Tracking State Implementation of 2025 Medicaid Work Requirements via 1115 Waivers
The 2025 reconciliation law mandates that states condition Medicaid eligibility for adults in the ACA expansion group on meeting work requirements starting January 1, 2027. However, states may implement these requirements earlier through State Plan Amendments (SPAs) or approved Section 1115 waivers. Nebraska is the first state to announce early enforcement via an SPA, beginning May 1, 2026, followed by Montana in July 2026 and Iowa in December 2026. Regarding 1115 waivers, Georgia remains the only state with an active waiver following litigation against the previous administration's attempts to halt it. The Centers for Medicare and Medicaid Services recently granted Georgia a temporary extension with new exemptions, valid until December 31, 2026. Several other states submitted waiver requests under the second Trump administration, though some may withdraw due to the new federal mandate. It remains unclear how pending waivers deviating from federal standards will be treated before the 2027 deadline. This analysis tracks the varying approaches states are taking to align with or accelerate the implementation of these significant healthcare policy changes.
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