The Centers for Medicare & Medicaid Services (CMS) issued guidance on January 11, 2018, allowing states to require Medicaid beneficiaries to engage in “work or other community engagement” activities to maintain their coverage. This is a dramatic departure from Medicaid policy over the past 50 years. Given that CMS is approving work and community engagement requirements through waivers designed to test new provisions in Medicaid, we propose important questions for careful consideration by states and CMS. Since most Medicaid enrollees are already working or would likely be exempt from the new requirements, it will be important to consider the full costs and benefits of the policy change.