Archive for: Medicaid Expansion

NASHP State Leaders Meet to Reflect and Plan in a Changing Health Care Environment

March 27, 2018/in Policy Blogs CHIP, Chronic Disease Prevention and Management, Cost, Payment, and Delivery Reform, Essential Health Benefits, Health Coverage and Access, Health Equity, Health System Costs, Healthy Child Development, Integrated for Pregnant/Parenting Women, Maternal, Child, and Adolescent Health, Medicaid Expansion, Population Health, Social Determinants of Health, State Insurance Marketplaces /by NASHP Writers

Last week, 24 National Academy for State Health Policy (NASHP) leaders, including state lawmakers and representatives from governors’, budget, and insurance offices, Medicaid and public health agencies, and insurance exchanges, CHIP and health policy commissions met in Washington, DC, to assess the issues and opportunities confronting state health policymakers. The robust discussion helps NASHP set its priorities for action and informs the annual NASHP conference agenda.
While NASHP members approached the discussion from markedly different states and perspectives, several clear themes emerged.
Costs, costs, costs: A recent Journal of the American Medical Association article that highlighted the high price of health care in the United States – double what is spent in other, developed countries due to high-priced services, drugs, devices, and administrative costs – helped frame the critical issue of cost and affordability. Members were eager to talk in-depth about:

The role of value-based purchasing, and how policymakers can measure value and at what price.
How investments in the social determinants of health (e.g., housing, nutrition, and education) can truly bend the health care cost trajectory.
Is there more do to with reference pricing and giving consumers more power to shop?
Are there better ways to manage long-term services and supports and provide effective chronic care and end-of-life support?

Members encouraged NASHP to continue its work to address rapidly-rising pharmaceutical costs and to expand that effort to address other drivers of escalating health care costs.
The changing health care marketplace: Consolidation of health providers, emergence of new players in the field such as the Berkshire-Hathaway proposal, and new mergers and acquisitions throughout health care raised questions about whether states’ current regulatory structures are keeping pace with these changes.

What is the role of state insurance regulators as providers develop new models of care and take on financial risk, a role that has historically been the purview of insurance companies?
Does the certificate of need program need to be re-examined and reformed to adapt to the changing market?
Do states have adequate data infrastructure to track and predict these changes?

Coverage and federal uncertainty: Officials reflected on a year of uncertainty and recounted their efforts to sustain programs while awaiting federal action or responding to federal changes. Children’s Health Insurance Programs (CHIP) were in limbo, but states managed to maintain coverage until Congress made a much-delayed decision to continue federal financing for 10 years.
Insurance regulators and state insurance exchanges reacted quickly to keep coverage in the individual market affordable when the Administration stopped funding cost-sharing reductions in the eleventh hour last fall. Now, they must contemplate how to sustain markets in light of proposed federal plans to extend short-term duration plans and launch association health plans that are exempt from Affordable Care Act rules. which could pull enrollees out of state marketplaces with their low-cost, low-benefit plans.
As the Centers for Medicare & Medicaid Services allows more flexibility in Medicaid programs, what does that mean in practice? How will work requirements play out? What other approaches might states take?
Health care workforce: A changing health care environment creates the need for new approaches to deliver care, such as telehealth, but NASHP members shared an overriding sense of urgency to address the growing demand for a health care workforce in both rural and urban areas. They reported challenges in their home states in every area of health care, including physicians, nursing, therapists, community health workers, dental providers, behavioral health practitioners, and long-term services and supports staff. Without an appropriate workforce, state efforts to improve care integration and delivery and payment reforms will be hindered. What can states do through licensure, education, salary, and benefits to expand this vital workforce? And, how does federal immigration policy affect the availability of these critical workers?
Improving health: As state leaders face day-to-day challenges, the over-arching focus of their work is to improve population health and directly address the social determinants that impact health so profoundly. The opioid crisis continues to demand leaders’ time and action, but comprehensive work is also underway to build sustainable systems to improve health. Leaders discussed new ideas to:

Create or strengthen linkages with school health programs;
Improve transitions for youth with disabilities who age out of supportive services;
Assist those leaving corrections systems;
Help children and youth with special health care needs; and
Employ new, evidence-based approaches that strengthen early child development.

Throughout the conversation, leaders stressed the need for state officials to break out of funding and administrative silos so they can work collaboratively and creatively to develop and implement efficient and effective policies during this period of uncertain federal priorities and funding.
Armed with these insights and concerns, NASHP will continue to work in these key areas and address them at its annual health care policy conference from Aug. 15 to 17, 2018, in Jacksonville, FL.

