State Proposals for Medicaid Work and Community Engagement Requirements

*Chart updated May 30, 2018*

In January 2018, the Centers for Medicare & Medicaid Services (CMS) issued a new policy allowing states to implement work and community engagement requirements for certain Medicaid enrollees. States would be permitted to seek federal approval to require non-elderly, non-pregnant, and non-disabled adults to participate in these types of activities to qualify for Medicaid or certain aspects of Medicaid coverage. This chart summarizes states’ pending and approved Section 1115 waivers, waiver renewals, and waiver amendments to implement work and community engagement requirements.

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Waiver Status
State Waiver Status
AZ Pending
AR Approved Mar. 5, 2018; implementing June 1, 2018
IN Approved Feb. 2, 2018
KS Pending*
KY Approved Jan. 12, 2018. Three organizations, including the National Health Law Program, the Kentucky Equal Justice Center, and the Southern Poverty Law Center, filed a lawsuit challenging the waiver on Jan. 24, 2018.
ME Pending
MS Pending
NH Approved May 7, 2018
NC Pending; dependent also on state legislation
OH Pending
UT Pending
WI Pending
Medicaid Expansion Status
State Medicaid Expansion Status
AZ Implemented Affordable Care Act (ACA) Medicaid expansion through waiver (originally implemented traditional expansion; state sought waiver and received approval in Sept. 2016 to implement alternative model)
AR Implemented ACA Medicaid expansion through waiver
IN Implemented ACA Medicaid expansion through waiver
KS Has not implemented ACA Medicaid expansion
KY Implemented ACA Medicaid expansion through waiver (originally implemented traditional expansion; state sought waiver in 2016)
ME Medicaid expansion referendum passed in November. 2017 (state has not yet implemented expansion as of January 2018)
MS Has not implemented ACA Medicaid expansion
NH Implemented ACA Medicaid expansion through waiver
NC Has not implemented ACA Medicaid expansion (state legislators have proposed legislation to expand Medicaid through a program called Carolina Cares, which would include work requirements)
OH Implemented ACA Medicaid expansion
UT Has not implemented ACA Medicaid expansion (state has waiver for the Primary Care Network program to provide Medicaid coverage to certain individuals who are chronically homeless, in parole or substance abuse programs, or receiving treatment for mental health issues, as well as some low-income parents) 
WI Has not implemented ACA Medicaid expansion (state has waiver to cover childless adults aged 19-64 up to 100% FPL)
Work Requirement Hours
State Work Requirement Hours
AZ 20 hours/week
AR 80 hours/month
IN Requirements will increase over the course of the individual’s first year of participation, beginning at five hours/week at the seventh month of enrollment and increasing to 20 hours/week at 18 months and beyond

Enrollees must meet the community engagement requirements for eight months per calendar year

KS 20 or 30 hours/week in one-adult households; 35 or 55 hours/week in two-adult households (maximum of 40 hours/week per individual)
KY 80 hours/month; requirements will be phased in by region
ME 20 hours/week, averaged monthly
MS 20 hours/week
NH At least 100 hours per calendar month
NC No details provided; waiver application indicates that work requirements would be a condition of eligibility but are contingent upon proposed legislation being enacted (which does not specify hour requirements)
OH 20 hours/week (80 hours averaged monthly)
UT Hours not specified; three-month participation period

Must participate in job search/training within first three months of enrollment

Must complete the requirement annually

WI 80 hours/month
Qualifying Activities
State Qualifying Activities
AZ -Employment

-Enroll in educational program (part-time, at least 20 hours in total that can be combined with other requirements; full-time students are exempt)

-Attend an Employment Support and Development program, which includes English as a Second Language (ESL) classes, parenting classes, disease management education, health insurance competency courses, and healthy living classes

-Engage in job search activities similar to those required to receive unemployment benefits

-Participate in community service; hours can count for individuals who are transitioning from justice system, living in high unemployment area, or face other significant employment barriers

