On February 1, 2018, Indiana became the second state to obtain approval by CMS for a Medicaid work requirement as the Trump Administration and CMS have encouraged.
In 2015, Indiana attempted to create a work requirement for Medicaid enrollees, but was prevented from doing so by the federal government. Instead, they created a “Gateway to Work” program as part of their expansion of Medicaid under the Affordable Care Act. Through this voluntary program, people working less than 20 hours a week would be referred by the state to programs that could help them with job searches or training.
Following favorable feedback from the Trump Administration, Indiana elected to amend a waiver that it had previously submitted to include a work requirement. Indiana’s new plan, known as the Health Indiana Plan 2.0 (HIP), amended the voluntary work training in favor of work requirements for able-bodied, working age Medicaid enrollees. The plan states it is designed to help transition Medicaid beneficiaries to commercial health insurance, as enrollees become more economically stable.
The work requirement, called the “community engagement” requirement, will begin in 2019 as a condition of continued coverage and eligibility for adult beneficiaries enrolled in HIP who do not meet an exemption. Exempt beneficiaries include:
- Pregnant women
- Those aged over 60
- The medically frail
- Some caregivers of dependents
- Those enrolled in active substance abuse treatment (the waiver includes a substance use disorder, “SUD” program to improve care and treatment for Medicaid beneficiaries)
In order to maintain coverage, non-exempt enrollees will be require to participate in 20 hours a week of community engagement activities to be phased in over a 18 month period. For example, enrollees will only need 5 hours of community engagement activities a week until their 10th month of enrollment. Community engagement activities include, but are not limited to, employment, education, job skill training, or volunteering. Enrollees must comply with the requirements eight months out of the calendar year. Enrollees that fail to meet the required hours in the preceding calendar year will have their eligibility suspended in the new calendar year until the month following notification by the state that they have completed a calendar month of required hours. If they fail to meet the requirements without an exemption, the individual will be disenrolled from Medicaid and have to reenroll. Good cause exemptions for failing to meet the requirements will be allowed.
HIP enrollees will need to reconfirm their eligibility through a redetermination period which begins 45 days prior to the end of their eligibility period by providing the requested information. Should the beneficiary not comply, they will be subject to disenrollment, but be allowed an additional 90 day reconsideration period. If the beneficiary does not reenroll or show good cause for noncompliance, they will be unable to reenroll for 3 months following the reconsideration period (in total, a 6 month period without coverage).
Other changes include how HIP Plus beneficiaries will be charged premiums. HIP Plus is a program that includes comprehensive benefits, like vision and dental based on a monthly contribution based on income. Following the first year of enrollment where beneficiaries will be encouraged to use state sponsored tobacco cessation options, the state will apply a premium surcharge for those who continue to use tobacco and do not participate in tobacco cessation activities. Additionally, HIP Plus beneficiaries will be charged a premium that is based on income ranges, not to exceed 2% total household income.
As stated in the earlier update, the Medicaid work requirements are highly controversial. In fact, a lawsuit has already been filed to fight the Kentucky requirements by three organizations, the National Health Law Program, the Kentucky Equal Justice Center and the Southern Poverty Law Center on behalf of 15 Kentuckians at risk of losing coverage. The suit claims that the health officials who approved the plan acted illegally and in conflict with Medicaid law that only Congress has the ability to change. It is probable that a similar suit will be filed in Indiana.
In the meantime, waivers including a work requirement are still pending for Arizona, Arkansas, Kansas, Maine, New Hampshire, North Carolina, Utah, Wisconsin and Mississippi. And, additional states, including South Carolina, Alabama, Louisiana, Virginia, Idaho and South Dakota have expressed their interest in developing Medicaid work requirements, with additional states likely to follow.
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