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.