Days after CMS first issued policy guidance on how states could require “able-bodied” Medicaid beneficiaries to work or face losing their coverage, Kentucky has become the first with an approved waiver to test out those requirements.

Under Kentucky’s Kentucky HEALTH (Helping to Engage and Achieve Long Term Health) plan, adult Medicaid beneficiaries will have to complete 80 hours per month of “community engagement"—which could include working, going to school, attending job training course or volunteering—in order to maintain their benefits.

Beneficiaries who are medically frail, have an acute medical condition, as well as the elderly, pregnant women and those who are the “primary caregiver” for a child will be exempt from the requirements. Kentucky Gov. Matt Bevin said at a press conference announcing the waiver approval that he expects his state to “become the model of the nation.”

“Most human beings don't like being wards of someone else,” he said. “It’s the antithesis of how we're created.”

Besides work requirements, the waiver also makes several other changes to Kentucky’s Medicaid program. Most beneficiaries will now have to pay premiums, up to a maximum of $15 per month for enrollees who make between 100 and 138 percent of the federal poverty level. Those same enrollees would also need to pay their premium before their coverage goes into effect.

Failure to pay a premium after a 60-day grace period would result in them losing coverage and being unable to enroll again for six months unless all past due and current premiums and the beneficiary completes a “state-approved health literacy or financial literacy course.” Enrollees can also get locked out for failing to register annually or report a life change which could impact Medicaid eligibility. Additionally, retroactive eligibility for Medicaid will be waived “for certain populations.”

Liberal-leaning groups had already hinted at challenging Medicaid work requirements in court before the Kentucky waiver was approved, and some of those same groups harshly criticized at the policies in the state’s demonstration project.

“This administration and its allies should be promoting access to care, not taking coverage away from millions,” wrote Janel George, senior counsel of the National Women’s Law Center. “This dangerous action, based on a false racist premise of Medicaid enrollees, will wreak very real harm on the health and economic security of millions of women and families.”