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- Nebraska and Montana implemented the new work requirement rules for Medicaid recipients earlier this year.
- In Nebraska, officials say there’s been confusion about basic eligibility, with some people who should have received exemptions being denied coverage due to procedural errors.
- Montana leaders stressed the importance of communication, particularly to Native American tribes, who should be exempt from the new rules.
- Officials in Wisconsin say they’re implementing ways to automatically determine whether someone is working or if they’re required to follow the new rules.
- Federal officials also narrowed the definition of medical frailty, meaning that people who have Medicaid because they are too medically frail to work will be required to prove their condition and the fact that it prevents them from working.
Starting in January, some Wisconsinites must prove they meet federal work requirements to enroll in Medicaid. Around 63,000 people are at risk of losing coverage, state officials say. It’s part of an effort by the Trump administration to reduce “waste, fraud and abuse” in the program and reduce federal spending by $326 billion over 10 years.
As Wisconsin prepares to implement the measures detailed by the One Big Beautiful Bill Act, states like Nebraska and Montana have already put work requirements into effect. How the process is unfolding offers key lessons for states like Wisconsin facing a Jan. 1 deadline.
Who needs to meet work requirements?
The new Medicaid requirements apply to states like Nebraska and Montana that voted to expand Medicaid to families living at 138% of the poverty level — with the exception of a few states that submitted a waiver to partially expand Medicaid, like Wisconsin.
That program, called BadgerCare Plus, applies to individuals who live at or below the federal poverty level — $33,000 annually for a family of four — as compared to the $45,540 income limit for expansion states.
Only childless adults aged 19 to 64 under the BadgerCare Plus program must meet work requirements — about 200,000 people, according to state officials. That means parents of dependent children under age 19 and people with coverage other than BadgerCare Plus, such as SSI Medicaid or home- and community-based service programs, are exempt.
Other exempt groups include Native Americans, pregnant or postpartum people, caregivers of young children or disabled individuals, veterans with a total disability rating, participants in addiction or rehab programs, and those too medically frail to work.
Starting Jan. 1, 2027, new BadgerCare Plus applicants must show they worked, volunteered or attended school for at least 80 hours in the previous month, or prove they were exempt for that month.
Current BadgerCare Plus members will face the requirements beginning in March 2027. They must show they met the work requirement in any one month of the last 12, or that they are exempt. They can show they received at least $580 in income in a single month or completed combined activities adding up to 80 hours.
In July, Wisconsin Department of Health Services Secretary Kirsten Johnson told reporters officials aim to automate the process as much as possible.
Those system changes will cost an estimated $10 million in the first year, Wisconsin Medicaid Director Amanda Dreyer confirmed, which will be split between the state and federal government.
Nebraska’s early lesson
Nebraska became the first state to implement the new requirements on May 1.
Officials began to disenroll Nebraskans who didn’t meet the requirements on Aug. 1. Nebraska Medicaid Director Drew Gonshorowski told Tradeoffs in July roughly 200 people could lose coverage on that day. The state Department of Health and Human Services has not released official numbers.
The state sent more than 75,000 letters, 38,000 text messages and 10,000 emails to notify people of the change. Amy Behnke, CEO of the Health Center Association of Nebraska, told Wisconsin Watch some residents still had basic eligibility questions.
“There’s some confusion over who the work requirements apply to and who they don’t apply to,” Behnke said. “The communication that went out from the state was pretty lengthy. It was about four pages long and at a collegiate reading level, and so it was a lot for somebody to digest.”
It’s also hard to know whether someone is part of the Medicaid expansion without contacting the state directly.
“Our health centers don’t have a really good way of being able to look that up,” she said.
Her organization supports Nebraska’s federally qualified health centers, which provide low-cost medical care and help people apply for Medicaid.
She’s already seen patients have their Medicaid applications denied due to procedural errors. One woman was denied because she didn’t meet work requirements — even though pregnancy made her exempt.
“She was able to get her Medicaid restored,” Behnke said. “But that’s always been our fear – that somebody’s not going to know that they’ve lost their coverage until they show up to pick up a prescription or they show up for a medical appointment.”
Residents can call the state’s Medicaid help line, but wait times have stretched as long as 90 minutes, Behnke said. She recommends states consider hiring additional caseworkers, which Nebraska has not done.
“They are hardworking individuals (at the call center), and there is just an additional load of work and information that’s needed that comes with these requirements,” Behnke said.
Wisconsin DHS plans to use the additional FoodShare staff secured last year to help with implementing Medicaid requirements, Johnson said, noting the increased budget will add flexibility for other staff to help Wisconsinites.
Behnke urged Wisconsin to prioritize flexibility in implementing the program. She highlighted that Nebraska requires members to meet requirements in just one month of the last 12 and allows individuals to self-attest to medical frailty — policies Wisconsin DHS confirmed it will follow.
A balancing act in Montana
Montana also implemented work requirements on July 1 — the first state to do so after the U.S. Centers for Medicare and Medicaid Services released stricter guidelines on medical frailty. For three months, Montana enrollees won’t be penalized if they fail to document community engagement hours.
Dr. Aaron Wernham, CEO of the Montana Healthcare Foundation, said the effects won’t become clear until Oct. 1 – the first day the state begins to disenroll people. The foundation estimates 29,000 people could lose coverage.
