State Medicaid Work Requirements (11 States Are Considering These Bills in 2025)

As states and the federal government look for ways to cut spending, an obvious place to look is one of the largest budget items for all jurisdictions: Medicaid. While actual cuts to services and population are not popular, the addition of work requirements for recipients has been a perennial (though so far unsuccessful), option for budget conscious legislators.

Federal Activity on State Medicaid Work Requirement Waivers

During the first Trump administration, the Centers for Medicare and Medicaid Services (CMS) approved 13 state work requirement waivers. However, Arkansas’ program was the first one to make it to implementation. That plan was adopted in 2018 but was stopped by a federal court after 9 months. This had the effect of freezing the other approvals. Then, when the Biden administration took over, it rescinded all 13 work requirement approvals.

Georgia’s plan began in July 2023 despite the withdrawal of support from CMS, due a court order restoring the waiver. The plan, called Pathways, expands eligibility to parents and legal guardians with incomes at or below 100% of the Federal Poverty Level (FPL) with children ages 0 to 6 and mandates participants to document 80 hours of work, volunteering, education or other approved activities per month. The program was expected to enroll nearly 200,000 Georgians, but currently has closer to 5,000 beneficiaries. 

In 2025, federal money associated with Medicaid may come with new strings. Speaker Johnson has indicated that adding a work requirement is on the table. As the federal government matches anywhere from $.50 to $.90 per state dollar spent on Medicaid, it’s a sizable chunk of the funding that states get for these programs. If the federal government decided to eliminate or curtail those dollars if work requirements were not implemented, it would have very serious consequences for state budgets.

State Legislation on Medicaid Work Requirements 

So far in 2025, 21 bills in 11 states have been introduced that would require some community engagement in order to receive Medicaid benefits (Mississippi’s bill HB 1597 died in committee). Of note, Missouri’s legislation (SJR 43) would enact a constitutional amendment requiring work or community engagement of Medicaid recipients, and Idaho HB 138 which would end Medicaid expansion if work requirements are not approved. Virginia HB 1804, passed both chambers and will be sent to the governor. It instructs the Department of Medicaid Assistance Services to seek approval from CMS for work requirements.

State Regulatory and Agency Activity on Medicaid Work Requirements 

Despite legislative attempts at implementing work requirements, it may be possible for some states to bypass the legislature altogether. Some state Medicaid agencies have the authority to apply for 1115 waivers without legislative approval. Those states may have an easier time of getting work requirements approved as there won’t be a political price for legislators to pay. These states’ governors can direct the agencies to apply for a waiver or state plan amendment. The second Trump administration has indicated it will again approve waivers and amendments that include work requirements. 

Track State Medicaid Policy

The ever-evolving state health policy landscape will continue to influence how health care organizations make business decisions. MultiState’s team pulls from decades of expertise to help you effectively navigate and engage. MultiState’s team understands the issues, knows the key players and organizations, and we harness that expertise to help our clients effectively navigate and engage on their policy priorities. We offer customized strategic solutions to help you develop and execute a proactive multistate agenda focused on your company’s goals. Learn more about our Health Care Policy Practice.