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CMS Approves Georgia’s Partial Medicaid Expansion

Last week, the Centers for Medicare & Medicaid Services (CMS) approved Georgia’s Pathways to Coverage Section 1115 waiver request, allowing for a limited expansion of Medicaid that provides coverage to individuals ages 19 to 64 earning up to 100 percent of the federal poverty level (FPL).

The state had submitted the 1115 waiver proposal and an accompanying Section 1332 waiver request to implement significant changes in its individual market last November. While CMS has not yet approved the 1332 waiver request, federal officials indicated they are working to finalize terms and conditions for its approval.

For more information about Georgia’s original waiver applications, read NASHP’s November 2019 blog, Georgia Proposes New Changes to its Individual Market and Medicaid Program in Two Federal Waivers.

Through its 1115 waiver, the state had asked permission to expand Medicaid eligibility only up to 100 percent of FPL at the enhanced federal match rate that is provided for the Affordable Care Act (ACA) adult Medicaid expansion group. CMS denied a similar request from Utah to receive enhanced federal matching funds for its partial expansion of Medicaid last August, and it rejected Georgia’s request as well. Georgia will receive its regular Medicaid match rate for the demonstration group. CMS did approve these following components of Georgia’s waiver.

Eligible individuals: Individuals ages 19 to 64 who are not currently eligible for Medicaid who have incomes up to 100 percent of the FPL.
Work requirements: As a condition of eligibility, individuals would be required to demonstrate they are working or engaged in other approved activities (e.g., community service, job training) for at least 80 hours per month, unless they meet a good cause exemption. Individuals will be required to report on a monthly basis, but enrollees who demonstrate compliance for six consecutive months will be exempt from reporting until they are reevaluated for eligibility, although they must inform the state if their employment status changes.
Employer-sponsored insurance (ESI) premium assistance program: If an eligible individual has access to ESI, the individual will be required to enroll in that coverage instead of Medicaid and the state will provide premium and cost-sharing assistance through Georgia’s health insurance premium program (HIPP) if it is deemed cost effective for the state.
Premiums: Some individuals will be required to pay premiums, and these premiums will be deposited in a Member Rewards Account.
- Individuals required to pay premiums:Individuals in the demonstration program who have incomes of 50 to 100 percent of the FPL will have income-based monthly premiums ($7/month for individuals with incomes between 50 to 84 percent of the FPL and $11/month for individuals with incomes between 85 to 100 percent of the FPL). For coverage to begin, individuals must make an initial premium payment within 90 days of being determined eligible.
- Exempt individuals:Individuals with incomes below 50 percent of the FPL; individuals with ESI enrolled in HIPP; and individuals who are enrolled in and two months after graduation from certain vocational education training programs of highly sought-after trades.
- Penalties for nonpayment:If an enrollee misses one or two premium payments after the initial payment, there is a 60-day grace period for each missed payment. Enrollees who accrue three missed payments will be suspended from the demonstration in the following month, and they will have 90 days to make a minimum of one payment in order to regain coverage.
Copayments: With the exception of individuals participating in the ESI premium assistance program, all demonstration enrollees will be required to make copayments for certain services. These payments will be assessed retrospectively and are consistent with the state plan, with the addition of a copayment for non-emergency use of the emergency department. The copayments are not to exceed 5 percent of an individual’s household income when combined with any premium payments.
Member Rewards Accounts: All enrollees except those who are receiving premium assistance for ESI coverage will have a Member Rewards Account (MRA), and enrollees’ premium payments will be deposited in these accounts. Individuals can earn non-monetary credits in their accounts by engaging in healthy behavior activities, such as smoking cessation classes or annual well visits. Funds in the MRA accounts can be used for copayments or to pay for additional services that are not covered, such as vision or dental care.
Benefit package and delivery system: Most enrollees will receive a benefit package that aligns with the benefits provided through the Medicaid state plan, with the exception of non-emergency medical transportation (NEMT). However, individuals ages 19 and 20 will receive Early and Periodic Screening, Diagnostic and Treatment (EPSDT) services, which will include NEMT. For individuals for whom the state is covering the cost of ESI, wraparound benefits are not covered, and their benefits are limited to those covered by their ESI plan. The demonstration program will use a managed care delivery system for all enrollees, although individuals participating in the ESI program are exempt from this requirement.
Other key elements: Through the demonstration, CMS is permitting the state to waive retroactive eligibility, and to have eligibility begin the month following the determination of eligibility and the payment of any premium required. Also, CMS is allowing the state to not provide hospital presumptive eligibility for individuals in the demonstration.
Implementation timeline: CMS is permitting the state to implement the demonstration beginning July 1, 2021, and it is approved through Sept. 30, 2025.

Legal challenges to the work requirements in the approved waiver are expected, as was acknowledged by CMS Administrator Seema Verma. While other states have received federal approval to implement Medicaid work requirements, currently there are no states with active work requirements. This is due to some states not having yet implemented them, legal challenges that have vacated some waiver approvals, and states’ decisions to suspend implementation. Explore the National Academy for State Health Policy’s A Snapshot of State Proposals to Implement Medicaid Work Requirements Nationwide for additional information.

A Snapshot of State Proposals to Implement Medicaid Work Requirements Nationwide

January 29, 2018/in Policy Charts Health Coverage and Access, Medicaid Expansion, Work Requirements Work Requirements /by Anita Cardwell

*Updated August 24, 2021

In January 2018, the Centers for Medicare & Medicaid Services (CMS) issued a new policy allowing states to implement work and community engagement requirements for certain Medicaid enrollees. States must seek federal approval to require non-elderly, non-pregnant, and non-disabled adults to meet these requirements to qualify for full or partial Medicaid coverage.

In February 2021, the Biden Administration took steps to rescind the 2018 guidance allowing states to implement Medicaid work requirements and sent letters to states indicating that CMS was in the process of determining whether to withdraw states’ approved work requirement waivers. This chart summarizes states’ pending and approved Section 1115 waivers, waiver renewals, and waiver amendments to implement work and community engagement requirements that were in effect prior to the Biden Administration’s actions.

For a printable version or to view the complete chart, click here.

