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A little more than a year from now, new Medicaid work requirements kick in. They are part of the domestic policy law approved by congressional Republicans and North Dakota is beginning the prep work to make sure systems are ready and people are aware of the changes.

By December 31 of next year, states must implement work requirements for adults receiving Medicaid coverage, if they fall under an expanded program. Each month, they will have to do 80 hours of work, school, or volunteering to stay eligible.

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Sarah Aker, executive director of the Medical Services Division for the North Dakota Department of Health and Human Services, said roughly half the recipients in North Dakota already work, with others meeting separate benchmarks. Still, she stressed outreach is needed.

"We anticipate doing a lot of education over the next year about this," Aker emphasized. "They should expect to get more mail from us informing them of these changes. We'll also be doing a lot of updates to our website."

She expects extra communication with providers, assistance groups and local public health leaders. Aker does not think North Dakota will feel the effects as much as other states, with 3 percent to 5 percent of recipients here at risk. Nationally, the Congressional Budget Office said the changes will result in several million people losing health coverage. Republicans insist Medicaid will be intact for the most vulnerable Americans.

Supporters of the changes said they promote self-sufficiency, but many policy analysts say enhanced work requirements create administrative burdens and allow recipients to fall through the cracks. In North Dakota, Aker noted they hope to automate eligibility checks as much as possible.

"We're going to try to reuse as many existing data sources or data points that we have," Aker explained. "Now, there are some things we don't know. For example, we don't collect information today on educational activities, so that'll be something that we'll figure out – what that process will look like – as we get more guidance from our federal partners."

Despite the state's optimism about minimal effects, advocates for low-income households warn about derailing progress in reducing uninsured rates. The requirements call for eligibility checks every six months. Even with exemptions for some populations, the American Association of People with Disabilities said many Medicaid recipients do not have a computer, smartphone or reliable transportation as they navigate administrative systems.