More than 30 states have proposed or are in the process of implementing Medicaid work requirements, in some cases to enable Medicaid expansion. Read what individual states are doing and what’s behind their efforts.
Since January, when the Centers for Medicare & Medicaid Services (CMS) announced it would allow states to require certain enrollees to participate in work or community engagement activities in exchange for Medicaid coverage, three states have secured federal approval to impose the requirements, nine have proposals pending before CMS, four are drafting them, and at least 16 state legislatures have introduced bills.
Under the new guidelines, states can seek CMS permission to add work requirements for non-elderly, non-pregnant, and non-disabled adults as a condition of Medicaid eligibility. State proposals vary in their scope and political context. In some states that implemented the Affordable Care Act’s (ACA) Medicaid expansion, the work requirement applies only to the expansion population. In other states, it affects a broader group of Medicaid enrollees. Some states are presenting work requirements as a compromise to win political support for or to retain Medicaid expansion, although many non-expansion states are also considering them.
Currently, Arkansas, Kentucky, and Indiana are in the process of implementing these requirements for certain Medicaid enrollees (Kentucky’s waiver now faces a court challenge). Additional states have pending proposals before CMS and others plan to submit them in the next few months. Alabama recently closed the comment period on its draft waiver proposal to add work requirements for parents and caretaker relatives covered by Medicaid. This week, Ohio submitted its application to implement work requirements specifically for its Medicaid expansion population.
Utah recently passed legislation that requires state officials to pursue a waiver to implement Medicaid work requirements in conjunction with its request to expand Medicaid up to only 100 percent of the federal poverty level. South Carolina’s governor directed the state Medicaid agency to develop a work requirements waiver, and the state is in the early stages of doing so. South Dakota’s governor mentioned in his annual address that the state would be seeking a Medicaid work requirement waiver, and a workgroup has begun meeting on the topic with plans to submit an application in July 2018.
In some states, Medicaid work requirement discussions are occurring in state legislatures, and are sometimes tied to proposals to expand Medicaid. During Virginia’s special legislative session in mid-April, the House of Delegates passed its most recent version of the budget that includes provisions to expand Medicaid and require the new, eligible enrollees to work. The legislative package now moves to the state Senate, but the Finance Committee will not be meeting until mid-May.
A number of other states that have not expanded Medicaid have proposed bills to seek federal waivers to implement work requirements for certain adults in their traditional Medicaid programs. Tennessee’s legislature recently passed a bill that is now headed to the governor, who is expected to sign it. Other non-Medicaid expansion states that have introduced Medicaid work requirement bills during their 2018 state legislative sessions include:
- Florida: While the House passed a bill, it did not progress past a Senate committee prior to the legislative session ending.
- Idaho: State legislators added Medicaid work requirements to a bill that also included the proposed Idaho Health Care Plan, but the legislature adjourned without advancing it.
- Missouri: In January, a bill was introduced in the Senate and remains in committee.
- Oklahoma: In addition to the governor issuing an executive order in March for the state to begin drafting a waiver, in mid-April, a bill passed the Senate and is now moving to the House.
- Wyoming: Although the legislature has adjourned, legislation did pass the Senate but did not move forward.
In some states that expanded Medicaid, state legislators have introduced bills that include work requirement proposals. Most of them would apply to a broader group than the expansion population and would include all “able-bodied” adults, such as some parents — with varying exceptions:
- Alaska: Bills were introduced in both the House and Senate in February, but they have not moved past the committee level.
- Connecticut: In February, a Senate bill was proposed (exempting individuals who are the sole caretaker of a dependent), but the legislation stalled.
- Illinois: A bill was introduced in the Senate (exempting adults with dependent children), but it did not move forward.
- Iowa: Legislators proposed a bill in the House, but it did not advance because it was deemed to need additional revision and would be too costly to implement. A similar bill in the Senate has also not moved forward.
- Louisiana: There are bills in both the House and Senate that remain in committee.
- Michigan: In mid-April, a bill was approved by the Senate and now moves to the House; however, the governor’s office has expressed opposition to it.
- Minnesota: A bill was introduced in the Senate in mid-March (exempting individuals who are the sole caretaker of a dependent) and is currently in committee.
- Pennsylvania: A bill in the House passed in mid-April and will move on to the Senate; however last year the governor vetoed a similar bill.
In Colorado, a Medicaid work requirements bill failed to pass a Republican-controlled committee in March — the legislator who voted against it suggested the state should assess the implementation process in other states like Kentucky before moving forward with the program change.
CMS’ guidance left many decisions about the parameters of a Medicaid work requirement to state discretion, such as the number of hours that individuals must complete, penalties for noncompliance, the types of qualifying activities, and how often individuals would need to submit documentation to demonstrate they are meeting the requirements. For states considering adding these types of requirements to their Medicaid programs, there are also many other policy and operational issues to address.