AR -Employment or self-employment, or those whose income is consistent with being employed/self-employed at least 80 hours/month

-Enrollment in educational program (high school, higher education, or GED classes)

-On-the-job or vocational training

-Job search or job search training (up to 40 hours/month)

-Community service

-Participation in classes on health insurance, using health care, or healthy living (up to 20 hours/year)

-Participating in programs through state Department of Workforce Services

-Compliance with either SNAP or Transitional Employment Assistance (TEA) employment programs

IN -Subsidized or unsubsidized employment

-Participating in state’s Gateway to Work program

-Managed care entities employment initiatives

-Job skills training

-Job search activities

-Education related to employment; general education (e.g. GED or community college)

-Accredited ESL education or homeschooling

-Vocational education/training

-Community work experience

-Community service/public service

-Volunteer work

-Caregiving services for a non-dependent relative or other individual with a chronic, disabling health condition

-Compliance with SNAP work requirements

Certain tribal members will be considered as meeting the Gateway to Work requirement due to tribe’s Pathways employment program.

Gateway to Work will also encourage enrollees with a substance use disorder to seek treatment by considering participation in treatment program as criteria for exemption.

KS -Unsubsidized or subsidized public or private employment

-Work experience (an unpaid, supervised assignment in the public or private sector to help individuals develop work history)

-On-the-job training

-Supervised community service

-Vocational education

-Job search/job readiness activities

-Job readiness case management

-Job skills training directly related to employment

-Education related to employment (e.g. Adult Basic Education, ESL courses, and other courses designed to provide knowledge and skills for a specific job)

-Secondary school attendance

KY -Subsidized or unsubsidized employment

-Self-employment

-Job skills training

-Job search activities

-Enrollment in educational program related to employment (e.g., management training)

-General education (e.g., high school, GED, college or graduate education, ESL classes)

-Vocational education and training

-Community work experience

-Community service/public service

-Caregiving services for a non-dependent relative or other individual with a chronic, disabling health condition

-Participation in substance use disorder treatment

ME -Paid employment

-Self-employment if individual is employed for 20 hours or more per week and receives weekly earnings at least equal to state or federal minimum wage

-Enrollment in educational program at least half-time, with goal of education to gain employment

-Participating in requirements of a state-approved work program

-Workfare or volunteer community service (24 hours/month)

-Job search/readiness assistance

-Combination of education and employment activities

-Receiving unemployment benefits

-Complying with SNAP or TANF work requirements

MS -Working in paid employment

-Self-employment

-Participation with Office of Employment Security

-Volunteering with approved agencies

-Participation in alcohol or drug abuse treatment program

-Compliance with SNAP and TANF work requirements

NH -Subsidized or unsubsidized employment

-Education directly related to employment, in the case of an individual who has not received a high school diploma or equivalent

-Secondary school/course of study leading to a certificate of general equivalence

-Enrollment at an accredited community college, college or university that is counted on a credit hour basis

-Vocational training (not to exceed 12 months)

-On-the-job training

-Job skills training related to employment

-Job search/readiness activities, such as job training workshops and time spent with employment counselors

-Participation in substance use disorder treatment

-Community service and public service

-Caregiving services for a non-dependent relative or other individual with a disabling health, mental health, or developmental condition

-Compliance with SNAP or TANF work requirements

NC No details provided; waiver application indicates that work requirements would be a condition of eligibility but are contingent upon proposed legislation being enacted (which does not specify qualifying activities)
OH -Work or participation in a community engagement activity (or a combination of the two)

-Community engagement activities include:

-SNAP education and training activities

-Job search/job readiness programs (for no more than 30 days)

-Work Experience Program

UT -Online job search/training, completed through the Department of Workforce Services; participation activities will be the same as those for SNAP program