Congressional Leaders Propose ACA Insurance Stabilization Measures in Omnibus Budget Bill

March 20, 2018/in Policy Blogs Cost, Payment, and Delivery Reform, Health Coverage and Access, Health System Costs, Medicaid Expansion, State Insurance Marketplaces /by Christina Cousart

On Friday, March 23, 2018, Congress faces an important deadline to pass an omnibus budget bill to avert a government shutdown. Measures to bolster states’ Affordable Care Act (ACA) markets are currently not in the bill, but a group of lawmakers have proposed an amendment that could strengthen and stabilize insurance markets.
Sens. Lamar Alexander and Susan Collins and Reps. Greg Walden and Ryan Costello released legislative language earlier this week that includes several significant provisions, including allocation of more than $30 billion to fund state reinsurance or high-risk pool programs.
A Congressional Budget Office analysis of the bill estimates the funding would decrease premiums on average by 10 percent in 2019 and 20 percent in 2020 and in 2021. Under this plan, middle-income consumers (earning more than 400 percent of the federal poverty level-FPL) would experience the greatest gains from the reinsurance/high-risk pool program. However, an accompanying analysis suggests the bill would lead to coverage losses due to consumers earning between 200 and 400 percent of FPL dropping their coverage as a result of federal funding for the cost-sharing reduction (CSR) program, which offers smaller federal subsidies for health insurance for this population.
Below is a summary of the major components of the Alexander-Collins-Walden-Costello proposal.
Reinsurance/High-Risk Pool Funding

Federal funding for a reinsurance or high-risk pool program. The program would allocate $10 billion per year from 2019 to 2021 to states to operate a reinsurance or high-risk pool program, and $500 million in 2018 to cover the costs of creating the program. The program would exist under ACA’s Section 1332 waiver authority, but exempts the program from budget neutrality and state matching requirements typically associated with 1332 waivers. The proposal gives states latitude to define their high-risk pool or reinsurance program, but authorizes the US Department of Health and Human Services (HHS), in consultation with the National Association of Insurance Commissioners (NAIC), to determine how funds should be allocated to states. HHS will operate a federal default program in states that do not pursue their own reinsurance or high-risk pool program. It also provides an expedited 45-day approval process for states seeking 1332 waivers to establish their program.

Changes to ACA’s 1332 Waiver Program

Streamlines administrative procedures for 1332 waivers. Extends flexibility by allowing states to pursue waivers if they secure certification from their governors (rather than securing state legislative approval.)
Loosens affordability standard for 1332 waivers. Changes the requirement that coverage under a 1332 waiver must be “as least as affordable” as coverage under the ACA. Instead, it establishes that coverage be of comparable affordability for low-income individuals, individuals with serious health needs, and other vulnerable populations.
Loosens budget neutrality requirements. Instead, mandates that the waiver should not increase the federal deficit over the term of the waiver and over the 10-year budget plan submitted in conjunction with the waiver application. It also provides flexibility so that HHS may consider the budgetary effects on other federally-funded programs (e.g., Medicaid) in assessing budget neutrality requirements.
Expedites waiver approvals: Shortens the time during which HHS must approve or deny a waiver from 180 to 120 days. Provides an expedited 45-day approval process for emergency waivers (where states are at risk of excessive premium increases or bare counties) and copycat waivers (waivers substantially similar to that approved in another state).
Extends the waiver approval period. Allows HHS to approve waivers for up to six years (as opposed to five) and allows waivers to be approved for additional six-year periods.
Limits suspension of waivers. Ensures that HHS cannot suspend or terminate waivers prior to the end of the waiver period unless the state has materially failed to comply with the terms of the waiver.
Requires HHS to develop model waiver language. Within 60 days, HHS must develop model waivers that could include plans to establish a reinsurance program or invisible high-risk pool, expand insurer participation and access to affordable plans, encourage value-based insurance design, and provide varied health plan benefit designs.
Eliminates all 1332 regulations and guidance issued prior to the enactment of this proposed law.

Funds the Cost-Sharing Reduction (CSR) Program

Appropriates funding for CSRs from 2017-2021. The appropriation would cover costs incurred under the CSR program from Oct. 1, 2017, through Dec. 31, 2021. Insurers would only be eligible for CSR payments in 2018 if the insurer did not otherwise increase its premiums to account for elimination of program funding. (Read more about CSRs.)

Extend Availability of Catastrophic (Copper) Health Plans

Removes restrictions on catastrophic health plans. Eliminates restrictions barring individuals older than age 30 from purchasing catastrophic health plans.
Merges catastrophic enrollees into a single risk pool. Ensures that catastrophic enrollees are included as part of the individual markets single risk pools.

Invests in Marketplace Marketing and Outreach

Dedicates federal funds for federal marketplace outreach and enrollment activities. Dedicates $105.8 million collected from marketplace issuer fees for outreach and enrollment activities in 2019 and 2020. HHS may give grants to states for the purposes of fulfilling these activities.
Requires reporting on enrollment and outreach programs. Requires HHS to issue biweekly enrollment reports during the 2019 and 2020 open enrollment seasons. Requires HHS to issue annual summary reports on Navigator performance and advertising and outreach activities conducted for in 2019 and 2020.

Regulations Related to Multi-State Compacts

Requires NAIC to issue regulations under Section 1333 of the ACA. Section 1333 allows states to form “health care choice compacts” under which insurers would be permitted to sell qualified health plans to consumers in any state participating in the compact.

Short-term Limited Duration Plans

Requires consumer education about limitation of short-term plans. Requires state insurance commissioners to require short-term plan insurers prominently display the fact that short-term plans do not meet the coverage and benefit requirements of ACA-qualified health plans in marketing materials, contracts, and application materials.
Codifies state legislative and regulatory flexibility over short-term plans. Establishes that states may regulate short-term plans as long as state regulations do not interfere with federal requirements.

