At least six states—Arkansas, Idaho, Indiana, New Hampshire, North Carolina, and Ohio—will require Medicaid recipients to provide immediate documentation to prove they are too sick to fulfill new work requirements. These requirements, set to begin in January 2027, are part of the One Big Beautiful Bill Act, a 2025 federal tax and policy law. While federal regulations allow states to accept a recipient's word for their medical status during the first year of the program, these states have implemented policies or laws that prohibit this practice, known as self-attestation.
The new mandate applies to approximately 20 million lower-income adults without children at home who are enrolled in Medicaid through the optional expansion adopted by 40 states and the District of Columbia. Under the law, beneficiaries must work or volunteer for at least 80 hours per month or attend school at least half-time to maintain their health coverage. Exceptions are provided for individuals classified as "medically frail," which includes those with disabilities, substance use disorders, or serious medical conditions. The Congressional Budget Office estimated in 2025 that the Medicaid changes would save the federal government $887 billion over a decade while resulting in 7.5 million fewer insured people.
In June 2026, the Centers for Medicare and Medicaid Services (CMS) published an interim final rule specifying that a condition must "significantly impair" a person's ability to work to qualify for an exemption. On September 18, 2026, five Medicaid enrollees and several provider groups, including the American College of Physicians and the American Academy of Pediatrics, filed a lawsuit challenging this rule. The plaintiffs argue the rule creates onerous steps for enrollees and forces doctors to perform work-capacity assessments that are outside their typical therapeutic relationship. This follows a July 31, 2026, court decision that dismissed a separate lawsuit brought by 25 states and Washington, D.C., which also challenged the medical frailty definitions.
The impact extends to health care providers and state administrative systems. Clinicians in affected states will be required to certify the medical status of patients to maintain their insurance eligibility, a task that provider groups argue diverts time from direct patient care. States are also expected to spend millions of dollars to upgrade computer systems to track these requirements. Precedent for administrative challenges exists; in Arizona, enrollment in the Supplemental Nutrition Assistance Program (SNAP) fell by 55% between April 2025 and April 2026, which the state attributed to the difficulties of implementing similar federal verification requirements.
What happens next depends on the outcome of the lawsuit filed in September 2026, which seeks to stay the CMS policy. If the current rules remain, Medicaid enrollees will notice the changes in January 2027 when the work requirements officially take effect. Starting in 2028, federal rules will permit states to accept self-attestation only once per enrollment period, with full documentation required at least every 12 months thereafter. States are expected to increasingly rely on third-party data, such as workers' compensation and prescription records, to verify claims of medical frailty. Missouri legislators have indicated they intend to reintroduce similar documentation requirements in their state during the next legislative session.