Time Sensitive: Medicaid Work Requirements

by Sarah Terzo

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At the end of this article will be a link to take action.

Medicaid work requirements will soon go into effect. States have some flexibility as to when they implement them, but every state must have them in place by January 1, 2027.

Details of the New Policy

To stay on Medicaid, adult recipients between the ages of 19 and 64 must document that they’re working at least 80 hours a month, are enrolled in an educational program, or have a monthly income equivalent to minimum wage multiplied by 80 hours.

There are some exceptions to the rule. However, some of these exceptions are optional and not required.

For example, states can (but don’t have to) temporarily exempt people who are in a nursing home, hospital, or care facility. They can exempt those who are living in a county with a high unemployment rate, or in a federal disaster area, and those who need to travel outside their community “for an extended period of time” to get treatment for “a serious or complex medical condition,” in themselves or in a dependent.

The bureaucrats involved will determine what medical conditions are “serious” and “complex,” and how long “an extended period of time” is.

The following are some of the mandatory grounds for exemption:

• Having a disability that “significantly impairs” one’s ability to work.

• Being a former foster care youth under the age of 26.

• Being the caregiver of a child under age 13 or a disabled person, although caring for an elderly relative is not technically an exemption.

• Veterans with a total disability rating.

• Taking part in a drug or alcohol treatment program.

• Being in prison or having recently left prison.

• Pregnant or having recently given birth.

Homelessness is not grounds for an exemption, despite the serious problems a homeless person, who may lack access to a shower, laundry facilities, and transportation, would have as barriers to working.

Most enrollees must submit paperwork every six months documenting that they are meeting the requirements or are exempt.

Who is Subject to the Requirements?

Many disabled people enroll in Medicaid through Social Security’s Supplemental Security Income (SSI) program. Applying for SSI is an arduous task, and approval can take years. These people would presumably be exempt from the work requirement.

However, many disabled people collecting Medicaid haven’t gone through the process of applying for SSI (or are currently going through it). These people would have to show they are eligible for the work requirement. (I haven’t been able to find out if people on SSI must also turn in paperwork every six months. Perhaps not, since the government has already acknowledged their disability.)

Among Medicaid recipients who are not receiving SSI and are between the ages of 19 and 64:

·    64% are working, with 44% working at least 35 hours a week.

·    10% are disabled.

·    12% are caregivers.

·    8% aren’t working for other reasons, including inability to find work or retirement.

Therefore, the vast majority of people on Medicaid either already meet the requirements or are exempt.

However, advocacy groups and researchers predict that far over 8% of Medicaid recipients will lose their benefits. To understand why, we must examine what occurred the two other times Medicaid work requirements were implemented—in Arkansas in 2018 and New Hampshire in 2019.

Results of Previous Medicaid Requirements

The requirement in Arkansas, which took effect in June 2018 and was ended by the courts in April 2019, required all adults aged 30-49 to work at least 20 hours a week. The exemptions were like those that will soon go into effect.

At the time, only 5% of 30-49 Medicaid enrollees in Arkansas were neither working nor exempt. However, by April 2019, 18,000 adults (or about one in four (25%) of 30-49-year-olds) had lost access to Medicaid. The vast majority of these people were already working or should have been exempt for other reasons. Paperwork issues caused the loss of coverage for nearly all of them.

In New Hampshire, the situation was even worse. Just two months after the new policy went into effect, 17,000 people, or 67% of those subject to the requirements, were facing disenrollment. State officials suspended the program.

What happened?

Lack of Knowledge About Requirements

In Arkansas, most people who lost Medicaid never turned in the paperwork, mainly because they didn’t learn about the requirements until it was too late.

A study found that about 35% of those subject to the work requirements didn’t know about them. Of those who did find out about the requirements beforehand, the Medicaid office notified less than half. The rest found out through other means, such as friends or family (about 17%), social media (14.6%), or the news (13%).

The same study attempted to find out why so many people on Medicaid weren’t notified by the Medicaid office. They asked those who had lost their insurance if they’d moved or changed phone numbers in the past year. According to their research, over a third had. However, just under half of those (45.6%) had informed the Medicaid office about their new address and/or phone number. Medicaid may not have followed through with updating their contact information.

New Hampshire’s Medicaid office tried to notify people through letters, phone calls, and even going door to door, but most Medicaid recipients still didn’t find out about the work requirements in time.

According to a report from the Urban Institute, the population on Medicaid “is transient, moves frequently, possesses limited-minute phone plans, and faces numerous social challenges related to mental health, substance use, and homelessness.” This presented unique challenges in notifying them.

One person who lost access to health care said they never received a letter about the requirements because they were “couch surfing, completely homeless.”

Others did receive one or more letters but didn’t understand them. One woman wrote:

I got 10 letters right in a row…I didn’t know how to read them. I don’t know how to read. [My husband] don’t know how to read either. He doesn’t understand.

According to the report, “Information conveyed was overly complex and left beneficiaries confused and bewildered about how the rules affected them.”

One person who helped draft some of the letters explained the problem:

The department wanted us to use certain language … but that language would have taken its own brochure [to explain]. We tried to simplify it as much as possible, but [the language] was still very confusing.

Other Medicaid recipients received conflicting information. One woman said, “You’ll get one [letter] that says you are required to do it and then get one that [says] you are exempt. It was very confusing.”