-Compliance with SNAP work requirements

WI Will follow state’s FoodShare Employment and Training program model
Population Group
State Population Group
AZ Able-bodied individuals age 19 or older in an ACA Medicaid expansion group
AR Non-medically frail individuals ages 19-49 in ACA Medicaid expansion group, with individuals ages 19-29 exempt in 2018 (in the waiver, the state also requested limiting the ACA Medicaid expansion eligibility group to those earning 100 percent of the federal poverty level (FPL) or less; this aspect of the waiver was not approved)
IN Able-bodied individuals enrolled in Healthy Indiana Plan (HIP), up to age 60
KS Able-bodied adults under age 65
KY Able-bodied adults ages 19 to 64

Kentucky HEALTH beneficiaries who have not been subject to the requirements in the past five years will be provided a three-month grace period prior to being subject to the requirements

ME Able-bodied adults ages 19-64
MS Non-disabled adults ages 19-64 covered under traditional Medicaid, including low-income parents and caretakers and individuals eligible for transitional medical assistance
NH Able-bodied adults covered by the ACA Medicaid expansion
NC If proposed legislation is enacted and ACA Medicaid expansion implemented, requirements would apply to adults eligible for Medicaid through the ACA Medicaid expansion
OH Able-bodied adults in ACA Medicaid expansion group, up to age 50
UT Initially Primary Care Network enrollees under age 60; adults without dependent children to be added at a later date
WI Adults ages 19-49 who are eligible for Medicaid as a childless adult
Exempted Groups
State Exempted Groups
AZ -Individuals 55 years and older

-Native Americans

-Post-partum women

-Former foster youth up to age 26

-Individuals with serious mental illness

-Individuals receiving temporary or permanent disability benefits

-Individuals determined to be medically frail

-Full-time high school students 18 and older

-Full-time college or graduate students

-Victims of domestic violence; homeless individuals

-Individuals recently impacted by catastrophic event (e.g. natural disaster or death of family household member)

-Parents, caretaker relatives, and foster parents

-Caregivers of family members in state long-term care system

AR -Individuals 50 and older

-Full-time students (attending high school, an institution of higher education, vocational training, or job training)

-Those exempt from SNAP work requirements

-Those receiving Transitional Employment Assistance (TEA) cash assistance or who are exempt from TEA work requirements

-Individuals incapacitated in the short term or medically certified as physically or mentally unfit for employment, or has an acute medical condition validated by a medical professional that would prevent compliance with requirements

-Caregivers of an incapacitated individual

-Those who live with a minor dependent child age 17 or younger

-Those receiving unemployment benefits

-Those participating in alcohol or drug addiction treatment program

-Pregnant women, through the end of post-partum care

IN -Full- and part-time students

-Pregnant women

-Primary caregivers of a dependent child below the compulsory education age, or who are primary caregivers of a disabled dependent

-Medically frail individuals

-Certification of temporary illness or incapacity

-In active substance use disorder treatment

-Individuals over age 59

-Former foster care youth under age 26 (they are not covered under the demonstration)

-Homeless individuals

-Individuals who are meeting or are exempt from TANF work requirements

-Recent incarceration (within last six months)

-Individuals enrolled in state’s Medicaid employer premium assistance program

-Some other exemptions possible based on individual review

KS -Individuals receiving long-term care, including institutional care and Money Follows the Person

-Individuals enrolled in or on the waiting list for certain Home- and Community-Based Services waiver programs

-Pregnant women

-Individuals with disabilities and who are receiving SSI

-Caretakers for dependent children under age 6 or those caring for a disabled household member

-Individuals who have an eligibility period that is only retroactive or who are presumptively eligible for Medicaid

-Individuals enrolled in MediKan program

-Individuals whose only coverage is under a Medicare Savings Program

-Individuals enrolled in Programs of All-inclusive Care for the Elderly (PACE)

-Individuals with TBI, HIV, or who are in the Breast and Cervical Cancer Program

-Certain caretakers of KanCare members age 65 or older who meet certain criteria

-State may also consider an exceptions process for individuals who have certain behavioral health conditions

KY -Children under age of 19

-Pregnant women

-Primary caregivers of a dependent (either minor child or disabled adult; limited to only one exemption per household)

-Medically frail individuals

-Full-time students

-Former foster care youth

-Individuals diagnosed with an acute medical condition that would prevent them from complying with the requirements

ME -Those residing in institutional residential facility (e.g., nursing facility)

-Those residing in residential substance abuse treatment and rehabilitation program

-Caregiver of a dependent child under age 6

-Providers of caregiver services for an incapacitated adult

-Pregnant women

-Those who are physically or mentally unable to work. If this is not evident then medical certification is required.

