Medicaid Eligibility in 2026: Who Still Qualifies, What Changes January 1, 2027, and What Losing It Costs

Medicaid eligibility used to be one test: is your income low enough? Starting January 1, 2027, it is two tests — income and paperwork — and the second one is where households will lose the most money. This guide gives you the dollar thresholds for your household size, the reporting rules that keep coverage, the exemptions that may spare you, and the monthly cost of the next option up if you lose Medicaid.

The Two Tests You Now Have to Pass

The 2025 reconciliation law, signed July 4, 2025, conditions Medicaid eligibility for adults in the ACA expansion group — and certain 1115-waiver enrollees — on meeting work requirements. CMS’s implementing rule, the interim final rule CMS-2454-IFC, was released June 1, 2026 and took effect July 31, 2026, with full implementation January 1, 2027. States must begin outreach at least three months before the first look-back month — September 2026 for states starting on time.

How many states are affected? KFF’s work-requirements tracker says 44 states (including DC) must implement. KFF Health News reports “42 states and the District of Columbia.” Those counts are reported differently by KFF’s tracker and its newsroom; we’re not going to pick one silently. Either way, the answer is “almost all of them.”

The requirement applies to adults ages 19–64 in the expansion group. CBO estimates roughly 18.5 million people are subject to it. Eligibility hasn’t disappeared — it has been restructured. If you’re in that group, your coverage now depends on documentation you must actively produce.

The Income Test: Where the 138% FPL Line Sits in 2026

The expansion threshold is 138% of the federal poverty level. The 2026 poverty guidelines from HHS/ASPE are below; the 138% column is computed from those guidelines (guideline × 1.38) — it is arithmetic, not an official quoted limit. The only quoted threshold dollar figure comes from KFF’s tracker, which states the expansion limit as “138% FPL ($21,597 for an individual in 2025)” — that is the 2025 figure, your prior-year benchmark.

Household size	2026 poverty guideline (ASPE, 48 states + DC)	138% FPL line (computed)
1	$15,960	$22,024.80 (~$1,835/mo)
2	$21,640	$29,863.20
3	$27,320	$37,701.60
4	$33,000	$45,540.00
5	$38,680	$53,378.40
6	$44,360	$61,216.80
7	$50,040	$69,055.20
8	$55,720	$76,893.60

Each additional person adds $5,680 to the guideline. Alaska and Hawaii use separate guidelines: Alaska’s 1-person guideline is $19,950 (computed 138% line: $27,531) and 4-person is $41,250 (computed: $56,925); Hawaii’s 1-person is $18,360 (computed: $25,337) and 4-person is $37,950 (computed: $52,371).

State-specific income limits, coverage rules, and costs vary — Healthcare.gov notes that eligible income levels may be different from state to state, and your state agency makes the actual determination. Check your state’s number before you budget around ours.

The Work Test: 80 Hours a Month, and What Counts

The work requirement is 80 hours per month of qualifying activity — employment, education, job training, or volunteer/community service — or at least half-time school enrollment. KFF Health News reports that six credit hours per semester meets the “half-time” threshold. Both AIR’s state-readiness brief and KFF Health News summarize the qualifying activities in overlapping terms; neither list is the regulatory text itself.

The mechanics matter as much as the hours:

Verification happens at application and at renewal at least every 6 months — states may check more often.
At application, states look back 1–3 consecutive months of work history; the law lets each state choose its window.
Self-attestation is allowed in 2027, one time only in 2028 — after that, documentation (pay stubs, employer statements, doctor’s notes) can be demanded.

Here’s the honest read: 80 hours a month is about 18 hours a week. Most people subject to the rule already work that much. The hours bar is modest; the reporting bar is the risk. Meeting the requirement and proving the requirement are two different things, and the second one is what terminates coverage.

The Work-History Look-Back: One, Two, or Three Months Depending on Your State

Getting on Medicaid is now harder in some states than others

The look-back window determines how much work history an applicant must show before enrollment. KFF Health News reports that Indiana set the longest window allowed — three consecutive months — in a law signed March 4, 2026, targeting roughly 33% of the state’s Medicaid population. Idaho passed a three-month requirement too (signed April 10, 2026), with similar moves in Arizona, Missouri, and Kentucky. Most states use one month.

Why this matters financially: a person who loses a job and applies for coverage mid-crisis cannot show three months of current work. In a three-month state, the income shock that makes you eligible can also make you unable to pass the look-back. Check your state’s window before you need coverage, not during one.

