Starting December 2026, Medicaid recipients between 19 and 64 who aren’t otherwise exempt must log at least 80 hours per month of “community engagement” — employment, education, job training, or volunteer work — to keep their coverage. The requirement is part of the One Big Beautiful Bill Act, which contains the largest single cut to Medicaid spending in the program’s history: roughly $625 billion over 10 years. The Congressional Budget Office projects 7.8 million people will lose Medicaid coverage as a result.
This isn’t abstract policy. Medicaid covers 90 million Americans. It’s the primary health insurance source for low-income adults, children, pregnant women, elderly nursing home residents, and people with disabilities. The work requirements apply to the adult working-age cohort specifically — but the paperwork burden will affect a much wider group, because the reporting mechanism will require all non-exempt recipients to verify their status each month.
Here’s who gets cut off, who’s exempt, and what the alternatives look like.
The 7.8 million figure deserves context. Many people who lose coverage under work requirements actually do work — they just fail to document it correctly. When Arkansas implemented a state-level Medicaid work requirement in 2018, over 18,000 people lost coverage before a court blocked the program. A study found that the majority of those who lost coverage were actually working or otherwise exempt — they lost coverage because they didn’t navigate the monthly reporting system correctly. A federal program applied at scale is expected to produce the same dynamic.
The people at highest risk are workers in informal or cash-based employment (domestic workers, day laborers, gig workers without formal records), people with inconsistent hours who may fall below 80 hours some months, and adults without reliable internet access to complete online reporting. The requirement starts December 2026, meaning the first round of potential terminations would hit in early 2027 for anyone who doesn’t file their first monthly report.
The law carves out several categories: parents or caregivers of children 13 and younger; pregnant women; full-time students; individuals who are medically frail (including people with serious mental illness, substance use disorder, physical disabilities, or complex medical conditions); veterans with certain service-connected conditions; and people already exempt under another federal program like SNAP. The exemption categories are broad on paper but narrow in practice — qualifying requires documentation, and the documentation burden falls on the recipient.
First: check whether you’re in an exempt category. If you have children under 14, a documented disability, or qualifying veteran status, you likely won’t face the work requirement — but you may still need to verify your exempt status monthly. Contact your state Medicaid office now, before December, to understand the reporting system your state will use.
If you’re in the non-exempt working-age category: start documenting your hours now. Keep records of pay stubs, employer verification letters, volunteer confirmation, or school enrollment. The documentation requirement is retroactive — you’ll need to show compliance for each month, and gaps create termination risk. If you lose coverage and need alternatives, healthcare.gov’s ACA marketplace has open enrollment in November. Community health centers funded by the federal government provide primary care on a sliding-scale fee basis regardless of insurance status.
No. The 80-hour requirement applies only to adults ages 19 to 64 who aren’t in an exempt category. Children’s Medicaid (CHIP) is not directly subject to the work requirement, though the broader funding cuts in the bill may affect states’ CHIP budgets separately.
The law defines community engagement broadly: paid employment, self-employment, job training through a recognized program, vocational education, community service at a nonprofit, or enrollment in an educational institution. The key is that it must be verifiable and meet the 80-hour monthly minimum.