-Those receiving temporary or permanent disability benefits issued by governmental or private resources

MS -Native Americans

-Pregnant women

-Children under age 19

-Disabled individuals; individuals enrolled in 1915 (c) waivers

-Individuals 65 years and older

-Individuals residing in an institution

Exemptions will also apply to an individual who is:

-Diagnosed with mental illness;

-Receives SSDI, or is a primary caregiver of individual who cannot care for self;

-Physically or mentally unable to work per determination by Disability Determination Services;

-Receiving or has applied for unemployment insurance

-Participating in an alcohol or drug abuse treatment program;

-Enrolled in an institution of higher learning at least part time; or

-High school student age 19 or older, attending at least half-time.

NH -Individuals temporarily unable to participate due to illness or incapacity as documented by a licensed provider

-Individuals participating in a state-certified drug court program

-Parent or caretaker where the required care is certified as necessary by a licensed provider

-Parent or caretaker of a dependent child under age 6 (only one exemption per household)

-Parent or caretaker of a dependent child of any age with a disability

-Pregnant women or women 60 days or less post-partum

-Medically frail individuals

-Individuals with a disability who are unable to comply due to disability-related reasons

-Individuals residing with an immediate family member with a disability and are unable to meet requirements due to family member’s disability

-Individuals who experience a hospitalization or serious illness, or who reside with an immediate family member who experiences a hospitalization or serious illness

-Individuals who are exempt from TANF or SNAP work requirements

-Individuals enrolled in state’s voluntary Health Insurance Premium Program

NC -Individuals who are caring for a dependent minor child, an adult disabled child, or a disabled parent

-Individuals receiving active treatment of substance use disorder

-Individuals who are medically frail

Waiver application also notes that the state and tribal representatives will work with the legislature to address the application of work requirements for tribal members

OH -Individuals age 50 and older

-Individuals who are physically or mentally unfit for employment

-Individuals who are caring for a disabled or incapacitated household member

-Pregnant women

-Parent/caretaker/individual residing in same house with minor child

-Individual who has applied for or is receiving unemployment benefits

-Students who are in school at least half time

-Individuals who are participating in a drug or alcohol treatment program

-Individuals who are subject to and complying with any work requirement under the Ohio Works First program

-Applicants for or recipients of SSI

-Individuals participating in the state’s Specialized Recovery Services program

-Eligible incarcerated individuals

UT -Individuals age 60 and older

-Physically or mentally unfit for employment (verification may be required)

-Parents/caretakers with dependent child under age 6

-Caretaker for incapacitated individual

-Receiving or has applied for unemployment insurance benefits

-Participation in drug and alcohol treatment program

-Student enrolled at least half time in any school or training program

-Participation in refugee employment services

-Family Employment Program (FEP) recipients or those issued a FEP diversion payment

-Individuals working more than 30 hours/week

WI -Diagnosed with mental illness

-Individuals receiving SSDI

-Primary caregiver of individual who cannot care for self

-Physically or mentally unable to work

-Receiving or has applied for unemployment insurance

-Participating in alcohol or drug abuse treatment program

-Enrolled in institution of higher learning at least half time

-High school students age 19 or older, attending at least half-time

Penalties for Non-Compliance
State Penalties for Non-Compliance
AZ Compliance must be verified every six months (bi-annually), along with any changes in family income or other eligibility factors.

Individuals who do not meet requirements will have an initial six-month grace period; noncompliance after this period will result in disenrollment. Individuals will be permitted to re-enroll after demonstrating compliance for at least 30 days.

