Twenty-five Democratic-led states plus the District of Columbia have sued the Trump administration over its new work requirements for people who get their health insurance through Medicaid.

At issue is a “medically frail” designation that the states say is too narrow and will make it too difficult for ill and disabled people to remain on Medicaid.

They’re challenging the administration’s guidance on who can be exempt from the work requirements included in the so-called One Big Beautiful Bill Act, the broad tax and spending measure President Donald Trump signed a year ago.

Medicaid is the publicly-funded health insurance for people with low incomes. Under the One Big Beautiful Bill Act, states that have expanded Medicaid eligibility to more adults under the Affordable Care Act — 40 states plus the District of Columbia — must require those adults to prove they’re working, going to school or serving their communities for at least 80 hours a month to receive Medicaid. Georgia, Tennessee, and Wisconsin, which have used federal waivers to expand their Medicaid programs, are also subject to the new work rules.

The new lawsuit specifically targets new federal guidance that narrows the definition of who can qualify as “medically frail,” a key exemption used to excuse Medicaid recipients from work requirements if they have serious disabilities or illnesses. The guidance came in the form of an interim final rule published this month by the U.S. Department of Health and Human Services and the Centers for Medicare and Medicaid Services (CMS).

The Democratic attorneys general and governors who are plaintiffs in the suit claim the feds surprised them with this new rule months after they’d already been working with CMS on how to implement the work requirements.

“This eleventh-hour attempt to further narrow protections for medically frail Medicaid recipients seeks to punish those who cannot fend for themselves,” said Rhode Island Attorney General Peter Neronha, a Democrat, in a statement.

“Further, this Administration is once again attempting to sidestep Congress by unlawfully reinterpreting the law, and coercing the states to rush to implement their last-minute changes or face penalties,” he said.

To qualify as “medically frail” and therefore exempt from work requirements, the new guidance says, a Medicaid recipient must have a significant health condition and be significantly impaired in their ability to work. It’s a distinction the states say Congress did not make in the One Big Beautiful Bill Act.

The states also claim the new guidance violates federal law by ignoring evidence that work requirements cause people to lose coverage due to red tape.

For example, Arkansas tried instituting work requirements for Medicaid recipients in 2018, during Trump’s first term. A federal judge halted the policy less than a year later, after 18,000 adults had lost coverage. Studies later found that Arkansas’ work requirements didn’t increase employment. A recent analysis from the Urban Institute projects that 3-7 million people could lose coverage because of the new work requirements.

Supporters of the new work rules say they are sufficiently flexible and that the category of who qualifies as “medically frail” remains broad.

“This rule helps Americans build skills and independence through work, education, job training, or community service, creating new opportunities for themselves and their families,” said Dr. Mehmet Oz, director for the Centers for Medicare & Medicaid Services, in a statement earlier this month announcing the new guidance.

The lawsuit says states have already invested significant resources into implementing the new work requirements based on the original law’s language and prior federal guidance. They’re staring down an August 31, 2026, deadline for notifying Medicaid recipients about changes to the “medically frail” designation, a timeline the states say is not workable. They face financial penalties for not meeting the deadline.

States are expected to put the new work requirements into place by January 1, 2027, though the feds could choose to grant them temporary extensions through 2028.

The lawsuit was filed by the attorneys general of Arizona, California, Colorado, Connecticut, Delaware, the District of Columbia, Hawaii, Illinois, Maine, Maryland, Massachusetts, Michigan, Minnesota, Nevada, New Jersey, New Mexico, New York, North Carolina, Oregon, Rhode Island, Vermont, Virginia, Washington and Wisconsin, as well as the governors of Kentucky and Pennsylvania.

Stateline reporter Anna Claire Vollers can be reached at avollers@stateline.org.

The state health department has launched a new webpage to explain the federal work requirement for some Medicaid recipients that will take effect in 2027.

The Wisconsin Department of Health Services is still reviewing the federal rule, released on June 1, governing how states are to implement the work requirements, a spokesperson said. Medicaid is known as BadgerCare in Wisconsin.