Waiver Status

State	Waiver Status
AL	Pending On Feb. 17, 2021, Alabama requested to withdraw its pending waiver
AZ	On June 24, 2021, CMS withdrew the waiver approval, indicating that it does not promote program objectives (as noted below, the work requirement had not been implemented) Originally approved Jan. 18, 2019; not yet implemented. On Oct. 17, 2019 the state indicated that it would postpone implementation of the work requirements due to litigation in other states.
AR	On March 17, 2021, CMS withdrew the waiver approval, indicating that it does not promote program objectives; withdrawal is effective April 16, 2021 unless the state appeals. Originally approved March 5, 2018; began implementing as of June 1, 2018. On Aug. 14, 2018, the National Health Law Program, the Legal Aid Society of Arkansas, and the Southern Poverty Law Center filed a lawsuit challenging the waiver. On March 27, 2019, a federal district court judge ruled that implementation of the work requirements must be halted; the federal government appealed the decision. On Feb. 14, 2020, a federal appeals court ruled that the waiver amendment approval was unlawful, confirming the earlier decision.
GA	On July 27, 2021, the state indicated to CMS that it would be delaying implementation of the waiver Approved Oct. 15, 2020; not yet implemented
ID	Pending
IN	On June 24, 2021, CMS withdrew the waiver approval, indicating that it does not promote program objectives (as noted below, the work requirement had been suspended) Originally approved Feb. 2, 2018; began implementing as of Jan. 2019 (but no work hours are required during the first six months). On Sept. 23, 2019, the National Health Law Program and Indiana Legal Services filed a lawsuit challenging the waiver. In response, in late October the state indicated that it would be suspending the work requirements until the lawsuit is resolved.
MI	On April 6, 2021, CMS withdrew the waiver approval, indicating that it does not promote program objectives Originally approved Dec. 21, 2018; implemented Jan. 1, 2020 (though implementation of the waiver’s premiums and healthy behavior requirements were postponed until Oct. 1, 2020). Also, SB 362 was signed into law, which exempts individuals from having to report compliance if the state can determine compliance through other data, and allows individuals more time to report compliance. On Nov. 22, 2019, a lawsuit was filed challenging the approved waiver. On March 4, 2020, a federal district court ruled to block the work requirements.
MS	Pending
MT	Pending
NE	On June 1, 2021, the state indicated that it would be withdrawing the waiver (as noted below, the work requirement for the Prime benefits package had not been implemented) and starting Oct. 1, 2021, all enrollees will receive state plan benefits (which are the same as Prime benefits) Approved Oct. 20, 2020; not yet implemented On Feb. 25, 2021, Nebraska Appleseed and the National Health Law Program filed a lawsuit challenging the waiver.
NH	On March 17, 2021, CMS withdrew the waiver approval, indicating that it does not promote program objectives; withdrawal is effective April 16, 2021 unless the state appeals. Originally approved May 7, 2018 (implemented as of March 2019, but reporting did not begin until June 2019). On March 20, 2019, the National Health Law Program, New Hampshire Legal Assistance, and the National Center for Law and Economic Justice filed a lawsuit challenging the waiver; in July 2019, a federal district court judge ruled to block the waiver. Also, on 7/8/19, Gov. Sununu announced that any penalties associated with noncompliance would be delayed through September 2019, and also signed into law SB 290, which adds additional exemptions for individuals, suspends rather than terminates coverage for noncompliance, and waives the work requirements if a substantial number of individuals are unable to comply.
OH	On Aug. 10, 2021, CMS withdrew the waiver approval, indicating that it does not promote program objectives Originally approved Mar. 15, 2019; not yet implemented
OK	Pending
SC	On Aug. 10, 2021, CMS withdrew the waiver approval, indicating that it does not promote program objectives Originally approved Dec. 12, 2019; not yet implemented
SD	Pending
TN	Pending
UT	On Aug. 10, 2021, CMS withdrew the waiver approval, indicating that it does not promote program objectives Originally approved Dec. 23, 2019; implemented Jan. 1, 2020; however on 4/3/20, the state suspended the work requirement due to COVID-19.
WI	On April 6, 2021, CMS withdrew the waiver approval, indicating that it does not promote program objectives Originally approved Oct. 31, 2018; not yet implemented

Medicaid Expansion Status

State	Medicaid Expansion Status
AL	Has not implemented Affordable Care Act (ACA) Medicaid expansion
AZ	Implemented ACA Medicaid expansion
AR	Implemented ACA Medicaid expansion
GA	Has not implemented ACA Medicaid expansion (approved waiver permits the state to expand Medicaid only to 100% FPL, with no enhanced federal match)
ID	Nov. 2018 ballot measure to adopt full ACA Medicaid expansion beginning 4/1/19 was passed by voters. However, state legislature passed and governor signed into law S 1204 in April 2019 to modify the voter-approved expansion to include work requirements, as well as other changes.
IN	Implemented ACA Medicaid expansion
MI	Implemented ACA Medicaid expansion
MS	Has not implemented ACA Medicaid expansion
MT	Implemented ACA Medicaid expansion (expansion was scheduled to sunset in July 2019; in May 2019 a bill to continue the expansion that adds work requirements was signed into law)
NE	Nov. 2018 ballot measure to adopt full ACA Medicaid expansion was passed by voters. A state plan amendment was submitted in April 2019, to implement expansion no later than Oct. 2020 (which occurred). The implementation delay was due to the state seeking a waiver to modify the expansion, including adding work requirements to obtain an enhanced benefits package of “Prime” benefits. Prime benefits consist of dental, vision, and OTC medications; individuals must also meet other requirements to qualify for Prime benefits, such as annual health visits and completing a health risk assessment.
NH	Implemented ACA Medicaid expansion
OH	Implemented ACA Medicaid expansion
OK	On June 30, 2020, Medicaid expansion was passed by ballot initiative, and took effect July 1, 2021
SC	Has not implemented ACA Medicaid expansion Waiver proposes to increase the income threshold for the Parent as a Caretaker Relative program to 100% FPL (approving in separate waiver) Waiver proposes to extend current coverage for pregnant up to 194% FPL from 60 days postpartum to one-year postpartum (not approved) Waiver proposes to expand coverage to individual not otherwise eligible for Medicaid who meet certain criteria–chronically homeless, justice involved, needing SUD treatment (approving in separate waiver as new Targeted Adult Group) Waiver also seeks to provide individuals who lose Medicaid eligibility due to employment and who are not eligible for ESI with financial assistance to purchase QHP coverage (not approved)
SD	Has not implemented ACA Medicaid expansion
TN	Has not implemented ACA Medicaid expansion
UT	Nov. 2018 ballot measure to adopt full ACA Medicaid expansion beginning 4/1/19 was passed by voters. However, state legislature passed and governor signed into law SB 96 in Feb. 2019 to modify the voter-approved expansion. The first phase of SB 96 only expanded Medicaid up to 100% FPL, at the state’s regular FMAP, and was approved in March 2019. This implementation toolkit outlines the state’s plan. In Nov. 2019, the state submitted a waiver for the “fallback” plan, which implements the full ACA expansion at the enhanced match rate, with work requirements, which was approved in Dec. 2019.
WI	Has not implemented ACA Medicaid expansion (state has waiver to cover childless adults aged 19-64 up to 100% FPL)

Work Requirement Hours

State	Work Requirement Hours
AL	35 hours/week; 20 hours/week for parents and caretaker relatives with a child under age 6
AZ	80 hours/month
AR	80 hours/month
GA	80 hours/month
ID	20 hours/week, averaged monthly
IN	Requirements will increase over the course of the individual’s first year of participation, beginning at five hours/week at the seventh month of enrollment and increasing to 20 hours/week at 18 months and beyond Enrollees must meet the community engagement requirements for eight months per calendar year
MI	80 hours/month
MS	20 hours/week
MT	80 hours/month
NE	80 hours/month To be eligible for the Prime benefits package, in addition to complying with certain wellness activities, individuals must meet the work requirements in the second year of implementation (scheduled for 4/1/22). During the initial benefit period after the work requirement takes effect, individuals must meet the requirement in four out of six months. For subsequent benefit periods, individuals must meet the requirement in each of the six months preceding the individual’s benefit review date (which begins the first day of the fifth month of the current benefit period).
NH	At least 100 hours per calendar month
OH	20 hours/week (80 hours averaged monthly)
OK	Average of 80 hours/month, with a phased-in hours per week approach available: -First three months no verification required (grace period); -At least 10 hours/week for 4-6 months of enrollment -At least 15/hours week for 7-9 months of enrollment -At least 20 hours/week for 10-12 months of enrollmentIndividuals recently released from incarceration will have a 9-month grace period
SC	80 hours/month
SD	80 hours/month On an individualized basis, the 80 hour requirement may be reduced to a lesser amount
TN	20 hours/week (averaged monthly)
UT	Hours not specified (see Qualifying Activities section)
WI	80 hours/month

