Pa. grapples with implementing Medicaid work requirements

by Whitney Downard, Pennsylvania Capital-Star
May 18, 2026

When 2027 gets underway, most states across the country will push forth new work requirements for select Medicaid enrollees while navigating vague exceptions and doubling verification workloads.

The federal law requiring this change didn’t include additional funds, putting the onus on states to backfill budget gaps.

State Department of Human Services Secretary Val Arkoosh said that 6,000 employees across county assistance offices would need additional education, not including the estimated 250 new hires needed to handle the additional work.

“All of that complexity is now being put into our systems, and we have to do a huge amount of training,” Arkoosh said at a recent legislative hearing in Philadelphia. “(Employees will) have to all be retrained on all these very complex processes on top of what is already a complex process.”

Most states told KFF Health News they would need to hire additional employees to meet the federal mandate, though most already have dozens of vacancies, including Pennsylvania. Arkoosh estimated the state would spend $50 million on technology upgrades to meet the demand.

The largely GOP push for more reporting requirements has been pitched as a way to preserve benefits for the neediest, since Medicaid is the fastest-growing line item for states.

In a recent policy discussion hosted by the University of Pennsylvania, Bruce Greenstein, the Secretary of the Louisiana Department of Health, said that “the true, overall emphasis of work requirements” was helping enrollees be more independent.

“Our overall approach is that we don’t want even one person to lose eligibility because of a cumbersome or complicated process. Period,” said Greenstein, who previously worked for President Donald Trump. “We would like to see as many people as possible lose Medicaid because they have a better job.”

Roughly 750,000 Pennsylvanians are covered under the expanded version of Medicaid, sometimes called Medical Assistance. When the new requirements kick-in in January, those who are between the ages of 19 and 64 and don’t have children under the age of 14 will need to prove that they work, volunteer or go to school for 80 hours each month to keep their insurance coverage.

There are exceptions for the following: former foster care youth; people receiving treatment for alcohol or substance use disorder; pregnant or recently pregnant women; veterans with 100% disability; caretakers of someone with a disability; medically frail individuals; or someone who has been incarcerated within the last 90 days.

In addition to documenting so-called community engagement hours, states will need to check enrollee income twice as often, every six months instead of annually.

A focus on the details

Many states report some confusion about the specifics, such as how to determine medical frailty or caretaker status.

Medical frailty has no federal definition, leaving states to craft their own list of qualifying health conditions, such as blindness, certain disabilities that don’t otherwise qualify, cancer or HIV. Pennsylvania doesn’t currently have a definition, according to health policy experts at KFF.

Healthcare claims can be a good way to verify someone’s health condition, but new patients might not yet have supporting documentation — which is why some states, including Pennsylvania, allow enrollees to self-attest, against the federal government’s wishes.

Greenstein, the Louisiana Health Secretary, said his state was allowing self-attestation and doctor affirmations at intake, then at the six-month they’ll re-evaluate.

“If the condition hasn’t yet been picked up (medical) claims — for example, a cancer treatment — and you haven’t begun active treatment, then we will take a medical frailty form that a physician will fill out. And we’ll use that until the claims start to flow through,” said Greenstein.

Maintaining coverage would be vital, he added, noting that someone with HIV and a suppressed viral load could continue to work every day without problems — so long as it was medically managed. But he urged administrators not to get bogged down with the details.

“Focus on action, not excuses,” Greenstein advised stakeholders. “In the early days, we were hung up on defining medical frailty and were convinced we couldn’t do anything until CMS gave us guidance. Once our minds opened up and we knew we would get course correction if we were going in the wrong direction, we just put the pedal to the metal.”

Louisiana and Pennsylvania are among the 36 states with a one month look-back period, meaning Medicaid beneficiaries will only need to prove they had 80 hours of community engagement for one month during the six-month redetermination. Indiana and New Hampshire will require enrollees to meet that requirement every month.

The commonwealth will also allow for four optional hardship exceptions, like 28 other states. Pennsylvanians on Medicaid will be exempt from requirements if they:

• Reside in a county with a high unemployment rate;
• Reside in a county experiencing a natural disaster;
• Recently were admitted to a hospital or nursing facility;
• Or must travel outside of their community to obtain medical care.

Do work requirements … work?

A handful of states have opted to put the new requirements into action before the January deadline. Nebraska became the first state to do so on May 1, though enrollees and hospital administrators alike are worried about unintended consequences.

Most adults on Medicaid who are capable of working already have a job, with expert Benjamin Sommers saying that the work requirements appeared to target less than 5% of the enrollees, “who weren’t working and really didn’t have a reason not to be.”

“It’s very small,” said Sommers, a professor of Health Care Economics at the Harvard T.H. Chan School of Public Health. “Meanwhile, more than 95% of folks are then having to go through all the verification to show that they’re already doing the things that we want them to do.”

Sommers co-authored a paper analyzing the rollout of work requirements in Arkansas, which launched the nation’s first Medicaid work requirements in 2018 but had to reverse course less than a year later after a court order.

In the first 10 months of the initiative, 18,000 adults lost their coverage, though most policies were restored by a federal court. Sommers and his colleagues found that “work requirements did not increase employment over 18 months of follow-up,” but those who lost their insurance faced adverse consequences — delaying medical care and medication or taking on burdensome medical debt.

He described other hurdles, saying that many beneficiaries either didn’t know about the work requirements or weren’t sure if it applied to them, despite extensive outreach.

New Hampshire hit pause on their own effort shortly after Arkansas’ attempt ended.

Georgia rolled out a version of work requirements in 2023, but only got 8,000 signed up out of an estimated 300,000 eligible Georgians as of last summer. More than 100,000 applied.

“From those three states I think what we’ve seen generally on Medicaid work requirements so far is a real risk of a lot of people losing coverage, including many of them who are probably doing the things that we want them to be doing,” said Sommers.

He advised states to “automate as much as you can” to “make sure the burden isn’t getting shifted to people who already meet the criteria.”

Pennsylvania will start reaching out to its Medicaid population in September, by calling, mailing and texting people to remind them about the requirements going into effect in January.

The state recently launched a process aligning its work programs to meet newly enacted work requirements for food benefits, an avenue that could also be explored for Medicaid beneficiaries.

Pennsylvania Capital-Star is part of States Newsroom, a nonprofit news network supported by grants and a coalition of donors as a 501c(3) public charity. Pennsylvania Capital-Star maintains editorial independence. Contact Editor Tim Lambert for questions: info@penncapital-star.com.