How Elimination of Cost-Sharing Reduction Payments Changed Consumer Enrollment in State-Based Marketplaces

March 20, 2018/in Policy Blogs Eligibility and Enrollment, Health Coverage and Access, Medicaid Expansion, State Insurance Marketplaces /by Christina Cousart

State health policymakers are eagerly waiting to see if Congress’ omnibus budget bill released this week will attempt to stabilize Affordable Care Act (ACA) insurance markets by reinstating ACA’s cost-sharing reduction (CSR) payments. An early proposal by US Sen. Lamar Alexander would fund the cost-sharing subsidies, which reduce a family’s out-of-pocket health care costs, retroactively from 2017 through 2021.
While this is a potential solution to how the federal government can subsidize health insurance for some consumers who purchase insurance through ACA markets, data collected by the National Academy for State Health Policy (NASHP) illustrates the complex interplay between marketplace subsidies and consumer decisions that states face.
States and insurers demonstrated incredible dexterity in quickly redesigning insurance plans in response to the Administration’s late-in-the-game decision to end CSR payments in October 2017. The result was that consumers faced new confusion as insurance plans were revamped and repriced in 2018, resulting in major enrollment shifts both off and within health insurance marketplaces. Below, NASHP presents 2018 enrollment data collected by state-based marketplaces (SBMs), which closely manage their own exchanges, highlight how state actions to address the loss of CSR funding influenced market decisions in 2018. Key findings indicate:

Decreased enrollment in marketplace silver plans, especially among consumers who no longer had access to CSR subsidies and who did not qualify for tax credits;
Enrollment growth in marketplace bronze plans;
Mixed enrollment growth or declines in gold plans; and
Mixed growth, and some declines in the total number of subsidized enrollees in the marketplaces.

The findings do not provide a complete picture of what has occurred in markets nationwide, as the data represent only 10 states and do not include complete information about off-marketplace enrollment patterns or full consideration of other factors that may have influenced enrollment during the 2018 enrollment period, including shortened enrollment periods and other factors influencing premium costs. However, they provide a glimpse into how states’ markets reacted to federal policy shifts and the serious ramifications of CSR changes wrought by Washington on consumer purchasing behaviors.
Background
Under the CSR program, insurers are required by federal law to cover certain out-of-pocket expenses (e.g., deductibles, copayments, coinsurance) for enrollees with incomes below 250 percent of the federal poverty level (FPL). CSRs are only available through silver-level health plans purchased on the state or federal health insurance marketplaces. Typically, silver-level plans have an actuarial value (AV) of 70 percent, meaning that the plan must cover in aggregate at least 70 percent of the health care costs received under the plan. CSRs change the AV of plans by varying amounts depending on the income of the qualifying consumer (see Table 1).

Table 1. Qualifying for CSRs
To qualify for the ACA’s CSR program, consumers must purchase silver-level health plans and have incomes between 100 to 250 percent of FPL, which in 2018 ranged from $16,642 to $30,150 for individuals and from $33,948 to $61,500 for a family of four.
CSR-Eligible Plan	Standard Silver	Silver 73	Silver 87	Silver 94
Income	Any	200-250% FPL	150-200% FPL	100-150% FPL
Actuarial Value	70%	73%	87%	94%

The ACA designed the CSR program so that insurers would be reimbursed for expenditures incurred under the program, and would be paid back whatever costs were charged to ensure that consumers who received services were only paying out-of-pocket expenses in line with the AV of their CSR-eligible health plan.
Questions about the exact language of the CSR law spurred litigation over whether it was legal for the government to issue reimbursements without an explicit appropriation for the program. Pending the outcome of this litigation, the Administration stopped issuing CSR reimbursements.
Response to Elimination of Federal CSR Reimbursements
After the Administration stopped CSR payments last October, most state regulators directed their insurance carriers to adjust their 2018 premium rates to account for CSR losses. Not responding to the issue would have left insurers exposed to the lost federal funding, possibly resulting in insurers opting to not participate in markets. As CSR payments most directly affected silver-level plans sold on the marketplaces, most states and carriers opted to load premium increases onto silver-level plans offered through their insurance marketplaces. The Congressional Budget Office (CBO) estimated that silver plan premiums increased by 10 percent on average in 2018 in response to elimination of CSR funding. Among the states that operate their own marketplaces, only three did not load the increases onto their silver plans. These included:

Colorado, which advised its insurers to distribute premium increases across all metal levels to mitigate the effect on silver-level plans;
Vermont, which similarly distributed premium increases across all metal levels due to uncertainty over the effects of the changes on its uniquely-merged individual and small group markets; and
Washington, D.C., which calculated that elimination of the CSR payments would have minimal effect on its market due to low enrollment of CSR-eligible individuals.

