Work Requirements: Coming to a State Near You
The public comment period on Medicaid Work Requirements has ended. Over 79 thousand comments were submitted through the Federal Register in total. Thank you to everyone who joined us in this effort. We encourage you to read through the full comments from our partner organizations and coalitions, available through AAHD’s Policy Updates page. Read AAHD’s comment on the work requirements here. Next Tuesday’s issue of Disability and Public Health News will feature a roundup of comments on the work requirements from a disability perspective. The American Disability and Aging Alliance called attention to the unique concerns of disabled enrollees in meeting these requirements:
“The greatest risk presented by the Interim Final Rule is not that eligible beneficiaries will refuse to work or participate in their communities, but that they will lose Medicaid because of inaccessible systems, complicated reporting requirements, documentation burdens, state administrative errors, or overly restrictive interpretations of disability-related protections”…
“The Interim Final Rule rests on an assumption inconsistent with modern disability policy: that an individual’s ability to consistently complete eighty hours of work or other qualifying community engagement activities each month is an appropriate measure of disability or functional capacity. Although the rule recognizes that some individuals should be excluded from the requirement, its overall structure reflects an outdated understanding of disability that does not align with current medical knowledge, federal civil rights law, or the lived experiences of people with disabilities and chronic health conditions.” …
“The Interim Final Rule implicitly divides beneficiaries into two categories: those who can engage in qualifying activities and those who cannot. Disability rarely functions in such binary terms. Functional capacity exists on a continuum and is influenced by numerous factors beyond an individual’s diagnosis. Whether someone can work, volunteer, attend school, or participate in community life depends on the interaction between their health condition and the accessibility of the surrounding environment. Transportation, workplace accommodations, caregiver availability, accessible housing, assistive technology, behavioral health services, home- and community based services, and the availability of direct support professionals often determine whether an individual can participate successfully in community life.”
Stable Medicaid coverage is essential for community living and for supporting the HCBS that make it possible. In the weeks ahead, CMS will respond to the concerns raised through this public comment period. We may see some changes to the work requirement rules. In the meantime, states are making changes to reflect the interim rule, with the January 2027 implementation deadline fast approaching.
States Respond to Work Requirements
New work requirement rules will require states to quickly:
- Update eligibility and enrollment systems and processes
- Educate current Medicaid enrollees about changes
- Share information about changes with potential Medicaid applicants
- Educate health care providers about changes (including managed care plans)
KFF offers best practices on how states can implement work requirements to make sure the right information reaches enrollees and applicants. As you help people enroll in Medicaid, be aware that these work requirements do not apply to all Medicaid enrollees. These changes apply to:
- Medicaid expansion states
- People aged 19-64 who receive Medicaid through the Affordable Care Act Medicaid expansion. This applies to people making up to 138% of the federal poverty line (FPL). Without Medicaid expansion, eligibility for the program is much more restrictive. Medicaid non-expansion populations typically only include certain qualifying residents making very low incomes, often below 100% FPL:
- Low-income pregnant people and parents/ caretakers of children under 19
- Children up to age 19
- People with disabilities
- Adults over age 65 who are blind or disabled (based on Social Security determination)
- People in 1115 Waiver Programs. These enrollees may be receiving home and community-based services. A state can also offer Medicaid coverage to adults up to 100% FPL through this waiver.
This map includes an overview of which states have Medicaid expansion, and populations likely to be impacted by this rule. Check to see if your state is impacted by work requirements. Disabled people who are applying for SSI are likely to be impacted by these requirements, with Medicaid serving as their primary form of coverage, as reported by KFF. People waiting on an SSI disability determination will have a slower renewal process than what is needed to meet the Medicaid eligibility timeline. Without an approved SSI application, many disabled people might not have documentation of their inability to work. This could put their Medicaid coverage at risk.
Health Affairs recently published a piece on the important Medicaid coverage gains made through voter ballot initiatives since 2019. Over 20 million people have gained steady coverage nationwide through the Medicaid expansion program. There are still over 1.2 million people in the 10 non-expansion states who are uninsured in this Medicaid coverage gap. Even more people are becoming uninsured who fall outside of the Medicaid expansion population, and would otherwise qualify for an ACA Marketplace plan. With the cost of ACA plans rising due to expired enhanced premium tax credits, rates of uninsurance are increasing nationwide.
Understanding the Health Care Affordability Crisis
Here are three recommended resources explaining different parts of the health care affordability crisis:
- “How Unaffordable is Health Care and What Can We Do About It?” Check out KFF’s recent webinar from the Health Wonk Shop in conversation on health care affordability in the broader cost of living crisis.
- Then check out KFF’s YouTube video series to go a little deeper into the issue of how health care got so expensive.
- The United States of Care Pulse Check is a series of reports reflecting insights from 30,000 conversations with people across the U.S. on their health care. Read the most recent report.
The NDNRC Newsletter is published biweekly through the summer. Archives of our weekly updates are available on the NDNRC website. This newsletter is supported by the American Association on Health and Disability (AAHD). Sign up to become an AAHD member today to support ongoing projects like this.