivers redundant.

A significant point of uncertainty involves how the Centers for Medicare & Medicaid Services (CMS) will handle pending 1115 waivers that attempt to deviate from the specific federal requirements established by the 2025 law. As of now, it remains unclear how CMS will treat these applications prior to the 2027 deadline.

The Georgia Precedent

Currently, Georgia stands as the only state with a Medicaid work requirement waiver currently in place, a situation resulting from previous litigation regarding the Biden administration’s attempts to block such requirements.

CMS recently granted a temporary extension for Georgia’s waiver, which included the addition of new exemptions from work requirements. Despite this extension, Georgia’s current waiver is set to expire on December 31, 2026. By January 1, 2027, the state will be required to comply fully with the new federal work requirements.

Key Takeaways for Medicaid Recipients

• The 2027 Deadline: All states must comply with federal work requirements for the ACA expansion group by January 1, 2027.
• Early Implementation: States like Nebraska, Montana and Iowa are implementing these requirements well before the federal deadline.
• Regulatory Uncertainty: The status of pending 1115 waivers that deviate from federal law is currently uncertain.
• Georgia’s Status: Georgia is operating under a temporary extension that expires at the end of 2026.

As states continue to navigate the implementation of these mandates, both healthcare providers and beneficiaries should remain vigilant regarding changes to state-specific eligibility rules. The transition toward these work requirements represents one of the most significant shifts in Medicaid administration in recent years.