The Implementation Crunch: States Race to Launch Medicaid Work Requirements
This article is part of our ongoing series examining the new Medicaid eligibility requirements under the One Big Beautiful Bill Act (H.R.1). The series explores how states are preparing to operationalize the nation’s first federal Medicaid work requirement, including technology, staffing, and funding challenges, and what these changes mean for program integrity and enrollee access.
A Nationwide Rollout Unlike Any Other
The nationwide rollout of Medicaid work requirements under H.R.1 presents an unprecedented administrative challenge for state Medicaid agencies. Unlike prior pilot programs, this federal mandate requires 43 jurisdictions, including 41 expansion states and certain waiver states, to establish new eligibility systems by the end of 2026.
State directors face a tight timeline to overhaul enrollment systems, coordinate across multiple programs, and manage growing workloads, all while minimizing coverage disruptions for millions of enrollees.
According to a recent KFF survey of Medicaid officials, the top concerns are clear: compressed timelines, major IT system changes, staff capacity constraints, fiscal concerns, and anticipated enrollee confusion that could lead to coverage loss.
Compressed Timelines and Evolving Guidance
The law directs that all states implement Medicaid work requirements by January 1, 2027, with the option to begin earlier via waivers. Regulations from HHS are due by June 1, 2026, defining key standards and terms. That leaves, at best, a few months for states to translate federal guidance into working systems and begin enrollee outreach—a process that typically takes several years.
State officials describe the timeline as “unrealistic.” Medicaid eligibility systems are large, complex, and deeply integrated with other programs. Updating them requires procurement, vendor development, testing, and training—none of which can be rushed without risk.
A particular challenge: states must make design decisions before full federal guidance is issued. If their interpretation of key provisions (such as the definition of “medical frailty,” acceptable documentation for exemptions, or allowable verification methods) differs from final CMS rules, they may have to redo major portions of their systems.
The law allows HHS to grant extensions until December 31, 2028, for states demonstrating a “good faith effort” to comply. However, as of late 2025, the criteria for these extensions remain undefined. States are effectively forced to plan for the 2027 deadline while hoping flexibility will exist later.
The uncertainty complicates planning. Should states invest aggressively now to meet the deadline, or conserve resources and risk noncompliance? Most are choosing to press forward, warning that the accelerated schedule “increases the risk of errors that could lead to unnecessary coverage losses” if implementation is rushed.
Lessons from Past Attempts
The handful of states that piloted work requirements under earlier waivers, such as Arkansas and Indiana, offer important lessons. Those efforts demonstrated that clear guidance, simple reporting processes, and accessible communication are essential to prevent widespread disenrollment among eligible people.
If states can apply those lessons now, the rollout under H.R.1 may achieve greater administrative stability. But without early clarity from CMS, even well-intentioned state efforts could be undermined by confusion and rework.
Next Step
For Medicaid and human services leaders staring down this unprecedented implementation timeline, now is the time to pressure-test your roadmap, systems, and risk assumptions. Drawing on more than a decade of instrumental support for CMS eligibility, Infocap partners with public-sector health programs to build and implement realistic eligibility operations that keep coverage disruptions to a minimum. If your team is grappling with how to translate federal and state mandates, reach out to Infocap to explore what this means for your agency or organization. Let’s talk.