CSR Loading Had Differing Impacts on Subsidized and Non-subsidized Consumers
Silver-loaded premiums shifted the affordability and value of plans offered through marketplaces, distorting costs and participation in the markets. For consumers who were eligible for premium tax credits to subsidize their coverage (82 percent of marketplace consumers in 2017), some coverage options became even more affordable. This is because the tax credit is calculated based on the second-lowest-cost silver plan available to a consumer. As a result, as silver premium costs increased in response to CSR elimination, so did the total amount of tax credit a qualifying consumer could receive. This increase in tax credits — combined with more marginal increases in premiums for bronze- and gold-level plans than for silver plans — meant that both bronze and gold plans became more affordable for these consumers. Availability of these more affordable plans may have attributed to the enrollment increases seen in some states’ marketplaces.
While the silver-loading strategy served the important purpose of insulating lower-income consumers from CSR losses, it resulted in increases costs for consumers who were ineligible for tax credits. The increased premiums escalated affordability concerns and forced many of these consumers to seek cheaper options, either by enrolling in lower-value bronze plans or by disenrolling from marketplace coverage entirely. These changes had important repercussions for both consumers and insurers participating in the markets.

Distorted market competition and enrollment. CSR payment elimination had disproportionate effects on marketplace insurers as they adjusted premium rates differently based on the proportion of CSR-eligible consumers enrolled in their plans. Insurers with a greater proportion of CSR-eligible individuals increased premiums by a higher amount than those with fewer CSR-eligible enrollees. In California, for example, CSR-induced premium rate increases ranged from 8 percent to as much as 27 percent. This lead to a distortion of premium prices between insurers and generated shifts in market share as consumers switched to insurers whose plans had smaller premium growth.
Increased consumer susceptibility to out-of-pocket spending. The lower-cost bronze plans, which offer less coverage, enticed more consumers to purchase them. While this lowered consumers’ annual spending on premiums, the lower AV of bronze plans means that these consumers are at greater risk of higher out-of-pocket spending. This is especially true for consumers who were once CSR-eligible but switched from silver to bronze plans without considering the resulting out-of-pocket costs.
Complete disenrollment from individual market coverage. While the total impact of CSR changes on enrollment cannot be known without additional data about off-marketplace enrollment, it is highly probable that premium increases and confusion over the changes in premium costs spurred some non-subsidized consumers to drop insurance coverage altogether. These drops in coverage led to altered market risk pools and premium increases.

Consumers Shifted Purchasing Patterns in 2018
While it is not possible to determine the absolute effect of CSR elimination on consumers’ behavior, initial data collected by the 10 SBM states indicate that state and insurer decisions to silver-load influenced consumers’ choices in 2018. Key patterns that emerged include:

Disenrollment in silver-level health plans, especially among unsubsidized consumers: While the majority of consumers from these states continued to select silver-level health plans, there was an almost a universal drop in the proportion of enrollees selecting silver-level plans (exceptions include Colorado and Vermont, which did not silver-load, and Minnesota, whose Basic Health Program for consumers earning up to 200 percent FPL offset the effect of CSR losses.) As expected, shifts away from silver plan selections were more common among individuals who did not receive tax credits.
Growth in enrollment in bronze plans: There was almost universal growth across all states in the proportion of enrollees who selected bronze plans, with the exception of Minnesota and Vermont, which only saw marginal reduction in bronze plan selections.
Varied growth or disenrollment in gold plans: Changes in gold selections vary across states, from Colorado where the proportion of gold enrollments dropped by nearly one-third to Maryland where gold enrollments increased nearly four-fold.

Different trends in enrollment among subsidized and unsubsidized consumers in these states indicate that CSR policies did not by themselves drive shifts in enrollment. It is also likely that the total effect of the CSR issue varied greatly across all states, depending on several factors including:

The proportion of unsubsidized marketplace consumers in the state — especially those enrolled in silver plans who were most susceptible to silver-loaded premiums; and
Baseline premium prices of bronze or gold alternatives for consumers seeking to shift away from silver plans.

Investments in education and outreach also affected how consumers responded to CSR-loading in various states. The Massachusetts’ Health Connector, for example, was among several states that took extensive steps to urge its unsubsidized silver-plan enrollees to seek more affordable options either on or outside the marketplace. Connector officials reported that they were successful in moving 82 percent of affected enrollees into new coverage plans. This meant that 18 percent of unsubsidized consumers remained in silver plans, despite its aggressive outreach efforts to inform consumers about the availability of more affordable options.
Outlook for States and Markets Pending Federal Action
While this information provides a snapshot of enrollment patterns in 2018 from 10 states, it indicates that responses to the CSR funding elimination had diverse effects on states’ markets and consumers. Similarly, if CSR funding is reinstated, the effect will reverberate differently across states’ markets and consumers. Significant changes could mean another year of disruption for insurers, who will need to adapt products and rates based on shifting federal policy, and consumers, who may need to once again actively shop around and switch plans next year. The CBO estimates that 500,000 to 1 million consumers would become uninsured from 2020 to 2021 if CSR funding was reinstated. These would mostly impact consumers with incomes between 200 to 400 percent FPL who would no longer would benefit from tax credits, which are larger than CSR subsidies.
While states and insurers rapidly responded to the Administration’s decision to end the CSR program in 2017, an absence of clear policies and continuous last-minute changes will spur unrest in markets. Without sustainable policies to stabilize the individual market, consumers will face higher costs, confusion, and anxiety about whether insurance coverage will be available when they need it.
While CSR funding remains a concern to some states, states are also seeking solutions that could bring immediate stability to markets, such as federal reinsurance funding. Whatever policies are implemented this spring, time is of the essence as state regulators are already in active negotiations with their insurers for 2019 offerings, with rate filings expected in some states as early as May. Ideally, future federal policies will grant states sufficient time and flexibility to respond to policy changes in a manner most appropriate for their markets.