Who Is Exempt or Excluded: The Categories That Don’t Have to Report

The requirement generally does not apply to:

Children
Pregnant and postpartum people
People 65 and older
SSI/SSDI disability recipients
The “medically frail” — which KFF describes as people who are blind or disabled, have physical, intellectual, or developmental disabilities, a substance use disorder, a “disabling” mental disorder, or “serious or complex” medical conditions
Caregivers of young children (per Manatt Health’s summary of the statute’s exemptions)

Two warnings from Manatt Health: the CMS rule “takes a narrower approach than H.R. 1’s plain language, including by limiting access to medical frailty exemptions and restricting self-attestation.” In other words, the exemption categories exist on paper but are harder to claim under the rule as written — and since self-attestation is restricted, even exempt enrollees should expect to document their status.

There’s also a geographic escape hatch: enrollees in counties with unemployment of at least 8% or 1.5× the national rate can be shielded — but only if their state applies for the exemption (KFF Health News). KFF’s analysis estimates 4.6 million people live in 386 qualifying counties under an any-month standard, or 1.4 million people in 158 counties using a 12-month average.

State Divergence: Where You Live Changes What You Owe

This is not one national program. KFF’s tracker counts 41 states (including DC) as expansion states, and lists the 1115-waiver populations subject to the requirement per CMS’s June 8, 2026 list: Georgia, Tennessee, and Wisconsin (non-expansion states), plus Hawaii, Massachusetts, New York, Oregon, and Utah. KFF also notes Idaho and Arkansas pursuing their own state-law variants.

Enforcement timing already diverges. Per KFF Health News, Nebraska began enforcing in May 2026, Montana started in July 2026 but does not terminate coverage until October, and Arkansas ran a “soft” launch from July 1, 2026 with no penalties until 2027. KFF’s tracker and CBPP’s coverage tracker frame Nebraska’s early implementation with coverage losses beginning August 2026 — the reports differ on early-state dates, so attribute before you act on one.

And the rules may still move: Manatt Health reports 26 states sued CMS over the rule on June 29, 2026. We won’t speculate about outcomes — but a live lawsuit is a reason to re-check your state agency’s pages, which in states like Arkansas, California, and Wisconsin are already publishing work-rule guidance.

What Losing Medicaid Actually Costs: The Coverage-Cliff Math

Now the money. KFF’s 2026 marketplace analysis quantifies what the next option up costs after enhanced premium tax credits expired at the end of 2025:

Average enrollee monthly payment rose 58%, from $113 to $178.
Average marketplace deductible rose 37% ($1,027 per person) to a record $3,786 in 2026, from $2,759 — the steepest increase since the marketplaces launched in 2014. Had the metal-level mix stayed constant, the rise would have been 6% (to $2,912).
A single person at 150% of poverty now pays 4.19% of income — about $82 a month — to keep a low-deductible silver plan.

Annualize the benchmark: $178 × 12 = $2,136 per year in premiums, plus a four-figure deductible exposure — the average 2026 marketplace deductible is $3,786 per person, up 37% in a single year.

Coverage situation	Monthly premium (benchmark)	Annual premium	Deductible exposure	Key risk
On Medicaid (compliant)	$0 (free or low-cost)	$0	Minimal	Paperwork failure despite working
On Medicaid (exempt)	$0	$0	Minimal	Proving the exemption (self-attestation restricted)
Lost Medicaid → marketplace	~$178 (2026 avg, KFF)	~$2,136	+$1,027 avg growth in 2026; record $3,786	Premium + deductible affordability
Lost Medicaid → uninsured	$0	$0	Full retail exposure	Medical bills at full price

KFF also projected a 114% premium increase if everyone had stayed in their same plan, and estimates effectuated marketplace enrollment could fall to about 17.5 million (possibly 16.5 million) from 22.3 million. Notably, KFF found 27% of the sign-up drop came from the 400–500% FPL income group — just 3% of 2025 selections.

The Reporting Treadmill: Why Compliant People Will Still Lose Coverage

The historical record on this is blunt. When Arkansas ran its waiver work requirement, 18,000 people lost coverage — and CBO cited Arkansas research showing many participants were unaware of the requirement or found demonstrating compliance too onerous. CBO has also previously concluded a work requirement “would not have any meaningful impact on the number of Medicaid enrollees working.”

The awareness problem is current, too. Jim Torres of Samuel U. Rodgers Health Center reported that only a “very small percentage” of the clinic’s clients have heard of the changes (KFF Health News). And KFF’s tracker reports about one in five Medicaid adults said they were not meeting the requirements and possibly not qualifying for an exemption. CBPP counts roughly 5 million fewer people on Medicaid in June 2026 than June 2025.

The pattern is paperwork failure, not work failure. Assume nothing is verified automatically in your favor.

The Big Numbers: What the Estimates Say (and Who’s Estimating)

Every figure in this section is an estimate from a named source — none is a fact about your household.

