By Melissa Patrick
Kentucky Health News
The Centers for Medicare & Medicaid Services launched its framework for Medicaid work requirements on Monday, June 1, which are now required under HR-1, or the federal One Big Beautiful Bill Act.
The interim final rule, which allows the regulation to take effect immediately upon publication without first seeking public comment, requires that certain adult Medicaid applicants and enrollees must, as a condition of Medicaid eligibility, meet an 80-hour-per-month work requirement through employment, education, work programs or community service.
The work/community engagement requirements will impact able-bodied and non-pregnant adults aged 19 to 64 who get their health insurance through the expansion of the Patient Protection and Affordable Care Act to people with incomes up to 138% of the federal poverty line ($22,025 for an individual in 2026). The requirements must be implemented no later than Jan. 1.
The most recent reports from the Kentucky Department of Medicaid Services show there are 1.3 million Kentucky adults and children enrolled in Medicaid, with around 440,000 of the adults enrolled through the expansion program, according to Priscilla Easterling, director of outreach and enrollment with Kentucky Voices for Health.
The final rule also defines which individuals are exempt from the work/community engagement requirement because of health-related needs and other qualifying circumstances.
These exemptions include individuals who are pregnant, postpartum, disabled, medically frail, American Indian or Alaska Native, parents or caregivers of young children and people with disabilities, and those who are already complying with similar requirements through the Supplemental Nutrition Assistance Program (SNAP) or the Temporary Assistance for Needy Families (TANF) program, according to a CMS news release announcing the new requirements.
GOP lawmakers and administration officials have described the policy as a way to combat waste, fraud and abuse in the Medicaid program.
“This rule helps Americans build skills and independence through work, education, job training or community service, creating new opportunities for themselves and their families,” said Dr. Mehmet Oz, CMS director, in the release.
Critics push back
“Critics of work requirements point to evidence that it kicks people off Medicaid who are otherwise entitled to it without meaningfully increasing the share of adults who are working,” Anna Claire Vollers reports for Kentucky Lantern.
For example, she writes, “Arkansas tried instituting work requirements for Medicaid recipients during Trump’s first term in 2018. By the time a federal judge halted the policy less than a year later, 18,000 adults had already lost coverage and reported problems paying off medical debt, delaying healthcare and delaying medications due to cost. Studies later found that Arkansas’ work requirements didn’t increase employment. And data shows that most adults on Medicaid under age 65 are already working.”
The American Academy of Pediatrics, in a statement, called on officials to rescind the Medicaid work requirement rule, saying it will make it harder for families to access healthcare and will lead to people losing their Medicaid coverage altogether.
Also in opposition to the work requirements, the American College of Physicians issued a statement saying, “Most adults covered by Medicaid are already working, caregiving, or would not be subject to this policy due to illness or disability; research shows us that instituting work requirements will not meaningfully increase employment. Community engagement requirements create a tangle of red tape that diverts resources away from patient care and worsens the administrative burden on physicians.”
Primary Care Collaborative President and CEO Ann Greiner also opposed the requirements, saying in a statement that they will “hamper access to preventive services and primary care” and “will undermine stability of practices across the nation.”
Key takeaways
Further, Nathaniel Weixel and Joseph Choi, with The Hill, report on five key takeaways for why the work requirements “may make it much harder for low-income sick people to maintain health coverage next year,” including:
1. An extremely narrow ‘medically frail’ carve-out, with no clear definition of what that meant. Further, the rules are much stricter than was anticipated.
“We do not believe it is reasonable to categorically consider conditions as serious or complex without factoring in criteria such as the severity of the condition,” CMS wrote in the rule.
“So now it’s not going to be enough that you’re in active cancer treatment, or that you have multiple sclerosis, that your diagnosis says as much. Now it has to be a two-step process that you are in active cancer treatment, and the active cancer treatment is prohibiting you from meeting the work requirements of 80 hours a month,” Serafi told The Hill.
2. Self-reporting, for now, but after next year, states will have to verify the exemptions using claims data and other available resources. The patient will have to provide documentation if the state doesn’t have data.
3. Patient groups push back with concerns that this will end up creating more barriers to care for people with serious medical needs, like HIV, viral hepatitis, chronic health conditions and cancer, who will now have to show that they are “sick enough” to qualify for Medicaid, Serafi told The Hill.
4. Millions projected to lose coverage. “Most Medicaid beneficiaries are already working or face barriers to employment. Several projections estimated the Medicaid work requirements will result in millions of people losing coverage,” Weixel and Choi write.
5. Very expensive for states that expanded Medicaid. Between a small window to build a new IT system and the changes to the “medical frailty” definition, states will have a financial burden, The Hill reports.
That said, The Hill reports: “The One Big Beautiful Bill Act provides a one-time appropriation of $200 million to assist with implementation costs. Half of this money will be divided equally across all states, while the other half will be divided out to expansion states by proportion of the residents subject to work requirements.”
Other concerns
Easterling said Kentucky Voices for Health is also concerned about the changes to the medically frail determinations, noting that instead of states being able to use claims data to help automate exemptions for people with complex medical conditions, a more individualized assessment will now be required, based on documentation the individual submits.
“KVH is especially concerned about the cumulative impact of these changes,” Easterling said in an email. “Kentuckians will be facing increased verification barriers, renewals moving from once a year to every six months, more paperwork and member action required to keep coverage, and other significant eligibility and program changes, all within a short implementation window. At the same time, the Department for Community Based Services is facing budget cuts following the state budget passed during this year’s legislative session, even though DCBS staff will be responsible for processing all of this newly required paperwork.
“All of these changes increase the risk that eligible Kentuckians will fall through the cracks and lose coverage, not because they are ineligible, but because they missed a notice, could not gather the right paperwork by the right deadline, or because the state was unable to process paperwork quickly enough.”