Click here to view a chart comparing marketplace enrollment by metal level in California, Colorado, Connecticut, Idaho, Maryland, Massachusetts, Minnesota, Rhode Island, Vermont and Washington State.

Federal Promotion of Short-Term Health Insurance Plans: How Will These Plans Impact State Insurance Markets?

March 6, 2018/in Policy Blogs Essential Health Benefits, Health Coverage and Access, Medicaid Expansion, State Insurance Marketplaces /by Christina Cousart

Last month, the departments of the Treasury, Labor, and Health and Human Services released a proposed rule that changes the definition of short-term, limited-duration insurance (STLDI) plans to make it easier to sell the plans, which do not have to adhere to Affordable Care Act (ACA) requirements, such as covering people with pre-existing conditions.
This proposed rule is the latest federal action to implement President Trump’s Executive Order promoting “health care choice and competition” in the United States. The cumulative effect of this proposed rule plus elimination of the individual mandate penalty and increased availability of association health plans under another pending rule is expected to significantly affect states’ insurance markets in 2019.
STLDI is insurance that individuals can purchase on a short-term basis, particularly consumers who need to fill a gap in coverage — such as when they change jobs and need interim coverage until their new employers’ insurance kicks in. Short-term plans are largely unregulated and exempt from many federal regulations, including several enacted under the ACA, including:

Guaranteed issue: Requires insurers to cover individuals regardless of pre-existing conditions;
Community rating: Prohibits insurers from charging consumers more for coverage based on their health rating;
Annual and lifetime limits: Prohibits insurers from setting annual and lifetime dollar limits on the amount of their plans’ coverage;
Medical-loss ratio: Requires insurers to spend at least 80 percent of premium dollars received on health care services; and
Essential health benefits: Requires all plans to cover certain benefits within 10 defined categories, including hospitalizations, maternity care, mental health and substance use disorder services, and prescription drugs.

Often, short-term plans are designed as low-cost, low actuarial value products targeting healthy individuals. States can impose their own laws and regulations over STLDI policies – even stricter than federal regulations. However, currently states have differing levels of regulatory oversight over STLDI. Given the federal government’s proposal to enhance the sale of these plans, some states are now reviewing and tightening their legislative reach over these short-term plans to make sure the consumer protections they want are in place in their markets.
Major Rule Changes Proposed
The proposed rule includes several changes aimed at expanding the availability and access to STDLI plans. The rule:

Allows for short-term plans to be sold to consumers covering a period of less than 12 months;
Allows for individuals to reapply for short-term plans, which had been prohibited under prior federal regulation;
Stipulates that consumers who purchase these plans must be informed that these short-term plans may not comply with ACA requirements; and
Continues to allow federal and state governments to not enforce STLDI regulations codified in 2016 insurance regulations.

The rule would be effective 60 days after enactment of the final rule, meaning that short-term plans meeting these parameters could be sold as early as this year.
This rule contrasts with a 2016 rule that stipulated that short-term plans could only be sold for a period of three months and limited consumer’s ability to renew STLDI coverage. The 2016 rule was designed to limit any negative impact that short-term plans could have on premium costs and risk mix of plans sold by state ACA marketplaces.
Effect of STDLI on State Insurance Markets
There is no question that the proposed rule will have a significant impact on most state markets. While short-term plans provide consumers with low-cost insurance options, the coverage is expected to provide limited benefits with high deductibles, putting consumers at risk of large out-of-pocket costs if they need to use comprehensive health services. Moreover, increasing the availability of short-term plans will draw consumers out of the individual market risk pool and could raise the risk of adverse selection—or unhealthy risk mix-in other individual market plans, including plans offered by state and federal health insurance marketplaces.
If enacted this year, the rule could lead to insurer instability in 2018. These carriers are locked into contracts and pricing that depended on a defined risk mix of customers – including a mix of healthy individuals and those with costly health care needs. Insurers could experience financial losses if healthy consumers leave these plans and enroll in STLDI plans this year. The rule will also lead to premium increases for individual market coverage offered in 2019 and beyond. The proposed rule estimates that 100,000 to 200,000 individuals will drop out of marketplaces to enroll in short-term plans in 2019.
Enrollment in short-term plans will be exacerbated by the elimination of the individual mandate penalty passed in the December 2017 Tax Reform Bill. Without a mandate requiring people to purchase “minimum essential coverage” (insurance that meets federal regulatory standards), consumers will be free to purchase de-regulated coverage options like STLDI. A recent Urban Institute analysis estimated that 4.2 million individuals would enroll in STLDI plans in 2019 if the rule were enacted as proposed. The report also estimates that individual market premiums will increase by an average of 16.4 percent in 2019 due to the cumulative effect of the loss of the individual mandate penalty and the enactment of the STLDI rule. See The Potential Impact of Short-Term Limited-Duration Policies on Insurance Coverage, Premiums, and Federal Spending for state-by-state estimates.
State Actions to Address STLDI
States have authority to impose their own regulations over short-term plans sold in their markets. Some have explicitly exempted short-term policies from benefit and other requirements imposed on other health insurance products. This enables issuers to offer low-cost options in certain states that serve as insurance protection against catastrophic events, but do not provide comprehensive coverage. Others have heighted restrictions over the sale of short-term plans in order to:

Preserve a healthier risk mix in their individual markets; and/or
Protect consumers against misleading marketing tactics practiced by some STLDI issuers and exorbitant out-of-pocket costs that might result.