Qualifying Activities

State	Qualifying Activities
AL	-Employment -On-the-job training -Job search and job readiness activities -Attendance in high school, GED certification classes, an institution of higher education, or vocational classes -Volunteer work activities or community service -Technical training Individuals who fulfill the work requirements but become ineligible due to their income level exceeding Medicaid eligibility levels will be provided with 18 months of transitional Medicaid coverage.
AZ	-Employment, including self-employment -Participating in employment readiness activities, which can include: -Education (less than full time) -Job skills training -Life skills training -Health education classes -Engage in job search activities similar to those required to receive unemployment benefits -Community service
AR	-Employment or self-employment, or those whose income is consistent with being employed/self-employed at least 80 hours/month -Enrollment in educational program (high school, higher education, or GED classes) -On-the-job or vocational training -Job search or job search training (up to 40 hours/month) -Community service -Participation in classes on health insurance, using health care, or healthy living (up to 20 hours/year) -Participating in programs through state Department of Workforce Services -Compliance with either SNAP or Transitional Employment Assistance (TEA) employment programs
GA	-Subsidized or unsubsidized public or private sector employment, including self-employment and employment as an independent contractor -On-the-job training -Participation in job readiness activities directly related to the preparation for employment, including habilitation and rehabilitation activities and GED programs -Community service with public or non-profit organizations -Vocational educational training (limited to 12 months in an individual’s lifetime, unless enrolled in vocational education for a highly sought after trade through the Technical College System of Georgia High Demand Career Initiative) -Enrollment in an institution of higher education (qualifying hours earned will vary based on course load) -Enrollment and active engagement in the Georgia Vocational Rehabilitation Agency Vocational Rehabilitation program, as long as the individual has been determined eligible for these services based upon a documented disability and complies with program terms
ID	-Working at least 20 hours per week, averaged monthly, or earning wages equal to or greater than the federal minimum wages for 20 hours of work per week -Participating in and complying with the requirements of a work training program at least 20 hours per week, as determined by the department -Volunteering at least 20 hours per week, as determined by the Idaho Department of Health and Welfare (IDHW) -Enrolled at least half-time in post-secondary education or another recognized education program, as determined by IDHW, and remaining enrolled and attending classes during normal class cycles -Meeting any combination of working, volunteering, and participating in a work program for a total of at least 20 hours per week, as determined by IDHW -Subject to and complying with a work program for TANF or participating and complying with a workforce program in SNAP
IN	-Subsidized or unsubsidized employment -Participating in state’s Gateway to Work program -Managed care entities employment initiatives -Job skills training -Job search activities -Education related to employment; general education (e.g. GED or community college) -Accredited ESL education or homeschooling -Vocational education/training -Community work experience -Community service/public service -Volunteer work -Caregiving services for a non-dependent relative or other individual with a chronic, disabling health condition -Compliance with SNAP work requirements Certain tribal members will be considered as meeting the Gateway to Work requirement due to tribe’s Pathways employment program. Gateway to Work will also encourage enrollees with a substance use disorder to seek treatment by considering participation in treatment program as criteria for exemption.
MI	-Employment, self-employment, or having income consistent with being employed or self-employed (e.g. makes at least minimum wage for an average of 80 hours per month) -Education directly related to employment (i.e. high school equivalency test preparation, postsecondary education) -Job training or vocational training directly related to employment -Unpaid workforce engagement directly related to employment (e.g. internship) -Tribal employment programs -Participation in substance use disorder (SUD) treatment (court ordered, prescribed by a licensed medical professional, or Medicaid-funded SUD treatment) -Community service completed with a nonprofit 501(c)(3) or 501(c)(4) organization (can only be used as a qualifying activity for up to 3 months in a 12-month period -Job search directly related to job training -Individuals in compliance with or who are exempt from SNAP or TANF work requirements will be deemed compliant with the Medicaid work requirements
MS	-Working in paid employment -Self-employment -Participation with Office of Employment Security -Volunteering with approved agencies -Participation in alcohol or drug abuse treatment program -Compliance with SNAP and TANF work requirements Individuals who fulfill the workforce training or community engagement requirement but become ineligible due to their income level exceeding Medicaid eligibility levels will be provided with 12 month transitional medical assistance coverage. Once this coverage is exhausted, an additional 12 months of coverage will be offered if these individuals continue to meet the workforce training or community engagement requirement.
MT	-Employment -Work readiness and workforce training activities -Secondary, postsecondary, or vocational education -Substance abuse education or substance use disorder treatment -Other work or work/community engagement activities that promote work or work readiness or advance the health purpose of the Medicaid program -Community service or volunteer opportunity -Any other activity required by CMS for the purpose of obtaining necessary waivers
NE	-Employment, including self-employment -Volunteering at a public charity -At least half-time enrollment at an accredited college, university, trade school, or post-secondary training program, including refugee employment program (individuals enrolled less than half-time can combine education hours with other approved activities to meet the requirement) -Participation in course of study leading to a GED -Participation in SNAP and/or TANF recognized job search activity for at least 20 hours per week (can be combined with other approved activities to meet the 80 hour/month requirement)
NH	-Subsidized or unsubsidized employment -Education directly related to employment, in the case of an individual who has not received a high school diploma or equivalent -Secondary school/course of study leading to a certificate of general equivalence -Enrollment at an accredited community college, college or university that is counted on a credit hour basis -Vocational training (not to exceed 12 months) -On-the-job training -Job skills training related to employment -Job search/readiness activities, such as job training workshops and time spent with employment counselors -Participation in substance use disorder treatment -Community service and public service -Caregiving services for a non-dependent relative or other individual with a disabling health, mental health, or developmental condition -Compliance with SNAP or TANF work requirements
OH	-Work or employment in exchange for money -Self employment -Work in exchange for goods and services (in kind work) -Unpaid work, including unpaid formal and informal volunteer, community service and public service activities -Education and training activities -Formal and informal job search or job readiness programs (for no more than 30 days in a year unless combined with another qualifying activity and less than half the required hours are spent in job search or job readiness programs or job search is the only activity completed) -Participation in and compliance with SNAP and/or TANF work registration or employment and training requirements
OK	-Employment -Workforce Innovation and Opportunity Act (WIOA) Program -Employment & Training (E&T) Program; job search or job search training activities when offered as part of other E&T program components are acceptable as long as those activities comprise less than half the total required time spent in the components -Education related to employment -General Education Development/Diploma (GED) -Vocational education/training -Participation in Oklahoma Works -Volunteer work (e.g. classroom volunteer, faith-based or community service programs) -Meeting any combination of work, participating in work training or volunteering the specified number of hours per week, averaged monthly
SC	-Subsidized or unsubsidized employment, including self-employment -Participation in adult secondary education program through public school district or technical college, including GED programs -At least half-time enrollment in a degree or certificate program in an accredited institution of higher education -Compliance with unemployment insurance work-search requirements -Compliance with SNAP or TANF work requirements -Participation in a tribal work program -Community or public service, including verifiable volunteerism with public entities or qualified charitable organizations
SD	-Employment Meeting monthly milestones through activities such as: -English as a second language courses -Health insurance literacy courses -Financial literacy courses -Disease management courses and other healthy living courses -Treatment for chronic or behavioral health conditions -High school equivalency education -Post-secondary education and training -Volunteer work -Caregiving for an elderly or disabled individual -Resume writing and soft skills training -Job searching Individuals will be connected with a case manager to assist with connecting individuals to support services and to develop an employment and training plan Individuals will be eligible for Transitional Medical Benefits (TMB) for 12 months if their income exceeds the Medicaid income eligibility limit, and for up to an additional 12 months of premium assistance if they have income above the Low Income Families program limit but below 100% FPL. One well-adult visit and one preventive dental visit is required during the period an individual is eligible for TMB to qualify for premium assistance.
TN	-Paid employment -Self-employment (individual must be able to demonstrate income consistent with working at least 20 hours/week, averaged monthly) -General education (e.g. high school or high school equivalency, college, ESL courses, etc.) -Vocational education and training -Participation in job search or job skills training activities sponsored by the state’s Department of Labor & Workforce Development -Accredited homeschooling -Community service (volunteering) in approved settings -Individuals complying with SNAP or TANF work requirements will be deemed compliant
UT	Individuals will be required within the first three months starting on the first of the month following notification that the individual is subject to the work requirement (whichever is later), complete the following activities: -register for work through the state’s online system; -complete an online assessment of employment training needs; -apply for employment, either directly or through the state’s automated employment application submission process, with at least 48 applications; -complete the online training modules, as determined appropriate by the online assessment. Once the required activities are completed, an individual will remain eligible for the remainder of the 12-month eligibility period.
WI	-Working in exchange for money or for goods or services -Unpaid work (e.g. volunteer work or community service) -Self-employment -Participating in allowable work, job training, or job search program (e.g. FoodShare Employment and Training and other state-approved workforce programs)