CBO, via KFF’s midterm update: the 2025 law reduces federal Medicaid spending by $911 billion over 2025–2034, and work requirements account for over one-third of that — $326 billion. The law increases the uninsured by 7.5 million per KFF’s October 21, 2026 update. The loss estimates differ across KFF’s own pages: KFF’s survey piece cites a CBO estimate of 4.8 million more uninsured in 2034 from work requirements, other KFF coverage says “over 5 million,” and KFF’s tracker cites 5.3 million of a projected 10 million more uninsured in 2034. We’re flagging the spread rather than smoothing it over.
Manatt Health estimates that implementing the CMS rule as written raises average annual coverage losses from 6.4 million to 8.2 million over FFY 2027–2034, using a 40% coverage-loss rate informed by New Hampshire’s experience — growing from 2.8 million in FFY 2027 to 9.2 million by FFY 2034, nearly 1 in 10 Medicaid enrollees.
CBPP reports CBO projects roughly 15 million people lose coverage and become uninsured by 2034 from the 2025 law plus the expiration of the enhanced premium tax credits.

The range is wide. The direction is not.

Your Pre-2027 Checklist: Moves to Make Before January 1

Verify your category. Ages 19–64, expansion group, in an implementing state? If you might be exempt — pregnancy, postpartum, 65+, SSI/SSDI, medical frailty, caregiving for a young child — start assembling that documentation now, because self-attestation is restricted under the rule.
Start a documentation file. Pay stubs, employer statements, school enrollment records, volunteer logs. The state’s electronic verification may fail even when you’re compliant; your paper file is the backup.
Learn your state’s look-back. One month in most states; three in Indiana and Idaho. Your state Medicaid agency’s page is the authority (Medicaid.gov confirms states determine eligibility).
Price your fallback now. Run your household on the marketplace before you have to. Use the $178/month average and the $3,786 average deductible as starting benchmarks, not as your quote.
Calendar your renewal dates. Verification happens at least every 6 months. A missed cycle is the single most common way compliant people lose coverage — the historical record is paperwork failure, not work failure.

FAQ

Do the work requirements start in 2026? Full implementation is January 1, 2027, per CMS’s rule. But some states started earlier: KFF Health News reports Nebraska began enforcing in May 2026 and Montana in July 2026, and Arkansas ran a soft launch July 1, 2026 with no penalties until 2027.

What if I work 80 hours but my state can’t verify it? That’s the core risk. Verification runs at application and at renewal at least every 6 months. Keep your own records — pay stubs, employer statements — because after 2027’s one-time self-attestation window, documentation can be demanded.

Are children and seniors affected? No. Children and people 65+ are generally not subject to the requirement, per KFF and KFF Health News. Pregnant and postpartum people, SSI/SSDI recipients, and the medically frail are also exempt — though Manatt Health notes the rule reads the medical-frailty exemption more narrowly than the statute’s plain language.

What does coverage cost if I fall off Medicaid? Benchmarks from KFF’s 2026 analysis: $178 average monthly premium (up 58% from $113) and a record $3,786 average deductible (up $1,027 per person). That’s roughly $2,136 a year in premiums at the benchmark, plus deductible exposure before most of the bill is covered.

Does my immigration status affect eligibility? Yes. Healthcare.gov’s eligibility materials reference lawful permanent residents, Cuban/Haitian entrants, and COFA migrants, and CBPP reported in October 2026 that eligibility narrowed further. Check healthcare.gov or your state agency for your category’s current status.

What if I’m in school? At least half-time enrollment qualifies, and KFF Health News reports six credit hours per semester meets the threshold. Keep enrollment records; they’re your documentation.

The Bottom Line

If you’re an expansion-group adult ages 19–64 in an implementing state, Medicaid eligibility in 2026 is a budgeting problem with a deadline. The income test is knowable — compute your household’s 138% line from the ASPE guidelines above. The compliance test is survivable — but only with documentation you gather before the reporting treadmill starts. And the cost of failure is measurable: roughly $2,136 a year in benchmark premiums, plus a deductible that grew about $1,000 per person in 2026. Treat the second half of 2026 — outreach begins September 2026 — as your preparation window.

How This Guide Was Built

This guide is based on reporting and primary documents from KFF, KFF Health News, CMS’s interim final rule via the Federal Register, HHS/ASPE poverty guidelines, Manatt Health, CBPP, AIR, Healthcare.gov, and Medicaid.gov, plus state Medicaid agency pages where noted. All 138% FPL dollar figures are our own computation from the 2026 ASPE guidelines (guideline × 1.38), not official quoted limits; the only quoted threshold is KFF’s 2025 figure of $21,597 for an individual. Where sources disagree — the 44-vs-42 state counts and the 4.8M/5.3M/5M+ CBO loss estimates — we’ve disclosed the discrepancy rather than resolved it. No enrollment was performed hands-on, and no coverage applications were submitted in the preparation of this article.