Summary
States are required to implement community engagement or work requirements for certain adults enrolled in Medicaid, starting January 1, 2027. Some people will not be required to meet these work requirements. If you’re dealing with substance use or mental health challenges, you may fall into this category. Here's what you need to know.
Medicaid work requirements are here. Here’s what you need to know.
Medicaid work requirements start in most states on January 1, 2027, and they’re already live in Nebraska and Montana. If you’re an adult on Medicaid, you may soon need to show 80 hours a month of work, school, job training or volunteering to keep your coverage.
But not everyone has to. People living with a substance use disorder or a disabling mental health condition, and people in addiction treatment, can qualify for an exemption.
If drinking, drug use, depression or anxiety is making it hard to hold a job right now, this is a good time to get care. Treatment helps you feel better, and it can help you keep the health coverage you rely on.
Below, you’ll find what’s changing, who’s exempt, and a link to your state’s official Medicaid page.
What are Medicaid work requirements?
Medicaid work requirements (states often call them “community engagement requirements”) are a new rule from the 2025 federal budget law, H.R. 1. They apply to most adults ages 19–64 who got Medicaid through the ACA expansion.
To keep coverage, you’ll need to show one of these each month:
- 80 hours of work, volunteering (community service), a job training program, or school at least half-time, in any combination
- Monthly income of at least 80 hours × the federal minimum wage (about $580)
When it starts:
- Already in effect: Nebraska (May 1, 2026) and Montana (July 1, 2026). Arkansas began a “soft launch” July 1, 2026.
- Coming soon: Iowa says by December 1, 2026.
- Everyone else: By January 1, 2027. Many states phase it in at your first renewal in 2027.
Your state will check whether you meet the rule when you apply and at renewal. If it can’t confirm you qualify, it must send you a notice and give you 30 days to respond before ending coverage. Open your Medicaid mail and answer by the deadline.
States like Florida and Texas that didn’t expand Medicaid generally aren’t affected. Georgia, Tennessee and Wisconsin have covered groups that are.
Who is exempt from Medicaid work requirements?
Federal law exempts several groups. You don’t have to meet the 80-hour rule if you are:
- In a drug or alcohol treatment program
- Medically frail, which includes people with a substance use disorder or a disabling mental health condition
- Pregnant or postpartum
- A parent or caregiver of a child 13 or younger, or of a person with a disability
- A veteran with a total disability rating
- American Indian or Alaska Native
- A former foster youth under 26
- Meeting SNAP or TANF work rules
- In jail or prison, or recently released
States can also give short-term hardship exemptions, for example during a hospital stay or after a disaster.
The two exemptions that matter most for addiction and mental health
1. Treatment program exemption. If you’re taking part in a drug or alcohol treatment program, you’re exempt. States define “treatment program” differently. Montana, for example, requires care at ASAM level 2.1 (intensive outpatient) or higher. Indiana counts one or more days of treatment in a month.
2. Medically frail exemption. Under the federal rule, “medically frail” includes:
- A substance use disorder, whether or not you’re in treatment (people in recovery 5+ years are excluded)
- A disabling mental disorder, such as severe depression, bipolar disorder or PTSD
- A serious or complex medical condition, or a disability
One catch: a diagnosis alone isn’t enough. The condition must make it significantly harder for you to work or meet the requirement. That’s why records from a licensed provider who knows you matter.
How states check if you’re exempt
Most states look at your Medicaid claims from the past 12 months first. If your records show treatment, you may be exempted automatically. If not, the state may send a form or ask your provider for a statement.
In 2027, many states will also accept your own signed statement (self-attestation). Starting in 2028, states can only do that once per enrollment period, so having treatment on record will matter more.
Too sick to work right now? This is the time to get treatment.
If addiction or a mental health condition is keeping you from working, you’re not alone, and you don’t have to choose between your health and your coverage. Getting treatment now can help in three ways:
- You start feeling better. Treatment is what makes it possible to get back to work, school and the people you care about.
- You may qualify for an exemption. Many states exempt people in a drug or alcohol treatment program, and people with a substance use disorder or disabling mental health condition.
- Your care is documented. A licensed provider’s records can support your exemption if your state asks for proof.
How Affect can help
Affect is a licensed, CARF-accredited outpatient program for addiction and mental health, delivered by telehealth on your phone. We accept Medicaid, and most members pay nothing out of pocket. Addiction treatment is available in 19 states, and mental health care in 10 of them.
- Substance use treatment for alcohol, fentanyl and opioids, heroin, meth, cocaine, marijuana and prescription painkillers
- Mental health care for depression, anxiety, trauma and PTSD, bipolar disorder, OCD and postpartum depression
- Medication for cravings, withdrawal and mental health symptoms
- Therapy, group sessions and peer support with licensed clinicians
- Rewards for progress (contingency management), plus help with housing, jobs and bills
- Documentation support: when your state asks for proof, we can provide clinical records where permitted
Affect can’t decide your Medicaid eligibility or guarantee an exemption. Your state makes that call. But we can help you get well and give you the records you need.