Population Group

State	Population Group
AL	Parent or Caretaker Relative eligibility group, up to age 60
AZ	Able-bodied individuals age 19-49 in an ACA Medicaid expansion group
AR	Non-medically frail individuals ages 19-49 in ACA Medicaid expansion group at or below federal poverty level, with individuals ages 19-29 exempt in 2018 (in the waiver, the state also requested limiting the ACA Medicaid expansion eligibility group to those earning 100 percent of the federal poverty level (FPL) or less; this aspect of the waiver was not approved)
GA	Individuals ages 19 to 64 who are not currently eligible for Medicaid, which includes childless adults up to 100% FPL and parents/caretakers with income 35-100% FPL
ID	Able-bodied individuals age 19-59 in ACA Medicaid expansion group
IN	Able-bodied individuals enrolled in Healthy Indiana Plan (HIP), up to age 60 (ACA Medicaid expansion group, Transitional Medical Assistance recipients, some parents and caretakers)
MI	Non-disabled adults ages 19-62 in ACA Medicaid expansion group
MS	Non-disabled adults ages 19-64 covered under traditional Medicaid, including low-income parents and caretakers and individuals eligible for transitional medical assistance
MT	Non-disabled adults ages 19-55 in ACA Medicaid expansion group
NE	Adults ages 21-59 in ACA Medicaid expansion group
NH	Able-bodied adults covered by the ACA Medicaid expansion
OH	Able-bodied adults in ACA Medicaid expansion group, up to age 50
OK	Non-disabled adults ages 19-50 covered under traditional Medicaid (exemptions noted in Exempted Groups section)
SC	Non-disabled adults under age 65 enrolled in the state’s Medicaid as a Parent Caretaker Relative program, Transitional Medical Assistance enrollees, and the new Targeted Adult Group
SD	Parents ages 19-59, in two of the state’s counties (Minnehaha and Pennington)
TN	Non-pregnant, non-disabled, non-elderly adults in parent/caretaker relative eligibility category
UT	Individuals in ACA Medicaid expansion group, under age 60
WI	Adults ages 19-49 who are eligible for Medicaid as childless adults

Exempted Groups

State	Exempted Groups
AL	-Disabled individuals, including anyone receiving SSDI, SSI, or Medicare -Medically frail individuals or individuals with a medical condition that prevents them from complying with the work requirements (validated by a medical professional) -Pregnant women or women receiving post-partum care -Individuals age 60 or older -Individuals required to care for a disabled child or adult -Individuals who are either compliant with or exempt from the TANF JOBS program -An individual who is a single custodial parent caring for a child age 12 months or younger, or caring for a child under the age of 6 for whom appropriate childcare is not available -Individuals who are able to provide a good cause for not meeting work requirement (similar to those in TANF JOBS program) -Only one individual in the household can be exempted for any of the reasons related to being the parent or caretaker of a child or disabled individual, unless there are valid extenuating circumstances
AZ	-Individuals 50 years and older -Individuals who are members of federally recognized tribes -Pregnant women and post-partum women up to the end of the month in which the 60th day of post-pregnancy occurs -Former foster youth up to age 26 -Individuals with serious mental illness -Individuals receiving temporary or permanent disability benefits or who are determined to be medically frail -Individuals who are in active treatment for a substance use disorder -Full-time high school, trade school, college, or graduate students -Victims of domestic violence or homeless individuals -Caretakers of a child under age 18 or of a child who is 18 and is a full-time student expected to graduate before turning 19 (limit one caretaker per child) -Caregivers who are responsible for the care of an individual with a disability -Individuals with an acute medical condition (physical or behavioral) that would prevent them from complying -Individuals with a disability as defined by federal disabilities rights laws who are unable to comply for disability-related reasons -Individuals complying with other state-approved work programs
AR	-Individuals 50 and older -Full-time students (attending high school, an institution of higher education, vocational training, or job training) -Those exempt from SNAP work requirements -Those receiving Transitional Employment Assistance (TEA) cash assistance or who are exempt from TEA work requirements -Individuals incapacitated in the short term or medically certified as physically or mentally unfit for employment, or has an acute medical condition validated by a medical professional that would prevent compliance with requirements -Caregivers of an incapacitated individual -Those who live with a minor dependent child age 17 or younger -Those receiving unemployment benefits -Those participating in alcohol or drug addiction treatment program -Pregnant women, through the end of post-partum care -Individuals determined to be medically frail
GA	No exemptions, other than good cause exemptions described in Penalties for Non-Compliance section
ID	-Individuals under age 19 or over age 59 -Individuals who are physically or intellectually unable to work (including behavioral health barriers) -Pregnant women -Parents or caretakers who are the primary caregivers of a dependent child under the age of 18 -Parents or caretakers who are personally providing care for a person with serious medical conditions or a disability -Individuals applying for or receiving unemployment compensation and complying with work requirements that are part of the federal-state unemployment insurance program -Individuals participating in a drug addiction or alcohol treatment and rehabilitation program -American Indians or Alaska Natives who are eligible for services through the Indian Health Service or through a tribal health program
IN	-Full- and part-time students -Pregnant women -Primary caregivers of a dependent child below the compulsory education age, or who are primary caregivers of a disabled dependent -Medically frail individuals -Certification of temporary illness or incapacity -In active substance use disorder treatment -Individuals over age 59 -Former foster care youth under age 26 (they are not covered under the demonstration) -Homeless individuals -Individuals who are meeting or are exempt from TANF work requirements -Recent incarceration (within last six months) -Individuals enrolled in state’s Medicaid employer premium assistance program -Some other exemptions possible based on individual review
MI	-Caretaker of a family member under 6 years of age (only one parent at a time can claim this exemption) -Individuals currently receiving temporary or permanent long-term disability benefits from a private insurer or from the government -Full-time student who is not a dependent or whose parent or guardian qualifies for Medicaid -Pregnant women -Caretaker of a dependent with a disability who needs full-time care based on a licensed medical professional’s order (this exemption is allowed only one time per household) -Caretaker of an incapacitated individual even if the incapacitated individual is not a dependent of the caretaker -Individuals who have proven they meet a good cause temporary exemption -Medically frail individuals -Individuals with a medical condition resulting in a work limitation according to a licensed medical professional order -Individuals who have been incarcerated within the last 6 months -Individuals currently receiving unemployment benefits -Individuals under age 21 formerly in the state’s foster care system
MS	-Native Americans -Pregnant women -Children under age 19 -Disabled individuals; individuals enrolled in 1915 (c) waivers -Individuals 65 years and older -Individuals residing in an institution Exemptions will also apply to an individual who is: -Diagnosed with mental illness; -Determined disabled by Social Security; -Physically or mentally unable to work; -Receiving or has applied for unemployment insurance -A primary caregiver for: a child under the age of 6; a person diagnosed with a mental illness; or a disabled family member; -Participating in an alcohol or drug abuse treatment program; -Receiving treatment for cancer -Enrolled in an institution of higher learning at least half time; or -High school student age 19 or older, attending at least half-time.