As described in the Urban Institute’s report, Massachusetts, New Jersey, New York, Oregon, Vermont, and Washington currently have laws that would prevent an expansion of STLDI. Michigan and Nevada have laws to “limit STLD policy expansion.”
A few state legislatures have taken up STLDI insurance legislation during their current sessions. Proposed legislation in Missouri (HB 1685) and Virginia (SB 844) will conform state STLDI policies with those under the proposed federal rule, specifically to allow the sale of short-term plans that cover up to 364 days. Additional legislation is pending in Missouri (SB 860) to exempt STLDI from meeting requirements imposed on other health insurance products while also enforcing specific disclosure notices that STLD issuers must provide to consumers to inform them about the limited scope of this coverage.
Legislation in New Jersey and Vermont would state tighten regulation over STLDI. New Jersey’s (S 1210) legislation would require STLDI policies to meet the standards of other health insurance products. Vermont’s (H 892) would institute the 2016 federal regulation requirements by restricting the sale of products to only three months and limiting the renewability of short-term plans.
The release of this proposed rule carries additional weight for states that are currently in the midst of negotiating 2019 health insurance rates with their carriers. Absent strong state regulations, some states may have to set rates without knowing what will be enacted in the final rule.
The National Academy for State Health Policy (NASHP) will continue to monitor state actions during the current legislation session and rate-filing season to share critical information about the impact of these policies on states. Comments on the proposed rule are due April 23.

How Governors Addressed Health Care in Their 2018 State of the State Addresses

February 26, 2018/in Policy Georgia, Hawaii, Idaho, Iowa, Massachusetts, New Hampshire, New Jersey, New Mexico, Rhode Island, South Dakota, Utah, Washington, Wisconsin, Wyoming Charts Behavioral/Mental Health and SUD, Chronic and Complex Populations, Chronic Disease Prevention and Management, Cost, Payment, and Delivery Reform, Health Coverage and Access, Health Equity, Health System Costs, Healthy Child Development, Housing and Health, Integrated Care for Children, Integrated for Pregnant/Parenting Women, Maternal, Child, and Adolescent Health, Medicaid Expansion, Medicaid Managed Care, Physical and Behavioral Health Integration, Population Health, Quality and Measurement, Social Determinants of Health, Value-Based Purchasing, Workforce Capacity /by NASHP Staff

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.

What’s a State to Do? A New Series Helps States Navigate a Rapidly-Changing Federal Landscape

December 5, 2017/in Policy Blogs CHIP, CHIP, Essential Health Benefits, Health Coverage and Access, Maternal, Child, and Adolescent Health, Medicaid Expansion, State Insurance Marketplaces /by NASHP Writers

Introduction by NASHP Executive Director Trish Riley
In a period of change and uncertainty at the federal level, states are on the front line, searching for firm footing and clear direction as they responsibly steward their public programs, protect their consumers, and balance state budgets.

When the federal government stopped funding cost sharing reductions (CSR) for the individual Marketplace, eligible consumers could no longer get help paying out-of-pocket costs required as part of their health insurance coverage. In response, most state insurance regulators and state-based marketplaces negotiated work-arounds with their issuers to make sure consumers continued to receive help paying those costs.
Federal funds for the Children’s Health Insurance Program (CHIP) were not renewed on Sept. 30, 2017, but states – aided by redistributed funds from the Centers for Medicare & Medicaid — are keeping their programs open as long as possible despite uncertainty about when and whether funds will be provided.

Today, as the tax bill appears headed to repeal the individual mandate, states will lose a tool that is critical to sustaining a more robust individual insurance market. By encouraging all to procure coverage, risk was spread among both the healthy and the sick, which kept a check on premium growth. Two Congressional proposals – the Cassidy-Murray insurance stabilization bill and the Collins-Nelson reinsurance bill — propose short-term stabilization strategies to preserve markets. But are these two limited, two-year appropriations that fund CSRs and reinsurance enough to stabilize markets and offset the impact of the loss of the mandate?
Amid this uncertainty, states await the imminent release of proposed federal rules that would expand the use of short-term policies and provide for association health plans. How might those changes impact the individual markets in states, and how will state officials make sure they have the information and analysis needed to address new opportunities and challenges that are fast emerging?
Today, the National Academy for State Health Policy (NASHP) launches a series, What’s a State to Do? with State Options to Protect Consumers and Stabilize the Market: Responding to President Trump’s Executive Order on Short-Term Health Plans, a policy analysis written by our colleague, Sabrina Corlette, of Georgetown University’s Center for Health Insurance Reforms. We are pleased to share her work and hope to continue these collaborations in the future.
States will make their own choices as they respond to these emerging opportunities for state flexibility, and we hope these columns will help states as they navigate these changes.

