New Medicaid Rules to Require Work, Community Engagement for Many North Carolinians

Low-income North Carolinians will soon face new requirements to maintain their Medicaid coverage, as federal rules mandate at least 80 hours of work or community engagement each month. These sweeping changes are set to take effect starting January 1, 2027, primarily impacting most adults aged 19 to 64.

Under the new “work and community engagement requirement,” most adults in this age group will need to log at least 80 hours per month in work, school, job training, or community service. Alternatively, a household can satisfy the rule by earning a minimum of $580 per month before taxes, an amount roughly equivalent to 80 hours worked at the federal minimum wage. State officials have stated that enrollees who do not meet this requirement or qualify for an exemption risk losing their Medicaid benefits.

The changes stem from a major federal budget law, H.R. 1, known as the “One Big Beautiful Bill,” which President Donald Trump signed into law in July 2025. This controversial legislation is projected to result in approximately 7.8 million people nationwide losing their health insurance over the next decade, according to the nonpartisan Congressional Budget Office.

Many individuals, however, will not need to meet the work requirement. State officials confirmed that exemptions apply to people with disabilities, parents with young children, and those receiving SNAP benefits. Furthermore, individuals with complex medical conditions may also qualify for an exemption, even if their specific condition is not explicitly listed, as noted by the North Carolina Department of Health and Human Services.

Before the work requirements roll out in 2027, several other significant Medicaid restrictions are scheduled to be implemented. These include tighter eligibility rules for noncitizens, a shift to twice-yearly renewals, and a shortening of retroactive coverage.

The renewal schedule for Medicaid beneficiaries will accelerate, moving from once a year to every six months, starting January 1, 2027. Individuals seeking to renew their coverage will also need to demonstrate that they have met the “work and community engagement requirement” for at least three of the six months leading up to each recertification. For instance, an enrollee renewing in July 2027 would be required to have met the work mandate for any three months between January and June of that year. If an individual loses their Medicaid coverage and cannot appeal the decision, they must meet the work requirement for three consecutive months before reapplying.

Retroactive coverage, which allows Medicaid to pay for health care costs incurred before an application is submitted, will also see changes. Starting January 1, 2027, this window will shrink from the current three months. Those who may still qualify for some form of retroactive coverage include individuals who died, individuals under 21, and pregnant individuals. It is important to note that for anyone who applies for Medicaid by December 31, 2026, the program will still cover approved costs for up to three months prior to the application date.

Starting October 1, 2026, eligibility rules for noncitizens will become stricter, potentially leading many to lose their Medicaid coverage. Noncitizens can generally get or keep Medicaid if they are U.S. citizens, permanent residents for at least five years, or belong to specific groups such as refugees, asylees, or those granted withholding of deportation. However, people lawfully present in the U.S. without permanent residency status, which includes refugees and people granted asylum, may no longer qualify for Medicaid. Individuals with temporary lawful status, such as those on student visas and work visas, were already ineligible for public health benefits like Medicaid and SNAP food assistance. Limited assistance for emergency care, known as Emergency Medicaid, will remain available for true medical emergencies for eligible patients, regardless of immigration status.

North Carolina expanded its Medicaid program in 2023 to include low-income adults who previously earned too much to qualify for traditional coverage. Since this expansion, nearly 735,000 North Carolinians have enrolled in Medicaid.

Enrollees needing assistance or clarification on these upcoming changes can contact the North Carolina Medicaid Ombudsman, an independent office dedicated to helping recipients understand their coverage, notices, and bills. Other organizations may also be able to provide support.