State of the States: Medicaid Work Requirements
With the change in administrations at the federal level, there has been a resurgence of activity around work and community engagement requirement waivers. Twenty-two states have previously sought and/or secured approval from the Centers for Medicare and Medicaid Services (CMS) for such waivers and, since January 2025, several states have taken steps to re-engage or newly engage around these waivers. In recent months, states have introduced legislation requiring submission of a waiver application, indicating they plan to submit new waiver applications, or submitted a waiver application to CMS. While a federal bill that would make work requirements a mandatory component of all state Medicaid programs is working its way through Congress – and is the focus of another article this month – this article provides an overview of state activity across the country.
Pending 1115 Demonstration Waivers & Waiver Amendments
Since January 2025, three states (Arizona, Arkansas, and Ohio) have submitted Section 1115 Demonstration Waivers and waiver amendments, and one state (Georgia) has submitted a waiver extension request to CMS. These states propose to take varying approaches to incorporating work requirements into their Medicaid programs, and their applications reflect lessons learned from initial attempts to implement work requirements:
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Ohio and Arkansas propose to leverage data in unique ways:
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- Arkansas’s waiver amendment requires able-bodied adults who are eligible through the new adult expansion to satisfy work requirements. The state’s Medicaid program will leverage data matching to identify individuals who are “not on track towards meeting their personal health and economic goals” to support them through “Success Coaching.”
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- Ohio’s waiver application does not include any hourly or reporting requirements and proposes to leverage state data to identify individuals who satisfy one or more of the criteria listed above. Ohio plans to presume employment for individuals with household earned income and intensive physical or mental health status for individuals who have applied for/enrolled in another program that has disability as a basis for enrollment. Ohio Benefits data will be used to verify the eligibility requirements outlined above, and a third-party vendor will be used to verify eligibility requirements for those whose status cannot be confirmed through state data.
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Arkansas and Georgia incorporate lessons learned into their revised work requirement proposals:
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- Arkansas’ takeaways include “providing clear communications through multiple means, simplicity in design, the need for personal interaction rather than over-reliance on technology… [and] the limitation of data matching.” Arkansas proposes to incorporate these lessons learned by streamlining new programmatic requirements and applying them to the entire population rather than phasing in requirements and exempting certain groups. Additionally, Arkansas seeks to leverage data matching and regular audits of activity and income in lieu of monthly reporting requirements, although the state will not rely solely on this data to assess individuals’ needs.
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- Georgia’s Independent Evaluator recommended that the state (1) amplify outreach and engagement efforts by investing in a tailored outreach and engagement; (2) expand eligibility opportunities by modifying qualifying activities; (3) reduce administrative burden and potential gaps in coverage by calculating qualifying hours on a bi-annual basis or annualizing the hours requirements. Taking these recommendations into account, Georgia’s extension application seeks to add caregiving of a Medicaid-eligible child up to age 6 to the QHA list, in addition to compliance with Supplemental Nutrition Assistance Program (SNAP) Able-Bodied Adults Without Dependents (ABAWD) program. Additionally, the extension application also proposes to change the hours’ reporting requirement from monthly to annually and lift the requirement that members provide self-attestation of activity hours on a monthly basis.
State-Level Activity
Several other states have taken preliminary steps toward submitting waiver applications to CMS, including Iowa, South Carolina, South Dakota, and Utah, each of which has a waiver out for public comment prior to submission to CMS. Indiana, Idaho and North Carolina have seen work requirements activity through their legislatures. States interested in learning more about how to design, implement, and evaluate work requirements under a Section 1115 Demonstration Waiver should review PCG’s Work Requirements and Community Engagement Toolkit.