Some North Carolinians who get their health insurance through Medicaid will soon have to meet a new work requirement, and others could lose coverage altogether as new rules from the federal government take effect later this year.
Long-term cuts to the program could put hundreds of thousands of North Carolinians’ coverage at risk, and now some state lawmakers say North Carolina might not have the time or money to implement the changes the federal government requires.
The changes come from one of the Trump Administration’s signature pieces of legislation signed into law last summer known as the “One Big Beautiful Bill.” It cuts $1 trillion from Medicaid over the next 10 years and creates stricter eligibility requirements.
On Tuesday, leaders from state and local agencies told a legislative committee that they are concerned about meeting certain deadlines in the law, including one that requires states to make sure Medicaid beneficiaries are meeting new work requirements by next year.
“I think it’s too fast, too much work to do, and I just don’t see how we can do it,” state Rep. Donny Lambeth told reporters after Tuesday’s meeting.
“I think we’ll need at least another six months before we can be in a better position,” adding that he would be in touch with North Carolina’s Congressional delegation to talk about extending the law’s deadlines.
Here’s what you should know about Medicaid, when the changes are coming, and who could lose coverage if the state can’t close the funding gap.
What is Medicaid?
Medicaid provides health insurance coverage for low-income individuals, children and some people with disabilities. It covers more than 3.1 million people across North Carolina, or more than a quarter of the state’s residents.
There are various eligibility requirements based on a family’s size and income. For example, North Carolina Medicaid covers single people who make $1,800 per month or less. It covers a family of four that makes $3,698 per month or less.
Medicaid, like other health insurers, has a network of doctors. If you’re on Medicaid, you have to find a doctor who accepts Medicaid or pay for your doctor’s visits out of pocket.
How did we get here?
In 2010, the Affordable Care Act greatly expanded Medicaid to cover the gap between people who did not make enough money to afford insurance through HealthCare.gov and those who earned too much to qualify for Medicaid as it existed then.
Republican leaders in the North Carolina legislature resisted Medicaid expansion, arguing the state’s program was already grappling with a budget deficit. They feared that the deficit could balloon if Congressional Republicans were successful in repealing the Affordable Care Act. They were also ideologically opposed to the law, known as Obamacare.
But in 2023, the federal government upped its financial incentives. Legislative Republicans drafted a bill that expanded Medicaid, but made it contingent on the federal government maintaining its share of funding for the program. Put simply, the cuts in the “One Big Beautiful Bill Act” could trigger North Carolina’s law to undo the expansion.
Medicaid enrollment climbed quickly after expansion officially started in December of 2023. In less than 18 months, 650,000 people got health insurance through the state’s Medicaid expansion.
How does the “One Big Beautiful Bill” change things?
The law makes sweeping changes to Medicaid, some of which are set to start later this year.
North Carolina’s Department of Health and Human Services outlined how and when changes to Medicaid will affect the state. Here’s what you need to know:
By January 1, 2027, states will have to show that certain Medicaid beneficiaries are meeting the law’s new work requirement: if you’re between 19 and 64 and are able to work, you will be required to log 80 hours per month of work or “qualifying activities.”
The state health department says that can include going to school, volunteering in your community, or participating in a work training program. You will have to log these hours with your county Department of Social Services each month.
Certain groups will be exempt from work requirements, including pregnant and postpartum individuals, parents or guardians of children age 13 or younger, and some people with disabilities.
Under the new law, your local social services department will start re-checking your eligibility every six months, a rule that some local officials say will require more staff and cost counties more money.
“Every Medicaid eligibility review, every SNAP redetermination, every verification step, and every new work-requirement check is executed by county employees, funded in part and often largely by counties,” Kevin Leonard, executive director of the NC Association of County Commissioners, said at Tuesday’s meeting.
“Congress may reduce federal costs, but it shifts enormous administrative and financial pressure onto state and county systems. Counties cannot absorb that without cutting services, delaying investments, or raising property taxes,” Leonard said.
- Eligibility for immigrant groups
Starting later this year, eligibility will narrow for certain lawfully-present immigrant populations.
The “One Big Beautiful Bill” ends Medicaid eligibility for refugees, asylum seekers and some humanitarian groups that previously qualified for coverage. It also explicitly prohibits coverage for people who are living in the country without legal status, though those individuals were already disqualified from Medicaid in North Carolina except in two specific circumstances: they are experiencing a life-threatening emergency like a heart attack or stroke, or they are giving birth.
Who is at risk of losing coverage?
People might still qualify for Medicaid on paper, but lose coverage because they miss paperwork deadlines, can’t easily document work hours, or struggle to navigate county social services offices.
This happened in Arkansas when the state added work requirements to Medicaid eligibility in 2018. About 1 in 4 people who were subject to the work requirement lost their coverage even though more than 95% of them met the requirements or should have been exempt.
“An estimated 255,000 North Carolinians are at risk of losing coverage under Medicaid work requirements and stricter eligibility checks due to federal legislation,” DHHS spokesman James Werner told NC Local in an email. “This includes approximately 213,000 individuals who recently gained coverage through Medicaid expansion.”
If you lose your coverage and can’t get insurance through your employer, you can seek coverage through HealthCare.gov. But Congress recently allowed some Affordable Care Act subsidies to expire and on average, premiums have doubled from what they were last year.
What happens next?
Part of the struggle for county officials and state health leaders stems from the lack of a state budget. North Carolina is the only state operating without a budget this year.
Leaders in the state health department and the NC Association of County Commissioners implored lawmakers to pass a state budget to provide funding for Medicaid by March.
But Republican leaders in the state House and Senate have been at odds over their budget proposals since last summer. State Rep. Donny Lambeth, co-chair of the Joint Legislative Oversight Committee on Medicaid, said Tuesday, “I’m not sure we’ll be back before April.”
As these changes roll out over the next few years, state lawmakers will decide how aggressively North Carolina complies, how much money to set aside, and whether to revisit any part of the expansion framework itself.
In the meantime, Medicaid participants should watch for any correspondence from their county Department of Social Services. A letter, email, call or text might tell you whether you will be subject to the new work requirement and how to file, or in the worst case, whether you might lose your coverage.
This article first appeared on NCLocal and is republished here under a Creative Commons Attribution-NonCommercial 4.0 International License.
