FRANKFORT, Ky. (AP) — Kentucky became the first state to require many of its Medicaid recipients to work to receive coverage, part of an unprecedented change to the nation’s largest health insurance program under the Trump administration.

The Centers for Medicare and Medicaid Services announced the approval on Friday. The change will require adults between the ages of 19 and 64 to complete 80 hours per month of “community engagement” to keep their coverage. That includes getting a job, going to school, taking a job training course and community service.

The decision marks a dramatic shift for Kentucky, which embraced former President Barack Obama’s Affordable Care Act under its last governor, a Democrat, and won praise for posting some of the largest gains in getting its residents insured.

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