Sweeping federal changes to the Medicaid program are set to begin rolling out this year, affecting approximately one in every four North Carolinians. These adjustments will bring tighter eligibility rules for noncitizens, new work mandates, and twice-yearly renewals over the coming months.
The changes originate from H.R. 1, a federal budget law also known as the “One Big Beautiful Bill,” which President Donald Trump signed into law in July 2025. This bill will implement stricter requirements for Medicaid beneficiaries in North Carolina and 39 other states that expanded Medicaid under the Affordable Care Act.
Medicaid is a government-funded program that provides health insurance for low-income residents, covering essential care such as doctor visits, prescription drugs, hospital stays, laboratory tests, and emergency services.
Starting October 1, officials indicate that many people who are not U.S. citizens could lose their Medicaid coverage. Individuals lawfully present in the U.S. without permanent residency status, including refugees and those granted asylum, may no longer qualify for Medicaid. Individuals with temporary lawful status, such as those on student or work visas, were already ineligible for public health benefits like Medicaid.
However, some noncitizens may still receive coverage through Emergency Medicaid, a limited program designed to cover the cost of care for “true medical emergencies” regardless of immigration status, provided patients meet income and other eligibility criteria.
Beginning January 1, 2027, most adults between the ages of 19 and 64 will be subject to a new “work and community engagement requirement” to maintain their coverage. This rule mandates enrollees to complete at least 80 hours a month of work, school, job training, or community service. Alternatively, individuals can satisfy this requirement by earning at least $580 a month before taxes.
The work mandate will coincide with a faster renewal schedule. Medicaid beneficiaries will be required to renew their coverage every six months, rather than annually. Those seeking renewal will also need to meet the work requirement for at least three of the six months leading up to each recertification period. For example, an enrollee renewing in July 2027 would need to have met the work requirement for any three months between January and June of that year. Should someone lose their Medicaid coverage and be unable to appeal the decision, they would need to meet the work and community engagement requirement for three consecutive months before reapplying.
Certain groups are exempt from this new requirement. These include pregnant individuals, individuals under 19 or over 64, individuals with disabilities (who are receiving specific federal benefits), individuals caring for a child under the age of seven or an incapacitated person, and individuals experiencing homelessness. Other exempt groups include those in substance abuse treatment, individuals categorized as medically frail, and those in foster care. According to the North Carolina Department of Health and Human Services, individuals with complex medical conditions may also qualify for an exemption, even if their condition is not explicitly listed.
Also starting January 1, 2027, the timeframe during which Medicaid will retroactively pay for health care costs incurred before an application is submitted will be reduced from the current three months. Those who qualify for retroactive coverage include children, pregnant individuals, and individuals requiring long-term care. However, for anyone who applies by December 31, 2026, Medicaid will still cover approved costs for up to three months prior to the application date.
North Carolina expanded Medicaid in 2023 to include low-income adults who previously earned too much to qualify for traditional coverage. Since that expansion, nearly 735,000 North Carolinians have enrolled in Medicaid. State officials advise enrollees to contact the North Carolina Medicaid Ombudsman, an independent office that assists recipients in understanding their coverage, notices, and bills, or other organizations for help.