MT	-Medically frail, blind, or disabled individuals -Pregnant women -Individuals experiencing an acute medical condition requiring immediate medical treatment -Individuals who are mentally or physically unable to work -Primary caregiver for a person who is unable to provide self-care -Foster parents -Full-time students in secondary school; students enrolled in the equivalent of at least six credits in a postsecondary or vocational institution -Individuals who are participating in or who are exempt from TANF or SNAP work requirements -Individuals under correctional supervision -Individuals experiencing chronic homelessness -Victims of domestic violence -Individuals living in an area with a high-poverty designation -A member of an entity subject to the fee provided for in 15-30-2660(3) -Individuals with income that exceeds an amount equal to the average of 80 hours per month multiplied by the minimum wage -Individuals otherwise exempt under federal law
NE	-Medically frail individuals -Individuals participating in a substance use disorder or mental health treatment program -Individuals receiving unemployment compensation or who have applied for it and are meeting work search requirements -Members of a federally recognized tribe -Pregnant individuals -High school students over age 21 who are attending at least half-time. -Individuals age 60 or older -Individuals residing in an area that has been granted a federal SNAP ABAWD waiver due to insufficient job availability -Victims of domestic violence, when participation would make it harder to escape, penalize the individual, or put them at further risk of domestic violence -Parent, caretaker relative, guardian, or conservator of a dependent child in the enrollee’s home -Individuals responsible for the care of an elderly or disabled relative; caretakers can qualify for the exception even if they live elsewhere -Participation in SNAP Employment and Training program or otherwise meeting SNAP ABAWD requirements -Participation in the TANF Employment First program
NH	-Individuals temporarily unable to participate due to illness or incapacity as documented by a licensed provider -Individuals participating in a state-certified drug court program -Parent or caretaker where the required care is certified as necessary by a licensed provider -Parent or caretaker of a dependent child under age 6 (only one exemption per household) -Parent or caretaker of a dependent child of any age with a disability -Pregnant women or women 60 days or less post-partum -Medically frail individuals -Individuals with a disability who are unable to comply due to disability-related reasons -Individuals residing with an immediate family member with a disability and are unable to meet requirements due to family member’s disability -Individuals who experience a hospitalization or serious illness, or who reside with an immediate family member who experiences a hospitalization or serious illness -Individuals who are exempt from TANF or SNAP work requirements -Individuals enrolled in state’s voluntary Health Insurance Premium Program
OH	-Individuals age 50 and older -Individuals who are physically or mentally unfit for employment -Individuals who are caring for a disabled or incapacitated household member -Pregnant women and women during the 60-day postpartum period -Parent/caretaker/individual residing in same house with minor child (under age 19) -Individual who has applied for or is receiving unemployment benefits -Students who are in school at least half time -Individuals who are participating in a drug or alcohol treatment program -Applicants for or recipients of SSI -Individuals participating in the state’s Specialized Recovery Services program -Eligible incarcerated individuals -Individuals residing in counties approved by the USDA Food and Nutrition Service for a waiver of the Able-Bodied Adults without Dependents time limit -Individuals who are exempt from SNAP and/or TANF work requirements -Medically frail individuals
OK	-Individuals under age 19 or over age 50 -Pregnant women -Individuals who are medically certified as physically or mentally unfit for employment -Parent or caretaker responsible for care of a dependent child under age 6 -Individuals complying with TANF or SNAP work requirements -Individuals participating in drug or alcohol treatment program -Students enrolled at least part time in a recognized school, training program, or institution of higher education -Individuals complying with a work registration requirement under Title IV of the Social Security Act or the federal-state unemployment compensation system -Self-employed individuals working a minimum of 30 hours/week or receiving weekly earnings equal to federal minimum wage multiplied by 30 hours -Individuals with disabilities -Individuals enrolled in Oklahoma Health Care Authority family planning program -Individuals in the Oklahoma Health Care Authority Breast and Cervical Cancer Program -Foster care parents -Former foster care members -Native Americans and Alaska Natives
SC	-Members of federally recognized tribal organizations -Individuals who are qualified as working disabled individuals -Individuals diagnosed with an acute medical condition that would prevent them from complying with work requirement -Primary caregiver of a child up to age 18 and/or a disabled individual -Individuals receiving Social Security Disability Insurance or Supplemental Security Income -Individuals participating in a Medicaid-covered treatment program for alcohol or substance abuse addiction, including opioid addiction -Individuals receiving treatment through Medicaid’s Breast and Cervical Cancer Program -Individuals who are compliant with or exempt from SNAP or TANF work requirements -Former foster care youth -Individuals residing in regional areas that have an unemployment rate of 8 percent or greater -Home and community-based services waiver participants or individuals in institutions -Medically frail individuals -Individuals who are pregnant through 365 days post-partum
SD	-Individuals age 18 or younger or age 60 or older -Full-time students -Pregnant women -Disabled individuals -Medically frail individuals -Individuals participating in other state workforce participation programs that meet the same objectives (e.g. SNAP, TANF, or unemployment insurance) -Nonparent caretaker relatives -Parents of dependent children under one year of age who are living in the parent’s residence -Primary caregivers of elderly or disabled individuals living in the caretaker’s residence
TN	-Individuals age 65 and older -Individuals who are physically or mentally incapable of work, as certified by a medical professional -Medically frail individuals -Individuals with a short-term or long-term disability or an acute medical condition that would prevent them from complying, validated by a medical professional -Individuals participating in inpatient or residential treatment or an intensive outpatient program for a substance use disorder -Individuals who are the primary caregiver of a child under age 6 (one exemption per household) -Individuals providing primary caregiver services for a household member (child or adult) with a disability or incapacitation or medical frailty that prevents the caretaker from meeting work requirement -Individuals receiving unemployment benefits -Individuals who have recently been directly impacted by a catastrophic event such as a natural disaster -Pregnant women and women during their period of postpartum coverage
UT	-Individuals age 60 and older -Pregnant or up to 60 days postpartum -Physically or mentally unable to meet requirements (as determined by a medical professional or documented through other data sources) -Parents/caretakers with dependent child under age 6 -Caretaker for disabled individual -Member of federally recognized tribe -Receiving or has applied for unemployment insurance benefits -Participating regularly in SUD treatment program, including intensive outpatient treatment -Student enrolled at least half time in any school or training program -Participation in refugee employment services -Family Employment Program (FEP) recipients who are working with an employment counselor -Individuals in compliance with or who are exempt from SNAP and/or TANF work requirements -Individuals working more than 30 hours/week
WI	-Individuals receiving SSDI or other disability benefits -Primary caregiver of individual who cannot care for self -Physically or mentally unable to work as determined by the state or verified as unable to work by a health care professional or social worker -Individuals experiencing chronic homelessness -Receiving or has applied for unemployment insurance and in compliance with unemployment compensation work requirements -Exempt from SNAP work requirements -Participating in certain alcohol or drug abuse treatment programs -Enrolled in institution of higher learning (including vocational programs or GED classes) at least half time -Individuals attending high school at least half-time