Individuals who meet the requirements, but then become non-compliant can become compliant by: 1) If determined non-compliant at redetermination and non-compliance was within three months of redetermination, an individual will have three additional months after redetermination to become compliant.

2) If determined non-compliant at redetermination and non-compliance was more than three months prior to redetermination and any circumstance changes were not reported, an individual is disenrolled and can re-enroll after demonstrating compliance for at least 30 days.

3) If individuals report changes in circumstance that result in non-compliance, they will have three months to become compliant.

Arizona is also proposing a lifetime coverage limit of five years for most able-bodied adults, which is connected to the work requirement:

· Time during which an enrolled individual is compliant with work requirement would not be counted toward this time limit.

· Time during which an exemption to the work requirement was applicable would not be counted toward the time limit.

AR Individuals must demonstrate compliance on a monthly basis.

Loss of eligibility if enrollee fails to meet work requirements for any three months during the coverage year (either consecutive or non-consecutive months), with coverage termination occurring at the end of the third month of noncompliance. Unless a good cause exemption is met, individual would be locked out of coverage until start of next coverage year and would need to file a new application at that time.

Good cause exemptions include:

-Disability of individual or if individual has an immediate family member in the home with a disability and is unable to meet requirements for due to this;

-Hospitalization/serious illness of the individual or an immediate family member in the home;

-Birth or death of a family member in the home;

-Severe inclement weather or natural disaster causing inability to meet requirement; or

-Individual has family emergency or other life changing event (e.g., divorce or domestic violence).

If state determines that an individual’s failure to comply or report compliance was the result of a catastrophic event or circumstances beyond an individual’s control, the individual will receive retroactive coverage to the date coverage ended without the need for a new application.

IN Each December, state will evaluate if enrollees have met work requirement hours for the prior 12-month calendar year.

If requirements are not met, eligibility will be suspended beginning on the first day of the new calendar year.

Individuals with suspended benefits can reactivate eligibility by meeting one of the following criteria: 1) becoming eligible under another eligibility group; 2) qualifying for an exemption; 3) completing one calendar month of the work requirement hours and submitting documentation information to the state.

Unless an individual reactivates eligibility, eligibility will remain suspended until redetermination date; if at that time the individual does not qualify for an exemption, enrollment will be terminated and individual will need to reapply to regain coverage.

Good cause exemptions include, but are not limited to: 1) Individual has a disability or has an immediate family member within the home with a disability and was unable to meet requirements due to this; 2) Individual is a victim of domestic violence; 3) Additional circumstances may be granted exemptions, as the state deems necessary.

KS Individuals who are subject to work requirements but do not comply with them can receive a grace period of up to three months of KanCare coverage in a 36-month period (state can authorize an additional month of eligibility for coverage in exceptional circumstances, e.g. natural disasters).

Individuals who exhaust their three-month grace period will be disenrolled from KanCare until compliance is achieved.

Individuals who are subject to work requirements and do comply with them are limited to a lifetime limit of 36 months of coverage. (on May 7, 2018, CMS indicated it would not approve this lifetime limit).

KY After a one-month opportunity to become compliant, individuals who fail to meet requirements for a month will have their benefits suspended unless a good-cause exemption is issued.

Good cause exemptions include:

-Disability of the individual or if individual has an immediate family member in the home with a disability and is unable to meet requirements for due to this;

-Hospitalization/serious illness of the individual or an immediate family member in the home;

-Birth or death of a family member in the home;

-Severe inclement weather or natural disaster causing inability to meet requirement; or

-Individual has family emergency or other life changing event (e.g., divorce or domestic violence).

Individuals can reactivate eligibility on the first day of the month after the individual complies with the requirements during a 30-day period or completes a state-approved health literacy or financial literacy course (the option to take a course is only available once in a 12-month benefit period).

