Published November 14, 2026 · By
Medicaid work rules created by last year's federal tax and spending law will still begin on Jan. 1, 2027, but states can now wait until July before cutting anyone off for failing to meet them. The Centers for Medicare & Medicaid Services (CMS) announced the optional six-month "hold harmless" period on Friday, Nov. 13, giving states more time to fix eligibility systems as enrollees, advocates and state officials prepare for one of the biggest changes in the program's history.
What CMS announced about the Medicaid work rules
According to the CMS press release, the hold harmless period runs through and including June 30, 2027. States that choose to use it must still check, starting in January, whether applicants and enrollees meet the requirement or qualify for an exclusion. What changes is the consequence: during those six months, participating states will not deny applications or remove otherwise eligible people solely because they did not meet the work requirement.
In practice, that means the first coverage losses tied directly to the Medicaid work rules would come no earlier than July 1, 2027, in states that opt in. The Associated Press reported that CMS told state Medicaid directors on Friday that states are making progress but face implementation challenges. The release quotes Dan Brillman, who leads the agency's Center for Medicaid and CHIP Services, and describes the window as a transition to modernize systems and improve the experience for applicants and beneficiaries.
The delay is optional. States that are ready may begin full enforcement of the Medicaid work rules in January, and at least one state has already started on its own timeline.
What states are being asked to do
CMS "strongly encouraged" states to use the extra time in four ways. First, states should rely as much as possible on automated verification, using data they already hold to confirm work activity or an exemption before asking people for paperwork. Second, notices should clearly say what has been verified, what is still missing and how to get help. Third, states should test their full process, including data matching, notices and eligibility decisions. Fourth, the agency asked states to work with community partners on job, training, education and volunteer programs under an effort it calls "Paths to Prosperity."
Who is covered by the Medicaid work rules
The requirement comes from the One Big Beautiful Bill Act, which President Trump signed in 2025. It applies to adults ages 19 to 64 who are covered through the Affordable Care Act's Medicaid expansion, which the AP says 40 states have adopted. The AP describes the target group as lower-income adults without children at home, and the rule does not reach people outside the expansion group.
Under the law and CMS' June 2026 interim final rule, people subject to the Medicaid work rules can qualify by meeting any of these standards each month:
- At least 80 hours of work, community service or a work program
- Enrollment in school or training at least half-time
- A combination of those activities totaling at least 80 hours
- Monthly income above a threshold set in the rule
Exemptions cover, among others, people caring for children under 14, people with disabilities and those considered medically frail. That last category has been contested in court. STAT reported that a federal judge in Boston recently rejected the federal definition of medical frailty and found that states had not been given enough time or resources to rebuild their eligibility systems.
How the Medicaid work rules played out in Nebraska
Nebraska became the first state to enforce the Medicaid work rules early, starting May 1. Preliminary state data reported by the AP showed that more than nine in 10 people who were subject to the rule and due for renewal in July and August qualified to keep coverage. Of those who did not, 533 were denied continued coverage, mostly for paperwork reasons such as not showing proof of work or an exemption. Only 43 lost coverage because they did not meet the requirement itself.
NBC News, citing state figures through August, reported that more than 1,000 Nebraskans in total either lost coverage or were denied benefits under the Medicaid work rules, a count that includes new applicants. The AP noted it is not clear how many of the people denied were actually not working. Amy Behnke, CEO of the Health Care Center Association of Nebraska, told the AP that some people who were still eligible likely lost coverage.
What each side is saying
The administration
The administration has said the Medicaid work rules encourage work and reduce waste in the program, NBC News reported. The White House declined to comment on the timing. CMS' release did not mention the court ruling, the midterm elections or any cost estimate, and it framed the extra months as a chance for states to learn from early experience and train their workforce.
Democrats
Earlier in the week, Sen. Ron Wyden of Oregon and Rep. Frank Pallone Jr. of New Jersey wrote to CMS Administrator Mehmet Oz asking for a delay, citing the Boston court ruling. Last month, five Democratic governors asked Health and Human Services Secretary Robert F. Kennedy Jr. to postpone the rule, saying their agencies were not ready. Democrats, who will control both chambers of Congress starting in January after the Nov. 3 midterms, have said they want to roll back the Medicaid work rules. Our earlier report on the Democratic push to delay Medicaid work requirements covers that letter in more detail.
Republicans
Republicans in Congress wrote the requirement into the 2025 law, and supporters have argued that able-bodied adults without young children should work, study or volunteer in exchange for coverage. None of the news reports reviewed for this article included new comment from Republican congressional leaders on Friday's announcement.
States and outside experts
Kate McEvoy, executive director of the National Association of Medicaid Directors, told the AP that state leaders "appreciate the additional flexibility that CMS is providing." Kathy Hempstead of the Robert Wood Johnson Foundation said the extra months should help states reduce coverage losses caused by administrative problems, though it is unclear which states will use them. Sarah Lueck of the Center on Budget and Policy Priorities, which opposes the Medicaid work rules, wrote on X: "Today's news lets states delay the harm."
The numbers behind the policy
The Congressional Budget Office estimated that the Medicaid work rules alone would leave 5.3 million more people uninsured by 2034 while saving the federal government about $317 billion, according to NBC News. That provision is part of nearly $1 trillion in Medicaid changes in the 2025 law. A six-month pause on coverage losses could shift some of those effects later, but the CBO has not published a revised estimate tied to Friday's guidance.
What it means for you
If you are an adult between 19 and 64 who gets Medicaid through your state's expansion program, here is a practical way to think about how the Medicaid work rules change affects you. This section is our own analysis based on the sources above.
- Your state still checks in January. Even in a state that opts in to the hold harmless period, you may get notices asking about work, school or an exemption starting Jan. 1, 2027.
- Respond to every notice. Nebraska's early data suggest paperwork, not unemployment, caused most denials. Keep pay stubs, school enrollment records and volunteer logs in one place.
- Check whether you are exempt. Caring for a child under 14, a disability or a serious medical condition may exclude you. Ask your state Medicaid office how to document it.
- Find out your state's plan. Not every state will use the delay. Your state Medicaid agency website should say whether it will enforce in January or July.
- Update your contact details. Notices go to the address, phone and email your state has on file, so make sure they are current.
Families who rely on more than one benefit program may also want to follow other federal changes, such as the recent SNAP stocking rule delay.
What happens next
States now have to decide whether to use the hold harmless window, and it is not yet clear when each state will announce its choice. The court ruling on the medical frailty definition also remains part of the picture. When the new Congress convenes in January, Democrats may try to change or repeal the Medicaid work rules, but any bill would still need President Trump's signature. For now, the Medicaid work rules remain on the books and set to begin on Jan. 1.
This article is for information only and is not financial, legal or medical advice.
Sources: Centers for Medicare & Medicaid Services press release (Nov. 13, 2026); Associated Press; NBC News; STAT; Congressional Budget Office.
