Sixteen states have submitted Section 1115 Waivers to the Center for Medicare and Medicaid Services (CMS), requesting that a person’s eligibility to receive Medicaid be contingent on their participation in community engagement activities (also referred to as “work requirements”). States have flexibility to define the activities that would meet community engagement or work requirements, and have included activities such as:
- Working full or part-time;
- Certain caretaking activities
- Volunteering at approved organizations;
- Attending school; and
- Participating in substance abuse programs.
States also have the flexibility to determine the population for which community engagement activities will be required. Most states exempt children under age 19, pregnant women, disabled individuals, individuals over age 65, and individuals acting as primary caregiver of a child or a disabled person.
Currently, CMS has approved waivers with community engagement activity or work requirements from Arkansas, Wisconsin, Indiana, Kentucky, and New Hampshire. Arkansas began implementation in June 2018, with the remaining states slated to begin in 2019.
In less than six months following their implementation, Arkansas removed 12,277 individuals from the state’s Medicaid program, causing concern among many health policy experts about the ramifications of implementing community engagement requirements. Earlier this month, the Medicaid and CHIP Payment and Access Commission (MACPAC), sent a letter to the Secretary of the U.S. Department of Health and Human Services articulating its concerns and suggested actions related to dis-enrollment of individuals from Arkansas Medicaid. In the letter, MACPAC outlined that 91.6 percent of those individuals who were required to report on community engagement activities in September 2018 failed to do so. Regardless of your feelings about these requirements, this data point underscores the need to approach such requirements with extreme diligence.
As the first state to enact this policy, Arkansas provides other states with the opportunity to observe its implementation and develop their own best practices. In particular, states hoping to implement such requirements should give careful consideration to the needs of the population being faced with responding to new requirements, technological changes, member communications, and reporting that this change entails.
States must consider what changes will be needed to the existing Medicaid Management Information System (MMIS) system related to the new eligibility standards. Specifically, states must decide how they will monitor and track individual compliance with the new requirements to ensure accurate eligibility determinations in accordance with the new policy. As evidenced by the MACPAC statistics above, states should also consider having more than one way by which beneficiaries may satisfy the reporting requirements than via an online portal.
Arkansas’ implementation included the design of an online portal for individuals to access and verify their exemption or compliance with community engagement activities. The online portal, described in Arkansas’s Eligibility and Enrollment Monitoring Plan, aimed to be administratively efficient, reduce paper documentation, and reinforce computer skills for the population subject to the new policy.
Operational and system limitation questions that states should consider when deciding whether to implement community engagement or work requirements include:
- What type of indicator will be used in the MMIS to distinguish individuals who are subject to community engagement activities?
- Will exempt populations also need an indicator in the MMIS?
- How will compliance with community engagement activities be reported to the Medicaid agency?
- Will the state offer more than one avenue for reporting to meet the needs of the population (e.g., mail, fax, and/or phone?)
- Should the state suspend or terminate eligibility?
- How will compliance with community engagement activities be relayed to the MMIS (e.g., manual input, data uploads, etc.)? If data uploads, how often will the data be accessed and uploaded into the MMIS?
- What system modifications are necessary to accommodate data-sharing opportunities to assist with reporting and/or monitoring compliance?
- Are data-sharing agreements needed for state partners such as SNAP, TANF, or Workforce Development agencies if they are assisting with monitoring and/or compliance?
- Does the waiver approval call for a lock-out period for non-compliant individuals and, if so, how will that impact eligibility determinations at the local level and in the MMIS?
States should make all decisions after giving careful consideration not only to the existing system limitations, but also to potential administrative burdens. For example, suspending member eligibility for reported non-compliance (as opposed to terminating it) may simplify an individual’s re-enrollment process. Since enrollment suspension negates the need for a new Medicaid application, opting for this method instead of termination would reduce the workload and paperwork necessary for member eligibility determination and benefit restoration, and potentially prevent almost 9,000 enrollees from being terminated in a single month.
In addition to considering system modifications, states implementing community engagement or work requirements should develop a member communication strategy that outlines a plan for disseminating policy change announcements and updates to affected Medicaid members, including:
- Specific information related to the new policy;
- Clear descriptions of acceptable activities;
- How eligibility will be impacted;
- Any lock-out periods for non-compliance;
- Methods for reporting compliance with the new requirements or method for obtaining an exception; and
- Who to contact with questions related to the new policy and how to obtain assistance with meeting community engagement activities.
States must also consider how they will send notices of adverse action to ensure compliance with Federal regulations related to eligibility notices, fair hearing and appeal processes for Medicaid eligibility. In order to be effective, communications should be frequent and ongoing.
Medicaid eligibility has traditionally been determined by income or health status. As such, community engagement or work requirements are a new concept for the majority of the Medicaid population. Many organizations are monitoring the implementation of these requirements for indications of a state’s success or failure. Therefore, it is important that states implementing community engagement requirements are able to accurately report changes in eligibility. If states are working with partners, such as workforce development agencies, to assist individuals in complying with the new requirements, it is important to develop tracking mechanisms for those individuals dis-enrolled from the Medicaid program. States should consider developing reports that detail:
- How many Medicaid members are subject to community engagement requirements;
- How many Medicaid members are in compliance with the new requirements;
- How many individuals were referred to a partner agency for assistance, and the result of the referral; and
- How many Medicaid members who are subject to the new requirements dis-enrolled from Medicaid and the reason for dis-enrollment.
Tracking an individual’s reason for dis-enrollment from the Medicaid program is vital to determining the impact of the new policy and making modifications, if necessary. For example, if a high percentage of individuals dis-enroll due to obtaining employment, that state’s implementation process could be described as a success. Conversely, dis-enrollment owing to a failure to report is a sign of barriers that need to be addressed.
Ultimately, if states’ overarching goal in introducing community engagement activities into their Medicaid programs is to assist individuals with obtaining employment and increase their social mobility, they should carefully consider how the policies they put in place impact those individuals in practice.