Individuals who, during a suspension period, become pregnant, are determined to be medically frail, become a primary caregiver of a dependent (either minor child or disabled adult — limited to only one exemption per household), are diagnosed with an acute medical condition that would prevent them from compliance with requirements (validated by a medical professional), or become a full-time student, or become eligible for Medicaid under an eligibility group not subject to the work and community engagement requirements can reactivate benefits, with an effective date aligned with their new eligibility category or status.

Individuals with suspended benefits at the time of their redetermination date who do not qualify for an exemption will have their enrollment terminated and will have to submit a new application to regain coverage

ME Failure to comply will include a determination of whether individual meets a good-cause exemption.

Individuals who are subject to the requirements and do not meet them may receive up to three months of coverage within a 36-month period

Individuals who fail to comply with the requirements and have exhausted the three-month allowance of coverage will be disenrolled until they become compliant.

MS Failure to comply will result in loss of eligibility on first day of the month following the report or identification of non-compliance.

Individuals who do not comply with requirements within six months of termination or within six months or less of their reassessment date will need to submit a new application for benefits.

NH Failure to comply will result in suspension of eligibility, unless there is a good cause exception.

Good cause exceptions include:

-Disability of the individual or if individual has an immediate family member in the home with a disability and is unable to meet requirements for due to this;

-Hospitalization/serious illness of the individual or an immediate family member in the home;

-Birth or death of a family member in the home;

-Severe inclement weather or natural disaster causing inability to meet requirement;

-Individual has family emergency or other life changing event (e.g., divorce or domestic violence); or

-Other reasons as defined or approved by the state.

If individuals are non-compliant, the state will inform individuals that their eligibility will be suspended at the end of the following month, until an individual reports that they meet a good cause exception or qualify for an exemption, or that they make up the deficient hours for the month that resulted in noncompliance.

If individuals remain non-compliant or do not meet an exemption, the state will suspend eligibility effective the first of the month following the one-month opportunity to cure.

NC No details provided; waiver application indicates that work requirements would be a condition of eligibility but are contingent upon proposed legislation being enacted (which does not specify penalties for non-compliance)
OH All Medicaid beneficiaries are required to report any changes that could affect eligibility within 10 days; given this, individuals subject to the work requirements must report if they are not meeting the requirements. Failure to comply will result in the termination of Medicaid coverage, unless a good cause reason or exception is met.

Good cause reasons include circumstances beyond an individual’s control, such as (but not limited to):

-Illness

-Illness of another requiring the presence of the individual subject to the requirements

-Emergencies

-Unavailability of transportation

-Domestic violence

If there is no good cause reason for the individual not meeting the requirements or the individual does not qualify for an exemption, the state will assign the individual to a new activity. If the individual declines to participate, Medicaid coverage will be terminated.

UT Failure to comply will result in loss of Primary Care Network eligibility

Individuals can become eligible again by meeting requirements; these individuals must reapply

Native Americans/Alaska Natives will be enrolled in the work requirement program but benefits will not be terminated for non-compliance

Utah is also proposing to add a 60-month lifetime limit on the number of months an adult can receive Primary Care Network (PCN) coverage or Medicaid for Adults without Dependent Children. Any month an individual receives Medicaid for Adults without Dependent Children will count toward the lifetime limit. Any month that an individual receives PCN and does not meet SNAP work participation exemptions will also count toward the lifetime limit. Native Americans will be exempt from the lifetime limit provision.

WI The state is also seeking to implement a 48-month enrollment time limit, which includes the following work requirement penalties and exemptions:

· The time during which individuals are not working will count toward the state’s proposed 48-month cumulative eligibility time limit (after which an individual would not be eligible for six months).

· The time during which individuals are working or participating in an employment and training program for at least 80 hours a month will not be counted toward an individual’s 48-month time limit.

Kansas submitted a waiver proposal to CMS in December 2017 that included Medicaid work requirements for certain individuals; on Jan. 24, 2018, officials indicated they will withdraw the request, but still seek to implement work requirements for some Medicaid enrollees.