Penalties for Non-Compliance

State	Penalties for Non-Compliance
AL	Individuals who are subject to the requirements will receive notice of the requirements, and will be given 90 days to become compliant or provide proof they qualify for an exemption. If after 90 days, an individual is non-compliant and non-exempt, the individuals will be terminated from the Medicaid program. Individuals who meet the requirements but later become non-compliant will also have 90 days to become compliant or demonstrate they meet an exemption.
AZ	Individuals will need to report monthly that they are meeting the community engagement requirements. Individuals who do not meet requirements will have an initial three-month grace period; noncompliance after this period will result in suspension of eligibility for two months. Individuals with suspended eligibility will have their eligibility reactivated after the end of the two-month suspension period, as long as they meet all other eligibility criteria. Individuals can request and demonstrate good cause if unable to complete activity hours or report participation. Good cause exemptions include: -Disability of individual or if individual has an immediate family member in the home with a disability and is unable to meet requirements due to this; -Illness of the individual or a family or household member requiring beneficiary to care for the individual; -Severe inclement weather, including a natural disaster; or -Individual has family emergency or other life changing event (e.g., divorce, homelessness, domestic violence, birth or adoption, or death). Arizona also proposed a lifetime coverage limit of five years for most able-bodied adults who failed to comply with the work requirements, but CMS did not approve this
AR	Individuals must demonstrate compliance on a monthly basis. Loss of eligibility if enrollee fails to meet work requirements for any three months during the coverage year (either consecutive or non-consecutive months), with coverage termination occurring at the end of the third month of noncompliance. Unless a good cause exemption is met, individual would be locked out of coverage until start of next coverage year and would need to file a new application at that time. Good cause exemptions include: -Disability of individual or if individual has an immediate family member in the home with a disability and is unable to meet requirements for due to this; -Hospitalization/serious illness of the individual or an immediate family member in the home; -Birth or death of a family member in the home; -Severe inclement weather or natural disaster causing inability to meet requirement; or -Individual has family emergency or other life changing event (e.g., divorce or domestic violence). If state determines that an individual’s failure to comply or report compliance was the result of a catastrophic event or circumstances beyond an individual’s control, the individual will receive retroactive coverage to the date coverage ended without the need for a new application.
GA	Reporting is required on a monthly basis. In addition to meeting the work requirements, individuals must timely pay required premiums, if applicable (premiums are required for individuals 50-100% FPL). If individuals do not meet the requirements, they will be suspended from the program. Individuals will have 90 days to meet the requirements for the suspension to be lifted, and can have coverage prospectively reinstated if proof of compliance is provided. If individuals do not meet the requirement by that time, they will be disenrolled. Individuals who have been compliant but become unable to comply due to certain circumstances will be allowed a maximum of 120 hours of non-compliance in a 12-month benefit year; the good cause circumstances include (but are not limited to): 1) enrollee or immediate family member is hospitalized or experiences a serious illness, preventing fulfillment of qualifying activities; 2) enrollee experiences a short-term injury or illness, preventing fulfillment of qualifying activities; 3) birth, adoption, or death of an immediate family member; 4) enrollee accepts a foster child or kinship care placement; 5) enrollee experiences a natural or human caused disaster, preventing fulfillment of qualifying activities; 6) enrollee has a family emergency or other life event (e.g. divorce, civil legal matter, or is a victim of domestic violence); 7) temporary homelessness; 8) enrollee is quarantining in response to having COVID-19 symptoms, diagnosis, or exposure, or closure of places where enrollee was meeting the hours and due to COVID-19 no longer can; 9) other good cause reason as defined and approved by the state. Individuals who demonstrate compliance for six consecutive months will be exempt from reporting, but will need to inform the state if their employment status changes. Individuals will be re-evaluated for eligibility during the annual redetermination.
ID	Individuals who fail to comply with the requirements will become ineligible for Medicaid for a period of two months, unless they can provide proof of meeting an exemption or can demonstrate compliance before the disenrollment effective date. Individuals may become eligible for Medicaid upon the earlier of: 1) after two months from the date of ineligibility; or 2) at any time sooner, after demonstrating compliance or an exemption.
IN	Each December, state will evaluate if enrollees have met work requirement hours for the prior 12-month calendar year. If requirements are not met, eligibility will be suspended beginning on the first day of the new calendar year. Individuals with suspended benefits can reactivate eligibility by meeting one of the following criteria: 1) becoming eligible under another eligibility group; 2) qualifying for an exemption; 3) completing one calendar month of the work requirement hours and submitting documentation information to the state. Unless an individual reactivates eligibility, eligibility will remain suspended until redetermination date; if at that time the individual does not qualify for an exemption, enrollment will be terminated and individual will need to reapply to regain coverage. Good cause exemptions include, but are not limited to: 1) Individual has a disability or has an immediate family member within the home with a disability and was unable to meet requirements due to this; 2) Individual is a victim of domestic violence; 3) Additional circumstances may be granted exemptions, as the state deems necessary.
MI	Individuals will need to demonstrate compliance on a monthly basis An individual is allowed 3 months of noncompliance within a 12-month reporting period. After 3 months of noncompliance, individuals who remain noncompliant will not receive health care coverage for at least one month. Individuals can have coverage reinstated once they come into compliance with the requirements. If an individual is found to have misrepresented compliance with the work requirements, the individual will not be allowed to participate in the Healthy Michigan Plan for a one-year period.
MS	Those who choose not to participate in the workforce training or community engagement activities and who do not qualify for another category of eligibility will lose coverage. Beneficiaries who lose coverage due to lack of participation will be reinstated immediately upon notification of compliance.
MT	Individuals who are non-compliant will have 180 days to come into compliance. Failure to comply within this time period will result in suspension from the program, unless an individual attests and the state confirms that the individual is exempt from the work requirements. Good cause exemptions include individuals who: 1) are hospitalized or caring for an immediate family member who has been hospitalized; 2) have a documented serious illness or incapacity or are caring for an immediate family member with a documented serious illness or incapacity; or 3) are impacted by a catastrophic event or hardship, as defined by the state, which prevents an individual from complying with the work requirements.
NE	Individuals who do not comply with the work requirements will not lose eligibility for the program, but will receive the Basic benefits package instead of the Prime benefits package. Specifically, these individuals will not receive Prime benefits for one six-month benefit period. (Non-compliance with some other requirements such as attending medical appointments and providing timely notification of eligibility changes result in a loss of access to Prime benefits for two six month benefit periods; see Table 2 in the waiver approval document for further details.) After the one- or two six-month Prime benefit suspension period, individuals can regain access to the Prime benefit package by meeting all engagement requirements or qualifying for an exemption or good cause exception. In instances where an individual is assigned to the Basic benefits package due to non-participation in the work requirements, individuals can appeal based on providing a good cause exception; these include (but are not limited to) the following: -The individual has a disability and is unable to meet the requirement due to the disability, or has an immediate family member with a disability, and the individual is unable to meet the requirement due to reasons related to the family member’s disability -The individual or an immediate family member living in the home with the individual experiences a hospitalization or serious illness -Birth or death of a family member living with the individual -Severe inclement weather or natural disaster causing inability to meet requirement -Individual has family emergency or other life changing event (e.g., divorce or domestic violence) -Individual experiences a temporary or short-term illness documented by a clinician
NH	Individuals will have 75 calendar days after the start of the requirement or after their eligibility determination to meet the requirement. Failure to comply will result in suspension of eligibility, unless there is a good cause exception. Good cause exceptions include: -Disability of the individual or if individual has an immediate family member in the home with a disability and is unable to meet requirements for due to this; -Hospitalization/serious illness of the individual or an immediate family member in the home; -Birth or death of a family member in the home; -Severe inclement weather or natural disaster causing inability to meet requirement; -Individual has family emergency or other life changing event (e.g., divorce or domestic violence); or -Other reasons as defined or approved by the state. If individuals are non-compliant, the state will inform individuals that their eligibility will be suspended at the end of the following month, until an individual reports that they meet a good cause exception or qualify for an exemption, or that they make up the deficient hours for the month that resulted in noncompliance. If individuals remain non-compliant or do not meet an exemption, the state will suspend eligibility effective the first of the month following the one-month opportunity to cure.
OH	Individuals subject to the requirements must demonstrate compliance on an annual basis. Beneficiaries will be non-compliant if the state is unable to verify via data available through state systems and data sources that the beneficiary is compliant or if the beneficiary has not reported their compliance to the state within 60 days of being notified that they are required to participate in community engagement. If a beneficiary does not report within the 60 days that they are completing a qualifying activity, meet the criteria for an exemption, or experience a good cause circumstance, the beneficiary will be considered non-compliant and be disenrolled from Medicaid. Disenrollment will occur the first day of the month following appropriate notice after the end of the 60-day period by which the individual was notified about the community engagement requirement. Individuals who are disenrolled for non-compliance can reapply immediately or at any time following disenrollment. Good cause reasons include but are not limited to: -Hospitalization or serious Illness -Illness of an immediate family member requiring the presence of the individual subject to the requirements or beneficiary has an immediate family member living in the home who experiences a hospitalization or serious illness -Emergencies, as defined by the state -Severe inclement weather (including a natural disaster) -Unavailability of transportation -Domestic violence
OK	Individuals who do not comply with the requirements will be terminated in accordance with current termination and notification policies Individuals who lose eligibility after non-compliance may re-apply if they comply with work requirements for at least the specified number of hours in a 30-day period Individuals can submit a good cause exemption request; the exemptions align in part with those in the SNAP program
SC	Individuals who are non-compliant and who do not meet the requirement within 90 days of receiving notice of non-compliance would be suspended, unless an appeal is filed or an individual has a good cause exemption. Individuals can have coverage reinstated if state receives notification of compliance with or exemption from the work requirements. If an individual remains suspended at the end of the eligibility period and is not eligible for Medicaid on another basis, the individual will be disenrolled. Circumstances constituting a good cause exemption include: -Disability of the individual or if individual has an immediate family member in the home with a disability and is unable to meet requirements due to this; -Hospitalization/serious illness of the individual or an immediate family member in the home; -Birth or death of a family member in the home; -Severe inclement weather or natural disaster causing inability to meet requirement; -Individual has family emergency or other life changing event (e.g., divorce or domestic violence); or -Individual experiences a temporary or short-term illness documented by a clinician.
SD	Newly enrolled individuals will be granted a three-month period from their initial application month before they become subject to the requirements During the first and second months of non-compliance, individuals must contact the Department of Labor and Regulation (DLR) within 30 days to develop a corrective action plan. After the third month of non-compliance, individuals will be given a 10-day notice of termination of Medicaid eligibility. Individuals who lose eligibility can work with DLR to take corrective action within 30 days of coverage closure to reinstate coverage, which will be determined by the Department of Social Services. Failure to obtain reinstatement during the 30 day period will result in a 90-day ineligibility period. Individuals who are disenrolled but are subsequently determined to qualify for an exemption and remain eligible will have eligibility reinstated starting the month they qualify for the exemption. Individuals can qualify for a good cause exemption prior to disenrollment due to non-compliance, which include but are not limited to: -Family member in the home with a disability and individual is unable to meet requirements due to serving as short-term caretaker for that family member; -Hospitalization/serious illness of the individual or an immediate family member in the home; -Death of a family member in the home; -Severe inclement weather or natural disaster causing inability to meet requirement; -Individual has family emergency or other life changing event (e.g., divorce or domestic violence)
TN	Individuals will be required to document compliance on a monthly basis. To maintain coverage, individuals must meet the requirement for four months out of every six-month period. Individuals who have not demonstrated compliance for at least four months of the six-month reporting period will be subject to benefit suspension. Benefits will remain suspended until an individual demonstrates compliance with the requirements for one month. Good cause exemptions may be granted for acute or short-term individual circumstances that warrant special consideration (e.g. individuals experiencing homelessness, victims of domestic violence, victims of human trafficking, etc.)
UT	Failure to comply within the three months an individual is required to complete the work requirements will result in loss of eligibility, unless s/he can demonstrate a good cause exemption. Eligibility is terminated on the last day of the month in which the individual receives notification of his or her non-compliance, unless an appeal is filed or the individual qualifies for a good cause exception. Individuals can become eligible again by meeting requirements; these individuals must reapply and would be re-enrolled with eligibility effective the first day of the month in which the individual re-applies. If the individual reports having met the requirements within one month of disenrollment, s/he will not have to submit a new application. Good cause exemptions include: -Disability of individual or if individual has an immediate family member in the home with a disability and is unable to meet requirements due to this; -Hospitalization/serious illness of the individual or an immediate family member in the home; -Birth or death of a family member in the home; -Severe inclement weather or natural disaster causing inability to meet requirement; -Individual has family emergency or other life changing event (e.g., divorce or domestic violence); -Individual has no access to internet or transportation to a place where the requirements can be completed, such as a job center or library; -There are fewer than 48 employers in the individual’s geographic area that potentially could offer employment or from whom the individual reasonably could be expected to accept an employment offer; or -Individual is the primary caretaker of a child age 6 or older and was unable to meet the requirement due to childcare responsibilities
WI	Individuals will be disenrolled and not allowed to reenroll for six months if they do not comply with the work requirements for an aggregate period of 48 months.Good cause exemptions include: -Disability of individual or if individual has an immediate family member in the home with a disability and is unable to meet requirements due to this; -Hospitalization/serious illness of the individual or an immediate family member in the home; -Birth or death of a family member in the home; -Severe inclement weather or natural disaster causing inability to meet requirement; -Individual has family emergency or other life changing event (e.g., divorce or domestic violence)The state originally sought to require individuals to complete drug screening assessments, and also a drug test if needed; in the approved waiver instead of these requirements, a completion of a health risk assessment is a condition of eligibility.