Healthy Child Development State Resource Center

November 15, 2017/in Policy Toolkits CHIP, CHIP, Chronic Disease Prevention and Management, Eligibility and Enrollment, EPSDT, Featured Policy Home, Health Coverage and Access, Health IT/Data, Healthy Child Development, Immunization, Integrated Care for Children, Lead Screening and Treatment, Maternal, Child, and Adolescent Health, Medicaid Expansion, Medicaid Managed Care, Population Health /by NASHP

States Share Innovations to Tackle their Opioid Epidemics

October 24, 2017/in Policy Annual Conference, Blogs Behavioral/Mental Health and SUD, Chronic and Complex Populations, Cost, Payment, and Delivery Reform, Health Coverage and Access, Health System Costs, Maternal Health and Mortality, Maternal, Child, and Adolescent Health, Medicaid Expansion, Medicaid Managed Care, Physical and Behavioral Health Integration, Quality and Measurement /by NASHP Staff

Mary McIntyre, MD, Alabama’s chief medical officer (left) and Ana Novais, executive director of Rhode Island’s Department of Health.

PORTLAND, OR – State health officials shared wide-ranging innovations in their uphill battle against the opioid epidemic that is sweeping their states at the opening day of the National Academy for State Health Policy’s (NASHP) 30^th State Health Policy Conference.
Officials explained they are experimenting with new strategies that use data, new treatment approaches, and reconfigured public safety responses to illegal drug use in a race against time as overdose deaths are expected to exceed the 63,000 recorded in 2016.
Kimberly Johnson, MD, director of the US Substance Abuse and Mental Health Services Administration’s Center for Substance Abuse Treatment, ticked off the various strategies and services that are being tried out in state incubator programs that show promise in tackling this national epidemic, including providing treatment on demand, decriminalizing illegal opioid use, creating safe drug use sites and needle exchange programs, improving diagnosis of people with opioid addiction, better use of data to identify drug use patterns in communities, and addiction treatment with medications, such as methadone, which is proven to lower relapse rates.
“The number one thing states can do,” she commented following her opening remarks Monday morning, “is to address prescribing practices among providers. But it really takes all of these strategies to stop this epidemic.”
While NASHP’s three-day conference addressed a host of state public health issues, the nation’s opioid epidemic was a frequent topic at various workshops. It remains the Achilles heel, officials noted, that exposes states’ conflicting and piecemeal public health approaches even while providing opportunities for innovation.
Ana Novais, executive director of Rhode Island’s Department of Health, highlighted her state’s effort to create a dashboard that pulls data from hospitals, police, emergency rescue workers, and providers to create an overdose reporting system. Armed with data, including the latest on fentanyl deaths and locations of overdoses, the state can launch responses that involve police, rescue workers, health care providers and community leaders.
In Ohio – where one in nine of the nation’s heroin overdoses occur — the Office of Health Transformation, led by director Greg Moody, is tackling opioid over-prescribing through a health care reform called value-based pricing that rewards Medicaid managed care providers who provide high-quality care at reasonable prices.
“We wanted to knit together strategies from different domains within state government to address the opioid crisis,” he explained to more than 200 officials who attended the session. To prevent future addictions, Ohio has spearheaded a payment innovation approach to discourage over-prescribing of opioids and reward “best-practice” painkiller prescribing in its Medicaid managed care program.
One of the quality measures Ohio uses to identify “high-value” health care providers is their opioid prescribing practice. The state examines how many opioids a provider – including dentists and orthopedic specialists — prescribe and for how long. Their prescribing practices are compared with the state average. Providers who prescribe above the average amount and duration of painkillers may not get referrals and may eventually lose financial incentives.
Pennsylvania’s approach to prevent future addictions is to provide Medicaid coverage for alternative pain management treatment, such as acupuncture and yoga.
Increasing access to medically-assisted treatment for addiction, educating providers to improve opioid prescribing practices, and building coalitions between public safety and communities to get people into treatment is daunting, officials noted. Some states are proposing to add a work requirement to their Medicaid programs, similar to what exists for adults receiving Temporary Assistance to Needy Families (TANF), which concerned some policymakers. “We want to make sure that if people are working toward recovery that they are not excluded from Medicaid eligibility,” one attendee pointed out.
Another official pointed out that lawmakers in her state wondered how much funding to invest in the naloxone program if emergency personnel keep reviving the same people after multiple overdoses.
“This is a disease,” said David Kelley, MD, chief medical officer of Pennsylvania’s Department of Human Services Office of Medical Assistance Programs, “does an emergency medical technician say, ‘you’ve had angina five times already, we won’t treat you this time?’ Addiction is a disease, we need to stop thinking how many times is enough.”
“We do have to deal with the political ramifications that people still think of addiction as a personal choice,” observed Mary McIntyre, MD, chief medical officer of Alabama’s Department of Public Health.
NASHP will be publishing many of the “State Innovations and Interventions in America’s Opioid Crisis” presentations and slides, and additional blogs in the weeks ahead at oldsite.nashp.org.

