There has been discussion in the news over the last few weeks about the President’s decision to allow states to require that people “work” in order to receive Medicaid. This is referred to as the Medicaid work requirement. We want to break down these changes for you and how this might impact the cancer community.
If you live in one of the states that is about to make changes to its Medicaid program, you should definitely keep reading.
What is Medicaid?
Medicaid is the federal health insurance program that covers more than 74 million individuals who have a low income, low resources, and meet some other category of eligibility, such as being a senior, a minor child, or having a disability (receiving Supplemental Security Income (SSI)). In 2014, the Affordable Care Act expanded access to Medicaid to all adults with an income level up to 138% of the federal poverty level ($16,753 for an individual in 2018). Eliminating the low resource requirement and the requirement to be receiving Supplemental Security Income, made it much easier for someone with a cancer diagnosis to get access to Medicaid coverage, and ultimately get access to care.
While Medicaid is a federal program, it is administered by both the federal government and states. Since 2014, 32 states have expanded access to their Medicaid program under the ACA.
There is a lot of discussion about the number of people who receive Medicaid, but don’t work, and whether or not that is fair. Those who are in favor of work requirements for Medicaid believe that “able-bodied” adults should be working if the federal government is going to pay for their health insurance coverage.
Those who are opposed to work requirements are concerned how they might impact people who are unable to work for a variety of reasons or who live in communities where work is difficult to find. Advocates are concerned that the additional administrative requirements will cause people to lose vital coverage, that people will be discouraged from applying for coverage, and that the number of uninsured people will start to rise again. One of the many benefits of lower numbers of uninsured individuals was that it decreases the amount of uncompensated care that hospitals provide. When hospitals have high levels of uncompensated care, they are more likely to close, which impacts access to care for everyone.
Who Receives Medicaid?
According to an analysis by the Kaiser Family Foundation, most Medicaid and CHIP enrollees would be actually be automatically exempt from the requirement because of their age or disability status.
What are the New Medicaid Rules?
In January, the Trump Administration announced its decision to make significant changes to the Medicaid program, by allowing states to apply for waivers to impose work requirements on Medicaid enrollees in their state. The Centers for Medicare and Medicaid Services (CMS) released rules for the states who want to apply for those waivers.
The rules forbids states from imposing work requirements on certain populations, such as the elderly, minor children, individuals who are pregnant, and those receiving SSI.
CMS also requires states to exempt individuals who are “medically-frail.” CMS defines “medically frail” as those who have “disabling mental disorders; chronic substance abuse disorders; serious and complex medical conditions; physical, intellectual, or developmental disabilities that significantly impact the ability to perform one or more activities of daily living; and those who meet Social Security disability criteria.”
While CMS does remind states to consider how some communities have high unemployment rates due to economic factors, it gives states significant flexibility to design their own requirements. CMS also suggested that states could allow for “community engagement” alternatives to work, such as job search, job training, volunteering, community service, or education.
Work requirements are likely to have an impact on everyone receiving Medicaid in a particular state, because everyone will have to document that they meet the requirements. And, the CMS rules allow for states to ask enrollees to certify they are still eligible as often as monthly.
Which States Want Medicaid Work Requirements?
These eleven states have already applied for waivers to add work requirements: Arizona, Arkansas, Indiana, Kansas, Kentucky, Maine, Mississippi (still in process), New Hampshire, North Carolina, Utah, and Wisconsin. Additional states are considering submitting requests.
Since the CMS announcement, Kentucky and Indiana’s waivers have already been approved and those states are moving forward with implementing plans for a Medicaid work requirement.
Click here to learn more about the impact of the Medicaid waivers and to see what the states are asking for in their waivers.
What is in Kentucky’s Waiver?
Kentucky’s waiver requires people to work 80 hours a month, or alternatively to engage in job searching, job training, community service, or education. Drug treatment and caregiving for a non-dependent relative or another person with a disabling medical condition are also considered work activities.
Kentucky Medicaid enrollees can obtain an exception to the work requirement if they can verify one of the following during their month of noncompliance with the work requirement:
- Disability, hospitalization, or serious illness of enrollee or immediate family member in the home;
- Birth or death of a family member living with the enrollee;
- Severe inclement weather including natural disaster; or
- Family emergency or other life-changing event such as divorce or domestic violence.
A primary caregiver of a dependent minor child or adult with disabilities per household is also exempt.
In addition to the medicaid work requirements, the waiver also establishes premiums, deductibles, benefit restrictions, and six-month coverage lock-outs, while eliminating non-emergency medical transportation.
Also included in Kentucky’s waiver is the elimination of the 3-month retroactive coverage for most adults, including those who are medically frail. This was very useful for someone diagnosed with cancer, so that they could start receiving care while their Medicaid application was being processed.
To read a breakdown of Kentucky’s waiver, click here. These changes are set to begin being phased in on April 1, 2018.
However, advocacy groups in Kentucky have filed a lawsuit to stop the implementation of Kentucky’s waiver. Kentucky Governor Matt Bevin has signed an executive order stating that if the court does stop the work requirements, that the Governor will eliminate the expanded access to Medicaid in Kentucky entirely. This would result in 48,000 people in Kentucky losing access to their health insurance coverage.
What is in Indiana’s Waiver?
Indiana’s waiver was approved on February 2, and requires adult enrollees to work an average of 20 hours a month and it is phased in over time. It also has a long list of exemptions and alternatives to employment. In addition to the work requirement, Indiana will also implement a “lockout” provision. Medicaid enrollees who fail to submit their paperwork showing that they still qualify for the program, will be blocked from coverage for three months. Click here to read Indiana’s Medicaid waiver.
Triage Cancer will continue to follow the changes to state programs and how those changes might impact the cancer community and share that information on our blog. Stay tuned.