Other State Activity

Kansas submitted a waiver proposal to CMS in December 2017 that included Medicaid work requirements for certain individuals; in December 2018, CMS approved the waiver, but the state asked CMS to defer consideration of the work requirements.

Kentucky’s request to implement work requirements under former Gov. Bevin was approved in Jan. 2018, but was never implemented due to legal challenges, and on Dec. 16, 2019, Gov. Beshear informed CMS that the state would not be moving forward with the Kentucky HEALTH waiver, and that the state is no longer challenging the March 2019 ruling that vacated the waiver approval.

Maine’s request to implement Medicaid work requirements that was submitted under former Gov. LePage was approved Dec. 21, 2018; on Jan. 22, 2019, Gov. Mills informed CMS that the state would not accept the terms of the waiver and would instead direct state officials to make vocational training and workforce supports available to enrollees.

North Carolina submitted a waiver proposal to CMS in November 2017 that included Medicaid work requirements, but the work requirements were contingent on proposed legislation to expand Medicaid through a program called Carolina Cares that did not move forward.

While Virginia submitted a waiver application in Nov. 2018 that included work requirements for the expansion population, in Dec. 2019 the governor said that the state will pause negotiations with CMS, indicating that with the General Assembly moving to Democratic control it is unlikely the state will move forward with the work requirement; and on July 1, 2020, Virginia submitted a formal request to withdraw the work requirements (and cost sharing provisions) from the state’s waiver application.

A Glimpse at Kentucky’s Newly Approved Medicaid Work Requirement Waiver

January 16, 2018/in Policy Kentucky Blogs Cost, Payment, and Delivery Reform, Health Coverage and Access, Health System Costs, Work Requirements /by Anita Cardwell

Last week, for the first time the Centers for Medicare & Medicaid Services (CMS) approved a Medicaid waiver application that includes work and community engagement requirements as a condition of Medicaid eligibility for certain enrollees. Approval of Kentucky HEALTH’s Medicaid waiver proposal, which will run through Sept. 30, 2023, came one day after CMS released guidance allowing states to implement these types of requirements.
The following outlines key components in the state Medicaid program’s work and community engagement requirements and other aspects in the approved Medicaid demonstration project:
Work and Community Engagement Requirements:

Applicable population groups: Able-bodied adults aged 19-64
Exempt population groups: Former foster care youth; pregnant women; primary caregivers of a dependent (either minor child or disabled adult; limited to only one exemption per household); medically frail individuals; individuals diagnosed with acute medical conditions that would prevent them from compliance with requirements (validated by a medical professional); full time students
Amount of hours required: 80 hours/month to maintain eligibility
Qualifying activities: Subsidized or unsubsidized employment; self-employment; job skills training; job search activities; enrollment in educational program related to employment (e.g. management training); general education (e.g. high school, GED, college or graduate education, English as a second language); vocational education and training; community work experience; community service/public service; caregiving services for a non-dependent relative or other individual with chronic, disabling health conditions, or participation in substance use disorder treatment
Enrollees meeting these requirements: Some enrollees will be deemed as satisfying requirements by the following:
- Individual meets requirements of the Supplemental Nutrition Assistance Program (SNAP) and/or Temporary Assistance for Needy Families (TANF) employment initiatives or is exempt from having to meet those requirements
- Individual is enrolled state’s Medicaid employer premium assistance program (a spouse or dependent of beneficiary enrolled in premium assistance program is also exempt)
- Individual is employed at least 120 hours per month
Reporting frequency:
- Enrollees must document participation in any one or combination of qualifying activities on at least a monthly basis.
- Individuals deemed as satisfying the requirements will not be required to actively document participation in qualifying activities, although they will need to timely report changes in eligibility.
Penalties for noncompliance:
- After a one-month opportunity to come back into compliance, individuals who fail to meet requirements for a month will have their benefits suspended unless a good-cause exemption is met.
- Individuals can reactivate eligibility on the first day of the month after the individual complies with the requirements in a 30-day period or completes a state-approved health literacy or financial literacy course.
- Individuals who, during a suspension period, become pregnant, are determined to be medically frail, become a primary caregiver of a dependent (either minor child or disabled adult — limited to only one exemption per household), are diagnosed with an acute medical condition that would prevent them from compliance with requirements (validated by a medical professional), or become a full-time student, or become eligible for Medicaid under an eligibility group not subject to the work and community engagement requirements can reactivate benefits, with an effective date aligned with their new eligibility category or status.
- Individuals with suspended benefits at the time of their re-determination date who do not qualify for an exemption will have their enrollment terminated and will have to submit a new application to regain coverage.
Implementation details:
- Requirements will be implemented on a regional basis. The state will assess areas that experience high rates of unemployment, limited economies and/or educational opportunities, and those with a lack of public transportation to determine whether there should be further exemptions from the work and community engagement requirements and/or additional mitigation strategies.
- Kentucky HEALTH beneficiaries who have not been subject to the requirements in the past five years will be provided a three-month period prior to being subject to the requirements.

