Medicaid and CHIP Eligibility, Enrollment, and Renewal Policies as States Prepare for Major Medicaid Policy Changes

Executive Summary

The 24th annual survey of state Medicaid and CHIP program officials conducted by KFF and the Georgetown University Center for Children and Families (CCF) provides a baseline of state Medicaid and CHIP eligibility, enrollment, and renewal policies in place as of January 2026 as they prepare to implement the changes included in the 2025 reconciliation law. Information collected through the survey highlights state policies and processes that will facilitate implementation of the requirements in the law and shows where states will need to make changes to comply with the new requirements. The survey also included questions about state decisions on implementation of work requirements. More detailed findings from those questions are included in a separate brief, An Early Look at Policy Decisions as States Get Ready to Implement Work Requirements. This report focuses on policies for children, pregnant individuals, parents, and other non-elderly adults whose eligibility is based on Modified Adjusted Gross Income (MAGI) financial eligibility rules (findings on eligibility and enrollment policies for non-MAGI populations are available in Medicaid Eligibility Levels for Older Adults and People with Disabilities (Non-MAGI) in 2026). Overall, 49 states and the District of Columbia responded to the survey (Florida did not respond). For purposes of this report, the District of Columbia is counted as a state.

Key Takeaways

• Many parents of older children in expansion states will be subject to new work requirements starting in January 2027. While the reconciliation law does not directly impact income eligibility levels, new work requirements and more frequent 6-month renewals for parents and adult enrollees in the ACA Medicaid expansion will make it more difficult for those adults to enroll in and retain coverage. Parents covered through the mandatory Section 1931 pathway – based on cash assistance eligibility thresholds in effect in 1988 — are exempt from work requirements, but parents in the expansion group with children ages 14 and over are required to meet the requirements. The median Section 1931 eligibility level in expansion states is 36% FPL, and as a result, some parents in the expansion group (i.e., those with incomes above those thresholds) who are not identified through data matching may need to verify they are exempt, and parents of children ages 14 and older with income above that level who are enrolled through the expansion will need to comply with the work requirements. In the ten states with the lowest Section 1931 eligibility levels (25% of the poverty level or less), many parents will need to meet the requirements or qualify for an exemption. Four expansion states cover parents up to 138% FPL through the Section 1931 pathway, creating an exemption from work requirements for all parents in those states.
• States continue to expand use of electronic communications and add features to online accounts and mobile apps—strategies that may help to maintain enrollment for individuals who remain eligible. States are increasingly using electronic communications through online accounts and text messages to send more frequent alerts and reminders to improve response rates at renewal. While just 14 states have mobile apps with enrollment features, these apps along with online accounts give enrollees more ways to manage their coverage. These strategies, already shown to ease administrative burden during the unwinding, could help expansion states assist enrollees navigate new requirements.
• States with Medicaid eligibility systems that are integrated with SNAP and decisions to adopt options to use SNAP data to enroll or renew Medicaid coverage could reduce the administrative burden of implementing work requirements and semi-annual renewals. Half of states have MAGI Medicaid eligibility systems integrated with SNAP eligibility and 15 states use verified income data from SNAP to enroll or renew Medicaid. SNAP data, in particular, can be used to verify compliance with work requirements or exemption status. States that do not currently share program data may need to establish data linkages to implement work requirements if required by CMS. While having an integrated eligibility system facilitates data sharing across programs, the reconciliation law also included changes to SNAP, so some states with integrated systems are having to make changes for both programs simultaneously.
• A small but growing number of states are using artificial intelligence (AI) in consumer assistance and eligibility and enrollment processes, including to perform some functions that may help with implementation of work requirements. Some states are using AI to review and extract information from uploaded documents and to enhance data matching, which could meaningfully reduce the paperwork burden that semi-annual renewals and work requirements will create. States are also using AI bots to assist enrollees in updating their contact information, saving eligibility or call center workers time in manually collecting and updating the information.
• The reconciliation law includes new administrative requirements for updating addresses and identifying deceased enrollees. The reconciliation law requires states to regularly obtain address information from reliable sources, including mail returned with a forwarding address, the USPS National Change of Address Database (NCOA), and managed care organizations (MCOs), by January 1, 2027. Two-thirds of states already use (MCO) or NCOA data. By January 2028, states must conduct data matching at least quarterly with the SSA’s Master Death File to identify deceased enrollees. Over half of states (29) already review the Master Death File on a quarterly or more frequent basis.
• Currently, 19 states charge nominal cost-sharing to Section 1931 parents, and 21 states charge cost sharing to ACA or waiver expansion adults, while the remaining states do not charge cost-sharing. Starting in October 2028, the reconciliation law requires states to impose cost sharing of up to $35 per service, with some exceptions, on ACA expansion adults with income 100%-138% FPL. CMS guidance is needed to clarify any flexibility that states may have in determining whether some or all non-exempt services must require cost-sharing. The limitation of $35 per service means that several states will have to lower cost-sharing on certain services, generally on inpatient hospital services, which could also implicate cost-sharing for 1931 parents or create inequity in how charges are assessed between low-income parents and ACA expansion adults.

Box 1:  Changes to Medicaid Eligibility and Enrollment Policies in the 2025 Reconciliation Law