Several Republican-led states impose stricter Medicaid work-requirement documentation rules than federal law mandates
Medicaid work requirements mandated by the 2025 federal tax and policy law take effect in January, requiring most non-disabled Medicaid expansion enrollees to work, volunteer, or attend school at least 80 hours per month. The Congressional Budget Office estimated the changes would save the federal government $887 billion over a decade and result in 7.5 million fewer insured people. At least six Republican-led states — Arkansas, Idaho, Indiana, New Hampshire, North Carolina, and Ohio — have enacted laws or policies barring self-attestation for the medical-frailty exemption from the start, going beyond what federal regulations require.
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Medicaid work requirements stemming from President Trump's 2025 tax and policy law are set to begin across the United States in January, affecting up to 20 million lower-income adults without children at home enrolled through the optional Medicaid expansion in 40 states and the District of Columbia. Federal regulations allow states to accept a recipient's word — known as self-attestation — for the first year to prove medical frailty, but a growing number of states are choosing not to offer that option.
Six states have already moved to require documentation immediately rather than permitting self-attestation: Arkansas, Idaho, Indiana, New Hampshire, North Carolina, and Ohio. The conservative Foundation for Government Accountability has been encouraging states to follow that path, with its vice president of research and policy, Jonathan Ingram, describing self-attestation as "fraud-by-design" and a policy that "maximizes enrollment at the expense of program integrity." Self-attestation carries a perjury penalty, though criminal charges for false attestation are rare, according to the AP.
The Centers for Medicare and Medicaid Services published a rule in June that exceeded what states and providers had anticipated, specifying that a condition must "significantly impair" someone's ability to work, volunteer, or attend school to qualify for a medical-frailty exemption — a stricter standard than what the underlying law spelled out. States will also be required to verify eligibility twice a year for most enrollees, up from once annually, and must rely more heavily on third-party data sources such as workers' compensation records and prescription information.