Other Notable Waiver Components Include:

Disenrollment and a six-month non-eligibility period for individuals who do not provide necessary documentation/information to complete annual eligibility redetermination or report a change in circumstance that would affect eligibility, with some exceptions;
Use of My Rewards Accounts, which allows enrollees to earn incentives to use for enhanced benefits;
Premiums charged as a condition of eligibility for enrollees earning more than 100 percent of the federal poverty level (FPL), with disenrollment and six-month non-eligibility period for nonpayment (exceptions include pregnant women, former foster care youth, and medically frail individuals). Individuals earning below 100 percent of FPL are also subject to premiums, but not as a condition of eligibility (nonpayment results in requirement to pay copayments for services and lack of access to My Rewards Account for six months);
Access to certain substance use disorder treatment services through an opioid/substance abuse program;
Waiver of non-emergency medical treatment for certain populations and services; and
Waiver of retroactive eligibility for certain populations.

Note: Kentucky initially implemented the Affordable Care Act’s (ACA) traditional Medicaid expansion under Democratic Gov. Steve Beshear. In 2016, newly-elected Republican Gov. Matt Bevin sought a waiver to modify the state’s Medicaid expansion model.

Overview of Medicaid’s New Work and Community Engagement Option for States

January 16, 2018/in Policy Blogs Cost, Payment, and Delivery Reform, Health Coverage and Access, Health System Costs, Work Requirements /by Anita Cardwell

Last week, the Centers for Medicare & Medicaid Services (CMS) issued guidance outlining a new policy that allows states to implement work and community engagement requirements for certain Medicaid enrollees. States would be permitted to seek federal approval to require non-elderly, non-pregnant adults who are not eligible for Medicaid due to a disability to participate in these types of activities as a condition of Medicaid eligibility or to qualify for certain aspects of Medicaid coverage.
CMS indicated that it will support state demonstration projects implementing these types of requirements to test whether they assist individuals in securing stable employment or other “productive” community engagement, and if this in turn leads to improved health outcomes. States may also design projects to include the additional goals of promoting independence and reducing poverty.
The new policy allows states to use Medicaid’s Section 1115 waiver authority to attach work and community engagement requirements to different factors such as:

As a condition of eligibility
A condition of coverage
A condition of receiving additional or enhanced benefits, or
A condition of paying lower premiums or cost sharing

Before the guidelines were released, 10 states had submitted proposals to CMS to implement work requirements in their Medicaid program (AZ, AR, IN, KS, KY, ME, NH, NC, UT, and WI) for Affordable Care Act (ACA) expansion populations or other Medicaid-eligible individuals. Kentucky’s waiver was approved Jan. 12, 2018, and it is expected that other waivers will be approved soon and that additional states will submit similar waiver requests. The following summarizes key information outlined in the guidance.
Definition of scope of work and community engagement activities:
The guidance does not identify a specific set of work and community engagement requirements that CMS would approve; instead it suggests states should consider a range of different types of activities in addition to employment, such as volunteering. Additionally, CMS does not specify guidelines, such as the number of hours that individuals would need to complete to be compliant, any penalties for noncompliance, or how often individuals would need to document compliance. Decisions about these program parameters would be made by states and proposals would be evaluated by CMS on a case-by-case basis.
Because many states have existing structures to implement work and community engagement requirements — such as those for Temporary Assistance for Needy Families (TANF) or the Supplemental Nutrition Assistance Program (SNAP) — CMS would support alignment of Medicaid work and community engagement conditions with these, if they are consistent with Medicaid objectives. States might consider alignment strategies when addressing exempted populations, protections and supports for individuals with disabilities and others who may not be able to comply with the requirements, the types of activities and the number of hours of participation that qualify as meeting the requirements, modifications to requirements due to certain economic or regional-specific factors, enrollee reporting requirements, and the availability of work support programs such as transportation or child care. Also, the guidance states that individuals who are complying with or who are exempt from a TANF or SNAP work requirement must be deemed as meeting Medicaid work and community engagement requirements.
States will be allowed to phase in or suspend aspects of their work and community engagement programs when needed due to factors such as local employment market forces or regions that lack adequate transportation.
In their proposals, states will also need to outline their approach to helping enrollees meet the work and community engagement requirements, such as strategies to connect individuals to child care assistance and transportation resources. However, states are not permitted to use Medicaid funds to pay for these types of services.
Other populations exempt from work and community engagement requirements:
While the work and community engagement requirements do not apply to individuals eligible for Medicaid based on a disability, CMS notes that some other Medicaid-eligible individuals could have an illness or disability as defined by other federal statutes that could affect their ability to comply with Medicaid work and community engagement requirements. States must make sure these individuals are not denied Medicaid due to any inability they may have to comply with the requirements and they must provide reasonable modifications for these individuals. Also, individuals whom the state determines as medically frail or who have acute medical conditions that would prohibit them from adhering to the requirements should be exempt from Medicaid work and community engagement requirements.
The guidance also specifically acknowledges the opioid addiction crisis facing many states, and requires states to implement reasonable modifications to the work and community engagement requirements for individuals with opioid addiction and other substance use disorders, as well as access to necessary Medicaid coverage and treatment services.
Evaluation requirements:
CMS will require states with approved work and community engagement demonstration projects to perform outcomes-based, independent program evaluations to determine whether these requirements are connected to improved health and well-being for individuals (and to also evaluate the independence goal if a state decides to incorporate this criteria). In addition to measuring whether the demonstration project is achieving its objectives, evaluations must also examine the effect of the program requirements on Medicaid enrollees and individuals who have a lapse in coverage or eligibility during the demonstration period because of the new requirements.
States will also need to include an assessment of how the requirements influence enrollees’ capacity to attain sustainable employment, and whether enrollees who transition from Medicaid obtain other health insurance coverage, as well as how these types of transitions affect enrollee health and well-being. Absent from the federal evaluation requirements is an analysis of the cost to states to administer the new policy.
Questions and issues for states:
There are a number of policy and operational questions and issues that states seeking to implement these types of requirements in their Medicaid programs should consider:

General operational issues:
- What additional staffing and amount of agency resources would be needed to implement work and community engagement requirements? With no additional federal matching funds, states interested in pursuing these requirements will need to carefully weigh these factors, given the Medicaid administrative match rate is only 50 percent and that there could be considerable staffing needs.
Tracking compliance and exceptions for certain individuals:
- How will states’ integrated eligibility and enrollment systems accommodate tracking enrollees’ participation in work and community engagement activities? Some states may opt to track compliance with these types of requirements monthly, whereas Medicaid eligibility is generally determined annually. Although CMS suggests that aligning Medicaid work and community engagement requirements with those in TANF and SNAP could reduce the administrative burden on states and enrollees, and that states’ integrated systems may be well-positioned to streamline verification processes, significant changes to eligibility determination systems and procedures would still be necessary. Additionally, not all enrollees may be able to provide electronic verification of compliance with the requirements and instead might need to submit paper documentation, which would be a challenge for individuals and an administrative burden for states.
- How will states manage the process of determining which populations are exempt from the work and community engagement requirements or eligible for reasonable modifications to the requirements? This could be challenging for determining exceptions related to individuals with opioid addiction or other substance use disorders.
Beneficiary education:
- How will states design effective beneficiary education initiatives, both to inform enrollees of specific program requirements and to assist individuals in identifying whether they might qualify for an exemption?
Beneficiary supports:
- How will states finance the requirement to provide supports, including links to resources such as child care and transportation to help enrollees comply with work and community engagement requirements?
Measuring impact:
- Although the CMS guidance indicates that the evaluation measures of health outcomes should use nationally-recognized sources and measure sets, how specifically will states be able to attribute health outcomes to the work and community engagement requirements?
- How will states measure the administrative costs and other potential challenges of implementing the work and community engagement requirements?

NASHP will be conducting additional analysis to better understand the potential administrative implications and operational issues for states that may be interested in implementing work and community engagement requirements in Medicaid.

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