The Administration Ends CSR Subsidy Payments — What Comes Next?

October 17, 2017/in Policy Blogs Cost, Payment, and Delivery Reform, Health Coverage and Access, Health System Costs, Medicaid Expansion, State Insurance Marketplaces /by Christina Cousart

On Friday, Oct. 13, 2017,the Trump Administration announced it would no longer make cost-sharing reduction (CSR) payments to insurers offering coverage on health insurance marketplaces. The announcement cited guidance from the US Department Justice that questioned the legality of the appropriation for these payments (for more Cost Sharing Reduction Debate: Why This Matters and How States Are Preparing for an Uncertain Future).
How It Impacts the 2017 Insurance Marketplace
The Affordable Care Act (ACA) requires insurers to offer CSR subsidies to individuals earning between 100 to 250 percent of the federal poverty level (up to $29,700 income for an individual or $60,750 for a family of four) who purchase plans on the marketplace. In 2017, approximately 7 million individuals — 58 percent of all marketplace consumers — received CSR subsidies. Long-standing consumer protection policies restrict the ability of insurance issuers to adjust rates or withdraw from markets mid-year, so issuers have few options but to fully absorb the costs of CSR subsidies paid on behalf of enrollees for the remainder of 2017.
What This Means for States and Insurers in 2018
Open enrollment for 2018 begins Nov, 1, 2017. On that date, rates and health plan offerings must be set so consumers have accurate information about their insurance plan choices. Insurers in most states were required to submit final rates for 2018 plans by Sept. 27, 2017, before the Administration issued its decision to stop CSR payments (See: Explore the Limited Choices States Face as Washington Debates CSR Payments). To date, most states and insurers chose to submit rates with CSR costs “loaded,” meaning their premium prices assumed the loss of federal CSR payments.
States and issuers that opted to “CSR load” have reported premium increases ranging from 6 percent (Colorado) to 20 percent (Idaho) on top of normal rate increases to account for CSR losses. Increased premiums will lead to a commensurate increase in tax credits to consumers as the tax credits are based on premium costs for silver-level health plans sold on the marketplace. As a result, consumers earning between 100 to 400 percent of the federal poverty level who qualify for the credits will largely be shielded from the premium increases because of the increase in tax credits.
Those most affected will be individuals and families making over 400 percent of the federal poverty level ($47,550 per year for an individual or $97,200 for a family of four), who do not qualify for tax credits and will now bear the full costs of these premium increases.
Insurers in at least 11 states did not originally set rates that included the “CSR load” (Alaska, Colorado, Georgia, Maryland, Massachusetts, Montana, North Dakota, Oregon, South Dakota, Vermont, and Washington). Because they own and operate their own technology, states that operate state-based marketplaces (Colorado, Maryland, Massachusetts, Vermont, Washington) have greater flexibility to adjust rates as deemed appropriate by state regulators, insurers, and marketplace operators. The remaining states utilize the federally-facilitated marketplace (FFM), which is operated by the Centers for Medicare & Medicaid Services (CMS). These states will be limited in their ability to issue changes, pending guidance from CMS. Some, including Alaska and Oregon, have signaled they will immediately adjust rates to account for CSR payment loss. With open enrollment set to begin, these states and insurers must rapidly pivot if they wish to make adjustments prior to the Nov. 1, 2017, sign-up date.
Prior to the Administration’s announcement, several insurers had announced their decisions to exit markets, citing growing costs and market uncertainty spurred by the Administration’s lack of clarity over CSR payments and enforcement of the individual mandate. To date, no additional insurer has announced its intent to exit an insurance market as a result of the Administration’s CSR decision. However, a provision in the 2018 contract for issuers offering through the FFM allows some latitude for these insurers to exit due to CSR funding issues.
Congress and States Take Action
The Administration’s decision may revive Congressional efforts to assure, at least temporarily, payment of CSR subsidies. This was one area of near universal agreement during recent bipartisan hearings on market stabilization held by the Senate Health, Education, Labor, and Pensions (HELP) Committee in September. Following these hearings, Sens. Lamar Alexander (TN) and Patty Murray (WA) have been working on a stabilization bill that is likely to include these payments. Sen. Ron Johnson (WI) has also expressed that he will propose language to fund CSR payments, while proposing other insurance market reforms such as additional flexibility for short-term plans and use of health savings accounts. However, even if a bill is passed, it is uncertain whether the President would sign a bill that is construed as bolstering insurance markets regulated by the ACA.
Meanwhile, 18 states and Washington, DC have filed a lawsuit against the Administration’s decision to discontinue CSR payments. It is possible that, while the case is pending, courts will require the Administration to continue to make CSR payments, drawing out the uncertainty of the issue until the legal case is resolved.
Regardless of future actions, states and consumer groups are actively preparing for the open enrollment season, including launching outreach efforts to lessen consumer confusion spurred by ongoing uncertainty over national health reform efforts. NASHP will continue to monitor their efforts and report as the open enrollment season approaches.

Sign Up for Our Weekly Newsletter

This form needs Javascript to display, which your browser doesn't support. Sign up here instead