Medicaid work rules don’t apply to Native Americans. They could still lose coverage.

CHEROKEE, N.C. — Two months before the deadline to implement new Medicaid work requirements, states had yet to receive detailed guidance from federal health officials on how to exclude Native Americans from those rules, leading to a patchwork of eligibility checks that pose challenges for qualified enrollees trying to keep their health insurance. President Donald Trump’s One Big Beautiful Bill Act excluded Native Americans from having to meet the work requirements to keep their Medicaid eligibility. But the rules issued by the Centers for Medicare & Medicaid Services didn’t provide a standardized system to help states identify Native Americans who should be excluded, leaving states to figure it out for themselves. Native leaders fear the limited guidance will mean a repeat of the Medicaid “unwinding” in 2023, when states resumed checking qualifications for eligibility after a covid-era pause. An estimated 850,000 Native Americans lost coverage by May 2024, often for paperwork reasons.

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