Work requirements for some Medicaid recipients begin in January across the United States. This is the result of President Donald Trump’s big tax cut and 2025 guidelines law, and a handful of Republican-led states are adopting stricter rules than the law requires.
The question is how someone can prove that they are medically too weak work. While federal regulations say the state can rely on the recipient’s word for the first year, at least six states require documentation immediately. There are ongoing efforts in other countries to eventually follow this example.
Advocates say that could cause problems, particularly for new applicants to the joint state-federal low-income health insurance program.
“Someone may not be able to work, but they can’t see a doctor because they can’t afford it. So now they apply for Medicaid,” said Jennifer Tolbert, director of state health policy and data at the research organization KFF. “But Medicaid says you need documentation from a provider.”
With some Republican-led states taking a tougher approach than necessary to implementing federally mandated changes, Democrats have representation in 25 states complain and claim that the rules are too strict.
Some say that documentary evidence is necessary to prevent fraud
According to the Congressional Budget Office’s 2025 estimate, the federal government’s Medicaid changes are expected to save $887 billion over the next decade and result in 7.5 million fewer people having health insurance.
The conservative Foundation for Government Accountability has urged states not to make it easy for people to avoid work requirements, saying able-bodied adults drive up enrollment and costs.
Jonathan Ingram, the group’s vice president of research and policy, has encouraged states not to rely on a beneficiary’s word, a process known as self-certification.
“Self-certification is intentional fraud,” he said via email. “It is a policy designed by bureaucrats to maximize enrollment at the expense of program integrity.”
Self-testification is punishable by perjury, so people who lie can be prosecuted – although such charges are rare.
Arkansas, Idaho, Indiana, New Hampshire, North Carolina and Ohio all have laws or policies that prohibit self-certification in order to qualify for the work requirement exception starting next year.
Missouri Republican Rep. Darin Chappell said he worked with the Foundation for Government Accountability to draft a proposed amendment that would have enshrined Medicaid work requirements in the state constitution. It would have required “documentary evidence” of work or reasons for exceptions, particularly a ban on self-certification.
The amendment passed the Missouri House of Representatives but failed without a vote in the Senate. Chappell plans to try again next year.
“If someone has a debilitating physical condition – or even a psychological condition – that prevents them from working, that’s completely legitimate,” he said. “But we don’t take anyone’s word for it. I don’t want to shock you, but people tend to lie about things like this.”
Most non-disabled benefit recipients under age 65 are already working
The new mandate applies to up to 20 million low-income adults without children at home who are enrolled in Medicaid through an optional expansion to 40 states and the District of Columbia. The requirement does not apply in the 10 states, primarily in the South, that have not expanded Medicaid.
Beneficiaries must work or volunteer at least 80 hours each month or be in school at least half-time to qualify, with the exception of situations such as medical frailty.
The law stated that medically frail people included those suffering from substance use disorders, disabilities or serious illnesses. But the Centers for Medicare and Medicaid Services published a rule In June, the law went further and was stricter than states and providers expected, saying a person’s condition must “significantly affect” their ability to work, volunteer or attend school, as required for an exemption.
Currently, states typically decide once a year whether Medicaid recipients remain eligible for benefits. The new law requires this to happen twice for most enrollees.
Starting in 2028, states will only be allowed to accept self-certification once each time a person enrolls. Documentation would be required at least every 12 months thereafter to confirm that the condition still exists and is still preventing her from working.
The government expects states to increasingly rely on third-party data to make decisions – such as workers’ compensation claims or prescription information. For illnesses that do not appear in the databases, states may require a medical certificate, a notice of recognition of a disability or other proof.
While states have increased their use of this information, work requirements are still a major game changer and many will do so for now Spend millions of dollars Improving their computer systems.
States are already struggling in some cases to make changes to the Supplemental Nutrition Assistance (SNAP) program required under Trump’s law, including an expanded work requirement.
In Arizona, for example, enrollment fell 55% from April 2025 to April 2026 — the largest decline in the nation — and more than 400,000 fewer people are now receiving benefits. Last month, said the state This was largely due to difficulties implementing new federal requirements, which resulted in higher call volumes and additional scrutiny.
Patient advocates fear qualified people will be denied help
Ingram said some of the concerns about eliminating self-certification are overblown and that people could receive diagnoses to prove their inability to work in many places, including charity clinics and federally qualified health centers. He also noted that Medicaid allows retroactive coverage for doctor visits that occur before enrollment.
Patient advocates say it’s not that simple.
“The additional paperwork and hurdles you have to jump through leads to loss of coverage,” said Nate Crippes, an attorney at the Disability Law Center in Utah, where a law provisionally allows self-certification to qualify for the work requirement exception.
An additional challenge is that most people in the Medicaid expansion group in his state have been diagnosed with a mental illness or a substance use disorder — or both.
“We choose to get people with health issues to overcome a series of hurdles,” said Camille Richoux, director of health policy at Arkansas Advocates for Children and Families.
It can be difficult if states decide to partially rely on patient diagnosis codes to determine whether recipients are fit to work.
Lucy Dagneau, senior director of the state and local campaigns team at the American Cancer Society’s Cancer Action Network, said the codes do not indicate the severity of a disease. For example, some patients with a particular cancer may continue to work, but others who are at a more advanced stage may not.
“Our concern is that by banning self-certification, unfortunately, state legislatures that pass these laws will contribute to more people in their state losing their insurance coverage than would otherwise be the case,” she said.