Wernham said it remains unclear how Native Americans, who are exempt from the requirements, will be asked to document their status. The state had limited interaction with the tribes and other stakeholders on how to communicate the change, he said, and urged Wisconsin officials to engage those groups now.
Wisconsin could improve implementation by working with partners such as Covering Wisconsin to develop forms, define medical frailty and plan outreach, Wernham said.
Montana has effectively automated systems to determine whether someone is working, Wernham said. But automatically verifying medical exemptions has been more difficult as officials struggle to access claims data, the Montana Free Press reported.
Defining medical frailty
The challenge comes as federal officials have tightened the definition of medical frailty. Rather than automatically exempting people with certain medical conditions, the rules require people to prove their condition and show that it significantly prevents them from working.
The tightened medical frailty definition has overshadowed concerns over Montana’s ability to automate processes, Wernham said.
“There are many patients with cancer that may have a disease that will be lethal if not treated, and yet they might not be too sick to work,” Wernham said. “The real question is, what’s going to happen with those people who have a very serious illness, any doctor would consider them medically frail, and yet it may be hard to say they’re too sick to work?”
For the first year, people can self-attest that they are too medically frail to work. Wisconsin officials confirmed DHS will rely on self-attestation and existing diagnoses codes, reassuring providers they would not have to determine medical frailty. But in 2028, states will have to determine how to verify those exemptions while risking federal audits.
Montana and other states should outline their plans for monitoring who is disenrolled from Medicaid and the potential impacts, Wernham said. That’s something Wisconsin has done by announcing that roughly 63,000 are at risk of losing Medicaid due to a lack of work history on file.
“States aren’t always eager to share their data, especially if it doesn’t look good with the public,” Wernham said. “But the fact is that transparency with regard to data on this program leads to better government.”
State budget woes
Medicaid funding is often the largest source of federal funds for states, so it can have a big impact on their budgets. State Medicaid budgets could be reduced by an estimated $665 billion through 2034 under the One Big Beautiful Bill Act.
This leaves officials with few choices: raise taxes, cut other programs or cut Medicaid — which would mean reducing provider rates or limiting benefits or coverage. The Congressional Budget Office estimated 10 million more people will be uninsured nationwide by 2034 as a result of the new law.
The cuts could affect the entire health care system, even those who are insured, said Vaishu Jawahar, director of policy programs at the national health care advocacy nonprofit Protect our Care.
Programs could be cut or premiums will increase because hospital budgets will be strained. Hospitals could face more uncompensated care as more uninsured patients seek treatment, tightening budgets and potentially increasing costs for privately insured patients.
Jawahar said people who lose insurance may forgo preventive care until their conditions become severe enough to require emergency treatment.
“They’re still going to have to provide care to uninsured people who will come in sicker,” Jawahar said. “… And so, how do hospitals make up for that? They will have to hike costs on people with employer-based insurance.”
Medicaid cuts are expected to hit rural hospitals hardest. A March report by Public Citizen found 446 hospitals nationwide were at risk of closing or reducing services due to cuts. Samantha Peck, rural hospitals and clinics program manager for the Wisconsin Office of Rural Health, manages funds that benefit critical access hospitals across the state.
About 13% of patients in Wisconsin hospitals use Medicaid, but Peck said critical access hospitals in Door County, Oconto, Shawano and New London average about 48% of patients on Medicaid, leaving them particularly vulnerable if more patients lose coverage.
Maternal and mental health programs could be among the first cut, Peck said.
“The biggest worry is that community hospitals will start reducing service lines,” Peck said. “What we’re already seeing is a reduction in maternal care, specifically labor and delivery.”
Clinics prepare to help Wisconsinites navigate changes
NorthEast Wisconsin Community Clinic, a free and low-cost health center in Green Bay, is educating people about the new requirements with its mobile outreach vehicle.
In 2025, 47% of the center’s clients were on Medicaid, which means it’s preparing its budget to receive less federal reimbursement next year. Executive Director Kim Franzen said the clinic will continue serving the uninsured.
“While I’m concerned, I want to make sure that as a health center, it’s our responsibility to take care of people regardless of their ability to pay,” Franzen said.
Franzen worries people might not realize their coverage was denied before racking up medical bills.
“If you lose your Medicaid, now a person could potentially have four therapy sessions (before realizing) that ‘Oh, I didn’t know my coverage lapsed,’ and then as an organization, we have to step back and go, ‘OK, so do we bill the person? Do you write off the expenses?’” she said.
Adam VanSpankeren is the navigator program manager for Covering Wisconsin, which receives federal funding from the Affordable Care Act Navigator Program and responds to calls about health insurance.
Despite recent funding cuts, VanSpankeren hopes people affected by the changes call Covering Wisconsin for help.
“I don’t love that people are affected, but that means we’re going to be able to help those people,” VanSpankeren said. “It’s the people that don’t call us that I worry more about.”
This story was produced as part of the NEW (Northeast Wisconsin) News Lab, a consortium of five news outlets.
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Some states started Medicaid work requirements early. What can Wisconsin learn? is a post from Wisconsin Watch, a non-profit investigative news site covering Wisconsin since 2009. Please consider making a contribution to support our journalism.