Get started with Affect today → · Check if we’re in your state · See accepted insurance
Medicaid work requirements by state
Find your state below for its start date, how it treats addiction and mental health, a link to its official Medicaid page, and the care Affect offers there. Rules are still changing, so always check your state’s page for the latest. Last updated October 8, 2026.
| State | Start date | Addiction & mental health exemptions | How to show you’re exempt | Official info | Get care with Affect |
|---|---|---|---|---|---|
| Alaska | Jan 2027 | Substance use condition is exempt; mental health not named yet | Answer any letters from the state | Alaska DOH | |
| Arizona | Jan 2027 | In SUD treatment; serious mental health and SUD conditions count as medically frail | Process not yet published | AHCCCS | Addiction, mental health & IOP |
| Arkansas | Soft launch July 1, 2026; penalties Jan 1, 2027 | Not yet spelled out | State runs automatic status checks | Arkansas DHS | |
| California | Jan 1, 2027 | Serious physical or mental health conditions, or substance use problems | County office will notify you | Medi-Cal (DHCS) | Addiction treatment |
| Colorado | Jan 2027 | In MH or SUD treatment; SUD and disabling mental illness count as medically frail | Data on file; otherwise a form or documents | Health First Colorado | Addiction treatment |
| Connecticut | Jan 1, 2027 | In a treatment program; medically frail | DSS will request documents if needed | CT DSS | |
| Delaware | Jan 1, 2027 | In a treatment program; mental health conditions count as serious health needs | Doctor-signed form | Delaware DMMA | |
| District of Columbia | Jan 1, 2027 | Details coming | Not yet described | DC DHCF | |
| Georgia (Pathways) | Jan 1, 2027 (federal changes) | In rehab or treatment; medically frail based on state condition lists | DFCS may ask for proof | Georgia Pathways | |
| Hawaii | Jan 1, 2027 | Not yet spelled out | Keep proof of work or school | Med-QUEST | |
| Idaho | Coverage periods ending on or after Jan 1, 2027 | Having an SUD or being in treatment; disabling mental health condition | Gather medical records; state will notify you | Idaho DHW | Addiction treatment |
| Illinois | Jan 1, 2027 | In a treatment program; medical condition that prevents meeting the rule | Data first; self-attestation accepted in 2027 | Illinois HFS | Addiction, mental health & IOP |
| Indiana | Jan 1, 2027 | One or more days in treatment exempts you that month; SUD and serious mental illness count as medically frail | Checked quarterly; notice if not confirmed | Indiana HIP | Addiction treatment (mental health coming soon) |
| Iowa | By Dec 1, 2026 | In a drug or alcohol treatment program; medically frail | May need medical documentation | Iowa HHS | Addiction & mental health |
| Kentucky | Jan 1, 2027 | In MH or SUD treatment; MH and SUD count as medically frail | Data first; self-attestation accepted in 2027 | Kentucky (kynect) | Addiction treatment |
| Louisiana | Jan 1, 2027 | In treatment or rehab; SUD and disabling mental illness count as medically frail | Self-attest on a form in 2027; provider proof may be required from 2028 | Louisiana Medicaid | |
| Maine | Jan 1, 2027 | SUD or disabling mental illness; in treatment or rehab | Tell OFI about your situation | MaineCare | |
| Maryland | Jan 1, 2027 | Serious or long-term health conditions; SUD and MH not named yet | Watch for state letters | Maryland Medicaid | Opioid treatment |
| Massachusetts | Jan 1, 2027 | In treatment or rehab; SUD and disabling mental illness count as medically frail | Awaiting federal guidance | MassHealth | |
| Michigan | Jan 1, 2027 (new applicants); renewals from Mar 1, 2027 | In treatment or living with an SUD; living with a mental health disorder | State data; letter if more is needed | Healthy Michigan Plan | |
| Minnesota | Jan 2027 | Check state page | Check state page | Minnesota DHS | |
| Missouri | Jan 1, 2027 | In treatment or rehab; medical conditions that greatly limit your ability to work | State data first | Missouri DSS | |
| Montana | In effect (July 1, 2026) | Treatment at intensive outpatient level (ASAM 2.1) or higher; SUD diagnoses on state list count as medically frail | Data first; otherwise proof per state list | Montana DPHHS | |
| Nebraska | In effect (May 1, 2026) | In a qualified treatment program; disabling mental health condition; medically frail | Claims data; self-declaration form if needed (30 days) | Nebraska DHHS | Addiction & mental health |
| Nevada | Jan 1, 2027 | Serious physical or mental health conditions | Show you qualify at renewal | Nevada DSS | Addiction treatment |
| New Hampshire | First renewal after Jan 1, 2027 | “Medically exempt” details pending | Reporting system in development | NH DHHS | |
| New Jersey | Jan 1, 2027 | Not yet clearly stated for members’ own SUD or MH | May request documents; online checker | NJ FamilyCare | |
| New Mexico | Jan 1, 2027 | In drug or alcohol treatment; medically frail | Automatic check, then 30-day notice | New Mexico HCA | Addiction, mental health & IOP |
| New York | Jan 1, 2027 | In an active treatment program; physical or MH condition that makes work hard | Data first; documents or self-verification | NY State of Health | |
