Over the past couple of months there has been lots of news—and lots of speculation—related to Medicaid work requirements (often referred to as community engagement). Some of the headlines include:
- Iowa Senate advances Medicaid work requirement bill
- Va. House may pursue work requirements for Medicaid
- Wyoming moves closer to Medicaid work requirement
- Trump administration sued over new Kentucky Medicaid work requirements
- From June To November 2018, 17,000 People Lost Arkansas Medicaid Benefits Over Failure To Meet Work Requirements
But figuring out what the landscape of work requirements means for the consumers you serve and your organization can be tricky. To assist with this process, our team put together an overview of the Medicaid work requirement landscape.
Before we dive into what states have and don’t have work requirements, I think it is important to level-set on what we mean when talking about work requirements and how they operate. Work requirements are an outgrowth of the non-traditional Medicaid expansion model under the previous administration that allowed states to require Medicaid expansion adults to pay premiums, complete healthy behaviors, and generally, “have skin in the game.” Under the current administration, guidance was released that allowed states to build on this model adding the requirement that able-bodied adults complete work requirements (see Opportunities To Promote Work & Community Engagement Among Medicaid Beneficiaries).
In general, work requirement programs allow able-bodied adults to not only comply by working, but through several other activities—such as education, job training, job search, and volunteering. Exemptions exist for various populations including the medically frail, those who are disabled (but are not eligible for Medicaid through the disability pathway), individuals acting as a caregiver, domestic violence survivors, and those completing addiction treatment. Importantly, states are required to design strategies that connect enrollees to job supports but may not use Medicaid dollars to pay for these support services.
Currently there are seven states that have work requirements approved by the Centers for Medicare & Medicaid Services (CMS). Of these states, six require enrollees to work 80 hours a month, while one New Hampshire, requires enrollees to work 100 hours a month. All seven states suspend enrollment for individuals who fail to meet the requirements, although the ability to “cure” missed hours and the number of non-compliant months that result in suspension vary by state. Additionally, six of the seven states require individuals to also pay premiums, which in some cases will also result in suspension for failure to comply. On top of this, an additional nine states have submitted proposals to CMS to implement work requirements.
For more the non-traditional Medicaid expansion landscape, check out State-By-State Analysis Of Medicaid Expansion, Work Requirements & Premiums: An OPEN MINDS Reference Guide. The report includes a list of states that have expanded Medicaid or are planning to expand Medicaid, the number of states which require premium payments, and the number of states with approved or proposed work requirements. The report also includes an overview of premium and work requirement program structures.
What are the results of these programs? It may be a little earlier to tell. Of those states with approvals only two—Arkansas and New Hampshire—have implemented their programs. New Hampshire implemented their program on March 1, 2019 and beneficiaries have a three-month grace period before the state enforces compliance with the requirements. Arkansas implemented their program in June 2018 and thus far more than 17,000 able-bodied adults have lost coverage.
To understand what all these changes mean for provider organizations, I reached out to Vic Topo, Chief Executive Officer of Center for Life Management in New Hampshire. He explained that work requirements, even when approved bring a lot of uncertainty:
Yes March 1st is the date being used as start of the transition toward the new requirement. However the detailed requirements as of this writing are in the process of being debated and revised by our legislature. We expect amended legislation intent on loosening the requirements such as reducing the hours down from 100 to 80, increasing the variety of circumstances that would result in dramatic decreases in enrollment, counting self-employment, among others. Although not yet decided it’s more likely then not that some or many of these changes will happen given the party swing from the November election.
And he noted that the impact that the events will have on staff and consumers:
Regarding impact to us as a provider, significant number of people currently being served are disabled and/or medically frail which are considered exempt from the requirements. For the others, the net effect of this policy shift at the federal level via the waiver places additional burden on the enrollee in the name of “personal responsibility.” And providers are already enormously challenged with workforce capacity and endless administrative paperwork burden experienced by our staff.
My takeaway? Executive teams of provider organizations should consider the possibility of work requirements as part of the scenario-based planning process (see Building & Executing Strategy In A Complex Market-A Three-Phase Best Practice Model For Success and Considering Future Scenarios: The OPEN MINDS Guide To Scenario-Based Planning). Executives should know how many of their current consumers are likely to be effected by the requirement and put in place the outline of a plan of action to deal with the increased regulations. That plan of action should involve staff engaging consumers and making sure they have an exemption, assisting them in setting their account to report hours, and connecting them to community resources that can help them meet the requirements.
For even more on this topic, join us at The 2019 OPEN MINDS Strategy and Innovation Institute in New Orleans on June 4 for the session, “Taking Action On Social Determinants: New Social Support Models For Consumers With Complex Conditions”—featuring Angela Choberka, Community Partnership Specialist, Intermountain Healthcare, Amber Rich, Community Partnership Specialist, Intermountain Healthcare, and Tracy Luoma, Executive Director, Optum Salt Lake County, Optum Consumer Solutions Group.