The state also tried to notify residents by phone. This also met with problems. For one thing, most people didn’t pick up the phone when they saw an unfamiliar number, thinking it was spam or a scam. One state official summed up this problem by saying, “I don’t pick up my phone if it is not someone I know. And these clients have prepaid or limited minutes.”

When people did answer, call center staff wouldn’t give any information until the recipient verified their identity by providing their Medicaid ID number or their Social Security number. Most people didn’t know their Medicaid ID, and few would give their Social Security number to a stranger who called on the phone. In fact, only 10% of people gave this information, meaning that 90% of the time, call center staff had to hang up without notifying the Medicaid recipient of the pending changes.

By June 2019, shortly before the work requirement was going to take effect in New Hampshire, officials from the Department of Health and Human Services realized that outreach efforts had been unsuccessful. They arranged for people to go directly to the homes of Medicaid recipients subject to the work requirements and notify them in person. This program cost the state $43,000.

Unfortunately, those going door to door only contacted 13% of the recipients. The high number of homeless people on Medicaid was one problem. Another was the fact that the visits occurred during the day between 10:00 AM and 3:00 PM, when many people were at work or school.

So despite multiple attempts at outreach, in New Hampshire, most Medicaid recipients subject to the paperwork requirements did not receive notification.

Problems Reporting Income

In addition, many people on Medicaid who were working had difficulty reporting their hours.

In Arkansas, officials set up a website where recipients could report their hours. This was initially the only way to report income. But many individuals lacked internet access or otherwise had difficulty using the site. Eventually, the state added the option of reporting by telephone.

Politicians in New Hampshire were aware of the difficulties people had reporting their income in Arkansas. Therefore, they gave different options for reporting. They mailed forms to recipients’ homes, set up a website for reporting, and allowed people to report by phone.

It still didn’t go well. Many people found the required forms confusing. For one thing, there were multiple different forms, and people trying to report had to select the correct one. In addition, the form for reporting income didn’t have a field for Medicaid participants to enter their work hours.

This state believed it already had this information in its records. However, they did not have this information for those who were self-employed. This meant that self-employed people could not report their hours. Others were confused by the question about their work hours, as they could not respond.

Those who used the online website reported frequent problems. Those who attempted to report by phone reported long wait times. People who were working didn’t always have time to wait on hold while at their jobs. Callers also reported that those answering the phones were rude.

Some people were confused about which number to call. One recipient said, “You call one number and have to transfer to 84 different departments until you get to the one you need.”

Problems Reporting Disability

Many disabled people in Arkansas and New Hampshire had difficulty verifying their disability. For one thing, having a regular doctor and medical records showing a history of medical treatment were important. But some people struggling with health problems hadn’t seen a doctor.

This is especially an issue for those struggling with substance abuse. A 2023 report found that of people with a past-year substance abuse disorder, only one in six received any treatment. Since these people would have lacked a formal diagnosis and medical records, they would have had a hard time getting an exemption.

Another pathway to getting a disability exemption was through a letter from a doctor, but this turned out to be problematic as well.

A study in the Journal of the American Medical Association found that 54% of general practitioners would refuse to write a letter for a patient eligible for an exemption who qualified. Doctors refused because they believed writing a letter was too burdensome and because of their political beliefs (registered Republican doctors were 74.5% less willing to write an exemption letter than Democrats).

The study concluded:

Our findings suggest that the administrative burden of exemption procedures is regarded as inappropriately high by many PCPs [Primary Care Physicians], and that it may cause a PCP to not seek an exemption even if it is warranted…

[I]t is critical that … patients qualifying for exemptions are not put at risk due to either the burdensomeness of exemption procedures, or physicians’ political or other views.

Disabled people in New Hampshire reported problems getting doctors to sign letters excusing them from work requirements. One woman, who had suffered six brain aneurysms, asked her doctor for an exemption letter, but he refused her request. The doctor told her, “If you can walk, you can work.”

Another disabled person said:

I brought my [exemption] paper to my doctor…and she knows me personally and knows that I try to do as much as I can, but she said, ‘Technically you don’t qualify for any exemptions on this, but I know you are taxed.’

My therapist ended up signing it because I have major depression. It took a few months [to get the exemption], after…all the back and forth.

One official was quoted saying:

We heard that some doctors would say, ‘I don’t know what to do,’ and others would say, ‘I don’t agree with this [work requirement] program, so I won’t sign the certification.’

The Consequences of Losing Medicaid

Many who lost access to Medicaid had to go without (or delay) healthcare. Of those disenrolled:

·    61.7% had to pay off medical bills over time.

·    49.8% had serious trouble paying medical bills.

·    55.9% had to delay care due to costs.

·    63.8% had to delay taking medication due to costs.

It is important to note that people who kept their Medicaid still struggle to pay for health care. Nearly a third of them also had to delay taking medication due to cost, and 28% had to delay other care.

But losing access to Medicaid makes things much worse.

Action You Can Take Right Now

You have an opportunity to advocate for the poor and disabled in your community and help them maintain access to medical care.

The government is currently taking comments on the Medicaid changes. The deadline is midnight on July 31.

Go here to leave a comment. It only has to be a sentence or two.

If you don’t know what to say, or don’t have time to compose a comment, you can automatically send one in here with just a few clicks of the mouse (though it is always better if you add a few sentences of original content).