On June 5, DHS posted a Federal Medicaid Work Requirement webpage with general information about the requirement, including when it takes effect, how participants in Medicaid might meet the requirement, and reasons people might be exempt from meeting it.

The DHS work requirement page also includes a screening tool that people can use to advise them whether they might have to meet the new requirement.

The screener is intended only as information, according to DHS. It is not an application form and the result it provides is not an official decision about coverage for the person completing the form.

A disclaimer on the first page of the screening form states, “No matter what the results of this tool say, you should still watch your mail for letters, read them, and follow all directions. If we ask you to send information or documents, it is important that you do so right away. If you don’t, you could lose your health care coverage.”

The tax and spending megabill HR 1, passed by congressional Republicans and signed on July 4, 2025, by President Donald Trump, added the work requirement for Medicaid participants who gained healthcare coverage through Medicaid expansion under the 2010 Affordable Care Act.

While Wisconsin did not adopt the full ACA expansion, the state added childless adults whose incomes are at or below the federal poverty guideline to its Medicaid program. About 190,000 childless adults in Wisconsin were covered by BadgerCare in April, according to DHS.

“If you could be affected by the federal work requirement, we’ll send you a letter in August or September to explain what you need to know and what will happen next,” the webpage states.

Under the federal requirement, childless adults ages 19 to 64 must report at least 80 hours of work or volunteer service in a month, or enrollment in education or a workplace training program, to qualify for Medicaid.

The requirement also provides for exemptions due to certain health conditions or other factors.

After the federal government issued its work requirement implementation rule June 1, advocates said it imposed stringent terms that will make it more difficult for people to remain covered by Medicaid, even if they fully qualify.

In an analysis published Tuesday at the Substack newsletter “Can We Still Govern?” Chloe East of the University of Colorado and Adrianna McIntyre of Harvard University wrote that research showed work requirements imposed in Arkansas in 2018 during the first Trump administration “had no positive effect on employment and made participants worse off.”

The paper was written in response to a new federal report from the Trump administration asserting that work requirements would “incentivize employment” and “reduce poverty.”

East and McIntyre wrote that the report’s assumptions were not supported by research literature on work requirements for Medicaid and federal nutrition aid programs (SNAP).

“One consistent finding across dozens of papers on work requirements is that they reduce program participation among vulnerable individuals and households,” East and McIntyre wrote.

The federal government released new guidance this week on how states should roll out the Medicaid work requirements that will affect  healthcare coverage for millions of Americans.

The new interim rule, issued by the federal Centers for Medicare & Medicaid Services, is intended to give states more details on how they’re supposed to verify the work status for about 20 million adults enrolled in Medicaid, the publicly funded health insurance program for people with low incomes.

The new details come as states are staring down the January 1, 2027, deadline to put the new work requirements in place, and have requested more clarity from the feds on how they’re supposed to implement them.

“States are being asked to carry out a complicated federal mandate without clear rules, without enough time, and with the risk that eligible people lose health care because of paperwork problems and system failures,” Oregon Democratic Gov. Tina Kotek said last week in a statement.

Kotek led a six-state coalition of Democratic governors in asking the Trump administration last week to slow the rollout of the new work requirements, calling the timeline unworkable.

Congress built the new work requirements into last year’s so-called One Big Beautiful Bill Act. Under the measure, states that have expanded Medicaid eligibility to more adults under the Affordable Care Act — 40 states plus the District of Columbia and another two that have partially expanded — will have to require those adults to prove they’re working, going to school or serving their communities for at least 80 hours a month to receive Medicaid.

The rules released this week are intended to clarify key parts of the new law, including exemptions for people who are considered “medically frail,” how to reach out to Medicaid beneficiaries, and methods for verifying Medicaid eligibility.

“This rule helps Americans build skills and independence through work, education, job training, or community service, creating new opportunities for themselves and their families,” said Dr. Mehmet Oz, director for the Centers for Medicare & Medicaid Services, in a statement announcing the new guidance.