For example, tracking whether enrollees are complying with the work requirements as well as determining which individuals qualify for exemptions is expected to be a complex and costly administrative task — and could result in coverage losses for individuals. An additional factor for states to weigh is that according to an analysis conducted by the Kaiser Family Foundation, most non-elderly adults covered by Medicaid already work — 60 percent are employed either in part-time or full-time jobs. Another 32 percent reported not working due to illnesses or disabilities, enrollment in school, or caregiving responsibilities, and consequently many of these individuals may qualify for work requirements exemptions.
Though many state legislative sessions are coming to a close, this issue is expected to continue to receive active consideration by state policymakers. NASHP will continue to monitor states’ work requirement waiver proposals that have been submitted to CMS in this chart.
If federal funding is not extended for the Children’s Health Insurance Program (CHIP) beyond September 2017, some children may need to transition to exchange coverage. NASHP’s new brief examines potential options and policy questions for improving exchange coverage for children in terms of both affordability and pediatric benefit adequacy. NASHP convened a group of stakeholders including state officials, health policy researchers and advocates to explore ways to maintain affordable and comprehensive children’s coverage. The brief summarizes the key themes from the group’s discussion and builds upon the policy options identified in this previous NASHP brief. Attending #NASHPconf16? Be sure to check out our newly announced session on CHIP.
As a result of the Affordable Care Act (ACA) and the creation of health insurance exchanges, there are more coverage options for pregnant women in all states. In addition to insurance through exchanges, all states offer Medicaid coverage for pregnant women and a number of states also offer them coverage through their CHIP programs. Although there are coverage options for most pregnant women, these different coverage types do have different eligibility criteria, cost sharing and benefits.
NASHP has created a few resources to help explain the different eligibility criteria for multiple coverage options, including a chart that details income eligibility for each state’s Medicaid and CHIP programs from 2013 – 2015 and maps that highlight the income eligibility ranges. NASHP also created a couple of infographics (Julie, Samantha) that note enrollment steps for pregnant women with different income seeking coverage and raise policy implications for states.
View the chart
View the map
Path to Coverage for Pregnant Women: Julie
Path to Coverage for Pregnant Women: Samantha
The following is a statement from NASHP Executive Director Trish Riley regarding the Supreme Court decision on King v. Burwell.
“With their decision today, the Supreme Court has protected coverage for 6.4 million Americans and avoided a crisis for states and their insurance markets, had the insurance subsidies been eliminated. The Court recognized the ACA was built on a state foundation and reaffirms whether a state chooses to establish a state exchange or not, affordable health coverage remains accessible for its residents.
The wait and see period is over and now states can move forward. Leaders in the 34 states that rely on the FFM can examine and improve coordination between their Medicaid and CHIP programs and the FFM to ensure a seamless coverage experience; consider ways to make coverage more affordable in their markets; design new exchange models to offer states more flexible roles; and carefully review opportunities to seek significant waivers in 2017 that will allow for more state experimentation in providing affordable, quality coverage.
The National Academy for State Health Policy (NASHP) looks forward to working with states as they continue their ACA implementation journey, post-King. We will be convening state health policy leaders in early July to discuss next steps and will release a summary of those discussions to inform the broader policy community later this summer.“
In addition to Trish Riley, two of our state health policy leaders are available for media interviews to discuss the case and next steps:
- Carrie Banahan, Executive Director, Office of the Kentucky Health Benefits Exchange
- Peter Lee, Executive Director of the California Health Benefit Exchange
To schedule an interview please contact Lesa Rair, 202-903-2785 or email@example.com
The National Academy for State Health Policy (NASHP) is an independent academy of state health policymakers who are dedicated to helping states achieve excellence in health policy and practice. A non-profit and non-partisan organization, NASHP provides a forum for constructive work across branches and agencies of state government on critical health policy issues.
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Many critical aspects of federal health reform will be implemented by the states. Through program design, regulations, policies and practices, state decisions and actions already play a profound role in shaping the American health care system. Both the House and Senate reform proposals would dramatically change the federal structure within which state health policy operates. Part I of this State Policymakers’ Guide provides a high-level view of existing state roles in the health care system and how federal reform will affect those roles.
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States will have enormous short-term and long-term needs for assistance as they grapple with federal health reform legislation. Significant federal and private resources to support state-level implementation will be necessary. Implementation support must be defined and coordinated quickly. Technical assistance must be provided in a manner that corresponds with state needs. State officials should be involved in the design of technical assistance so that it is most effective given varied state circumstances, needs, and capacities. Technical assistance should inspire innovation among leaders even as it helps all states meet minimum standards of performance.
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This State Health Policy Briefing presents the issues identified by NASHP’s state leadership as their most significant priorities for improving their health systems. As Academy members discussed their priorities, a set of broader themes emerged. These larger policy goals are: Connect People to Needed Services; Promote Coordination and Integration in the Health System; Improve Care for Populations with Complex Needs; Orient the Health System toward Results; Increase Health System Efficiencies. This briefing also provides a more detailed list of states’ priorities presented in four major categories of state health policy: Coverage and Access; Health Systems Improvement; Special Services and Populations; and Long Term and Chronic Care.
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