| North Carolina | Jan 1, 2027 | In treatment or having an SUD; disabling mental illness | Medical records or proof to local DSS | NC Medicaid | Addiction & mental health |
| North Dakota | Jan 1, 2027 | In a treatment program; special health needs | Existing data; 30-day notice if not confirmed | ND HHS | |
| Ohio | Jan 1, 2027 | In SUD treatment; SUD (including up to 5 years in recovery) or disabling mental illness counts as medically frail | Claims data first; otherwise a doctor or treatment-program statement | Ohio Medicaid | Addiction, mental health, IOP & PHP |
| Oklahoma | Jan 1, 2027 | SUD or disabling mental illness; in a treatment program | State reviews info on file; notice if needed | SoonerCare | |
| Oregon | 2027 (notices began Sept 2026) | SUD services now or in the past 5 years; disabling conditions including depression | 2027: self-report, no provider note; 2028: proof needed | Oregon Health Plan | Addiction, mental health & IOP |
| Pennsylvania | Jan 1, 2027 | In SUD treatment; SUD and disabling mental illness count as medically frail | Data on file; otherwise a letter with 30 days to respond | Pennsylvania DHS | |
| Rhode Island | 2027 (first renewal) | In treatment; MH or SUD condition that makes work hard | Auto-renew if data on file; otherwise a notice | Rhode Island | |
| South Dakota | Jan 1, 2027 | In treatment or rehab; medically frail | Data first; physician statement for medically frail | South Dakota DSS | |
| Utah | Jan 1, 2027 | In treatment or rehab; medically frail | Proof at each 6-month review | Utah Medicaid | |
| Vermont | 2027 (first renewal) | In treatment; disabling mental illness that significantly limits you | Self-attestation in 2027 | Vermont DVHA | |
| Virginia | Jan 2027 (phased in) | Having an SUD and/or in treatment; disabling mental illness | May need documentation | Cover Virginia | Addiction & mental health |
| Washington | Jan 1, 2027 | In alcohol or substance use disorder treatment | Screening survey on state page | Apple Health (HCA) | Addiction & mental health |
| West Virginia | Jan 1, 2027; renewals from Mar 2027 | Not yet spelled out | Watch your mail | WV BMS | |
| Wisconsin | Jan 1, 2027 (applicants); Mar 2027 (renewals) | Certain treatment programs; serious medical conditions | Checked at renewal | Wisconsin DHS |
Don’t see your state, or live in Florida or Texas? States that didn’t expand Medicaid, including Florida and Texas, generally aren’t affected by the federal rule. Affect still offers addiction treatment in both. See all states where Affect offers care.
5 steps to protect your Medicaid coverage
- Update your address and phone number with your state Medicaid office so you get every notice.
- Open all Medicaid mail and respond by the deadline. You usually have 30 days.
- Check your state’s rules using the table above.
- If addiction or mental health is making work hard, get treatment now. Ongoing care with a licensed provider can support an exemption and, more importantly, help you recover. Start with Affect.
- Ask your provider for documentation if your state requests proof. Affect members can ask their care team.
Frequently asked questions
When do Medicaid work requirements start?
Most states must start by January 1, 2027. Nebraska (May 2026) and Montana (July 2026) have already started, and Iowa plans to start by December 1, 2026. Many states apply the rule at your first renewal in 2027.
Does addiction treatment exempt me from Medicaid work requirements?
Yes. Federal law exempts people taking part in a drug or alcohol treatment program. Each state defines which programs count, so check your state’s page.
Does a mental health condition exempt me from Medicaid work requirements?
It can. A “disabling mental disorder” counts as medically frail under the federal rule. The condition must significantly limit your ability to work; a diagnosis alone isn’t enough.
Does having a substance use disorder count as medically frail?
Yes. Under the federal rule, a substance use disorder counts as medically frail whether or not you’re in treatment, as long as it significantly limits your ability to work. People in recovery for 5 or more years are excluded.
Does telehealth treatment count?
Federal rules don’t exclude telehealth. Outpatient telehealth care from a licensed provider like Affect can count, but your state makes the final decision.
What happens if I don’t meet the requirement?
Your state must send you a notice and give you 30 days to show you meet the rule or qualify for an exemption. If you don’t respond, you could lose coverage.
Can Affect guarantee I’ll be exempt?
No. Only your state can decide your eligibility. Affect can provide treatment and, where permitted, clinical documentation if your state asks for it.
How much does Affect cost with Medicaid?
Affect accepts many insurance plans, including Medicaid. Most members pay nothing. Check your coverage.
Get care now, before your renewal
Medicaid work requirements are a big change, but they don’t have to cost you your coverage or your health. If addiction or a mental health condition is getting in the way of work, getting treatment now is one of the best things you can do for yourself.
Start treatment with Affect today →
This article is for general information and isn’t legal advice. Medicaid rules vary by state and are still changing. Your state Medicaid agency makes all eligibility decisions.