But critics of work requirements point to evidence that it kicks people off Medicaid who are otherwise entitled to it without meaningfully increasing the share of adults who are working.

For example, Arkansas tried instituting work requirements for Medicaid recipients during Trump’s first term in 2018. By the time a federal judge halted the policy less than a year later, 18,000 adults had already lost coverage and reported problems paying off medical debt, delaying healthcare and delaying medications due to cost. Studies later found that Arkansas’ work requirements didn’t increase employment. And data shows that most adults on Medicaid under age 65 are already working.

Supporters say the new requirements are flexible. They say the feds have created a broad category of “medically frail” people who are exempt from the work requirements, and they’re permitting states to allow people to self-attest that they’re exempt one time before documentation is required.

The new work requirements will apply to about 20 million people who are eligible for Medicaid through expansion, according to estimates from health research organization KFF. These expansion enrollees make up about 30% of all Medicaid enrollees.

A recent analysis from the Urban Institute projects that 3-7 million people could lose coverage because of the new work requirements.

Stateline reporter Anna Claire Vollers can be reached at avollers@stateline.org.

WASHINGTON — State officials say they need more information from the Trump administration before they can fully implement new requirements for Medicaid, according to a survey released Thursday by KFF and the Georgetown University Center for Children and Families.

Republicans’ “big, beautiful” law made several changes to the state-federal health program for lower income people and some people with disabilities, including that enrollees between the ages of 19 and 65 work, participate in community service, or attend an education program for at least 80 hours a month.

The survey of Medicaid program officials from 43 states showed the people tasked with implementing the law have questions about how exactly they should determine if someone meets the new requirements or is exempt. 

“In addition to how to define medical frailty, states wanted additional direction in many areas including what qualifies as community service, how to calculate half-time school attendance, and what is considered a ‘significant relationship’ to qualify for the caregiver exemption,” the report states. “They also indicated they need guidance about what sources can be used for verification, whether self-attestation will be allowed if other sources are not available, and how long verification of exemptions remain valid.”

The law includes several additional carve-outs, including for Medicaid enrollees who are pregnant, have dependent children, are tribal community members or are in the foster care system, and for individuals released from incarceration in the last 90 days, among others.

The vast majority of state officials surveyed said they would implement the new requirement for work, education, or community service at the start of next year.

There are, however, a few states moving forward earlier. 

Nebraska plans to begin May 1, Montana on July 1 and Iowa officials said they will begin this year, though they haven’t provided a date, KFF said. Arkansas has planned a “soft launch” for July but won’t actually remove anyone from Medicaid for not meeting the new requirements until next year, according to the report.

Hardship exemptions

The KFF-Georgetown survey says that nearly all states will allow hardship exemptions for people in counties with higher unemployment; those who recently experienced a natural disaster; those who have been admitted to a hospital or nursing facility; or those who need to travel outside their community for medical care.

Indiana and Iowa are the only two states so far that don’t intend to allow any hardship exceptions from the requirement that Medicaid enrollees work, attend community service, or enroll in an education program, the report said. 

“Oklahoma is not adopting the exceptions for residents of counties with high unemployment or with a declared natural disaster while Missouri is not adopting the exception for residents of counties with high unemployment,” the report says. “New York is not planning to adopt the exception for individuals traveling outside their community for medical care. Twelve states had not made a decision.”

Look-back periods vary

Thirty-six states will look back one month when someone applies for Medicaid to determine whether they’re working, participating in community service, or enrolled in an education program. Indiana and Idaho will look back at the last three months before the person applied to determine whether they meet the new requirement. 

Thirty-four states will look back one month during the renewal process, which must happen at least every six months under the law. 

“Indiana and New Hampshire will check quarterly and at renewal to verify that enrollees meet the requirements every month between renewals,” according to the report. “Arkansas will also look back three months at renewal but is not planning quarterly checks. States that had not made a decision at the time of the survey included five states for application, six states for renewal, and seven states for more frequent checks.”