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Health Care · Report · File No. 261113-685

Medicaid work rules exempt Native Americans, but spotty state checks could cost coverage

Federal law excludes tribal citizens from Medicaid work requirements. With little federal guidance, states are using different proof rules, and Native leaders fear a repeat of the 2023 coverage losses.

By the Kitchen-Table Desk · · 2 min read

Every quote in this story (2) was matched word for word against its source. How we work

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Native Americans are exempt from the new Medicaid work requirements. But some could still lose coverage because the federal government gave states little direction on how to identify them, KFF Health News reported Friday. 1

President Donald Trump's One Big Beautiful Bill Act excluded Native Americans from the rules, which require many enrollees to show they are working, in school or in another qualifying activity. The federal Centers for Medicare & Medicaid Services (CMS) did not set a standard way for states to find those people. States were left to work it out themselves. 1

A patchwork of proof rules

KFF Health News asked 14 states how they would apply the exemption and found they plan to check tribal status in different ways. 1 Arizona, Colorado, Montana, Nevada, New Mexico and Washington let people identify their tribal status on the Medicaid application. 1

North Carolina requires a tribal enrollment card, a tribal census record, or confirmation from the Eastern Band of Cherokee Indians' managed-care program. 1 Utah says people whose status is not verified may have to meet the work requirement every month to keep Medicaid. 3

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CMS's June guidance told states to use data they already have before asking Native enrollees for more records. It did not set a standard process, so states can demand more proof than federal rules require. It also did not require states to share data with tribes. 1

There’s still going to be folks that fall through the cracks,
A.C. Locklear, CEO, National Indian Health Board1

A.C. Locklear is CEO of the National Indian Health Board. He said that if CMS waits until December to issue more specific guidance, states will have already set their own processes. CMS did not respond to KFF Health News' questions about whether it plans more guidance. 1

Why leaders are worried

Native leaders point to the Medicaid "unwinding" in 2023, when states resumed eligibility checks after a covid-era pause. An estimated 850,000 Native Americans lost coverage by May 2024, often because of paperwork. 1

I’m nervous. I’m extremely nervous,
James Burns, Oversees the Eastern Band of Cherokee Indians' Medicaid managed-care program1

About 87% of Native people live outside areas the Census Bureau calls tribal statistical areas, such as reservations. A Navajo citizen living in Connecticut, for example, may be hard for that state to identify. Several states told KFF Health News they do not track tribal affiliation, and ethnicity questions on applications are optional. 1

The exemption also leaves out some Indigenous people, such as Native Hawaiians. 1

What happens next

Montana, Nebraska, Arkansas and Georgia are already running work-requirement checks ahead of the Jan. 1 federal deadline. Iowa starts Dec. 1. 1 The National Council of Urban Indian Health has asked HHS and CMS for binding guidance so states apply the exemption automatically. 2

That matters because the exemption exists on paper but depends on state computers and caseworkers to work in practice. In North Carolina, 3,400 Native enrollees are verified as exempt and will be exempted automatically. The state does not know how many more may qualify. 1 The pattern from 2023 is that people who qualify lose coverage over missing paperwork.

The Record

  1. An estimated 850,000 Native Americans had lost Medicaid coverage by May 2024 after the pandemic-era pause ended, often over paperwork 1
  2. CMS published its work-requirement guidance in June, telling states to use existing data first and setting no standard proof process for tribal status 1
  3. KFF Health News reports states use different proof rules, weeks before the Jan. 1 federal deadline 1
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Sources

  1. KFF Health News, “Medicaid Work Rules Don’t Apply to Native Americans. They Could Still Lose Coverage” (2026-11-13). kffhealthnews.org/health-care-costs/medicaid-work-rule-requi
  2. National Council of Urban Indian Health, “NCUIH Releases New Resource on Medicaid Work Requirements and the AI/AN Exemption” (2026-08-14). ncuih.org/2026/08/14/ncuih-releases-new-resource-on-medicaid
  3. Utah Medicaid, “Information for American Indians and Alaska Natives (AI/AN)” (2026-11-13). medicaid.utah.gov/aian/

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