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Kentucky Is First To Get Federal OK For Medicaid Work Requirement

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The federal government has approved most of Governor Matt Bevin’s proposed changes to the state’s Medicaid program.

Bevin’s proposal includes requiring many of the state’s Medicaid enrollees to perform some kind of “community engagement” — work, volunteer service, job training or education. The federal government paved the way for the approval on Thursday, when it announced it would allow work requirements as a condition for Medicaid coverage.

Bevin noted in a news conference Friday that Kentucky’s is the first waiver with a community engagement requirement approved.

“Kentucky is leading the nation in this reform in ways that are already replicated by well over a dozen states and growing,” he said.

“The idea that we should keep doing what we’re doing is an insult to the people of Kentucky. It’s an insult to those for whom a better opportunity is available and possible. And I’m excited by the fact that Kentucky will now lead the way.”

Bevin is calling the waiver “Kentucky HEALTH.” The acronym HEALTH stands for “Helping to Engage and Achieve Long Term Health.”

The changes are aimed at decreasing what the state will have to pay to run the program, which was expanded to cover many more people under the Affordable Care Act. But the changes also would make it harder for people to keep their Medicaid coverage.

The Bevin administration says it will reach out to enrollees starting Friday, and the program will kick off in July.

The federal approval comes 17 months after the changes, which the feds call a “waiver,” were first submitted.

The Changes

Here are some of the changes coming for Kentucky’s Medicaid enrollees:

People who are enrolled because they make under $12,060 a year for a one-person family, but are not disabled will have to work, volunteer, take education classes or be in job training for at least 80 hours a month.

Enrollees who will be exempt from this include full-time students, former foster care youth, pregnant women, people with an acute medical condition and primary caregivers. People working 120 hours a month are also exempt.

They will continue to get vision and dental benefits, and either have to make a monthly payment — called a premium — or a payment at the time of a medical service.

Pregnant women and children won’t have premiums, won’t have a change in benefits and won’t have to complete the community engagement requirement.

People who gained coverage through Medicaid expansion (who can make up to $16,670 for a one-person family) will have to pay a copay or premium. But they’ll only get access to vision and dental coverage if they pay a premium.

Enrollees will have to work 80 hours a month, or volunteer and do other “community engagement” activities. Enrollees will have to show proof of these hours. If they don’t, they’ll have until a state-determined date to make up those hours. They could also take a financial or health literacy course. And if they haven’t done any of those things by that predetermined date, they’ll get kicked out of Medicaid for six months and have to reapply.

If a person hasn’t had Medicaid coverage for the previous five years, he or she will get a three-month grace period for the work requirement. If a person had Medicaid for three months or more for the past five years, he or she will go straight into the work requirement.

These Medicaid enrollees will have to submit any changes to income and employment information if it affects their Medicaid eligibility. If enrollees don’t submit that information and the state finds out, enrollees will be locked out of coverage for six months.

“Medically-frail” adults and former foster care youth won’t be subject to the community engagement requirement and there is no change in benefits.

There have been questions from advocates about what “medically-frail” will mean, and how people will get that designation. The federal government defines “medically-frail” as people with serious physical, mental, substance abuse or behavioral health conditions.

Jill Hunter, deputy commissioner of the Kentucky Department of Medicaid Services, said in November that her office estimated about 10 percent of Medicaid recipients in Kentucky will get a “medically-frail” designation and be exempt from the premiums, copays and work or volunteer requirement.

Hunter also said there will be a few ways people will be designated medically-frail: through a diagnosis, health insurance claims, or a doctor or the enrollee attesting to the medically-frail status.

“Recipients will be able to attest to it themselves,” Hunter said at the Kentucky Primary Care Association Conference in Lexington in November. “They’ll be able to fill out a document to say, ‘I encounter these things, whatever the diagnosis may be.’”

Medicaid Expansion Rollback

Former governor Steve Beshear originally expanded Kentucky’s Medicaid program to include people making up to 138 percent of the poverty limit after the Affordable Care Act passed in 2010, setting up a funding stream for states to expand the program for low-income Americans.

Bevin ran on dismantling that Medicaid expansion before his election in 2015, citing high costs. Last summer, he submitted a plan to the federal government outlining a truncated version of both Medicaid and Medicaid expansion.

The state estimated the move would save $16.8 million just in the first year of implementation. The federal government, meanwhile, would save $121.7 million in that year.


Democrats and health advocates were both quick to criticize the Medicaid changes. Here are some of the reactions:

“By approving Governor Bevin’s dangerous and irresponsible Medicaid waiver, the Trump administration has agreed to end health coverage for 95,000 Kentuckians. During the campaign, Bevin pledged to end Kentucky’s highly successful Medicaid expansion, but as governor, he did not have the courage to do it. Instead he is sabotaging it by raising premiums for families who can’t afford them and creating new barriers to coverage that will—by the Governor’s own admission—force tens of thousands of Kentuckians to lose access to life-saving health care. Make no mistake: people will die because of this. Thousands of Kentucky families will face financial ruin. Governor Bevin and President Trump are creating an entirely unnecessary crisis in our Commonwealth for entirely political reasons. It is an unconscionable attack on our state’s health, and I will continue to fight for every Kentuckian to get the health care they need and deserve.” —Rep. John Yarmuth

“The last thing we should be doing is removing access to health care — particularly in eastern and western Kentucky.  Life can’t be your highest value only part of the time. Either you value life or you don’t. And Bevin has shown he doesn’t care about the lives of these nearly 100,000 Kentuckians. This waiver will surely cost us more in tax dollars with an uninsured population and this waiver not only lacks safeguards for the costs it creates, but it’s morally deficient.” —Kentucky Democratic Party Chair Ben Self

“No matter how it’s packaged, Kentucky HEALTH is not about giving Kentuckians back their dignity — because they already have that. It’s not about personal responsibility — most already work. And it’s not about promoting financial independence — we have yet to see a plan for creating better paying jobs that offer benefits. Instead, this is an effort to transform Medicaid into a work program for low-income adults with healthcare as the prize.” —Emily Beauregard, Executive Director of Kentuckians Voices for Health

The National Health Law Program’s Legal Director Jane Perkins said litigation is expected because the approval violates federal law.

“The U.S. Department of Health and Human Services’ (HHS) approval is problematic for several reasons. For example, the federal law only authorizes the secretary to allow states to ignore Medicaid’s consumer protections when a state is implementing an experimental project designed to promote the objectives of the Medicaid Act. While we are still reviewing the details of this approval, we have yet to identify such an experiment, and the action appears designed to achieve significant cuts in Medicaid enrollment rather than Medicaid’s stated purpose of furnishing medical assistance to low-income people,” Perkins said.

On the other side of the aisle, Republican Senate Majority Leader Mitch McConnell praised the move.

“I applaud CMS and Governor Bevin for recognizing the unaffordable mess left behind by his predecessor and responding with innovative, common-sense steps to engage patients, improve health, and reduce the burden on Kentucky taxpayers,” he said. “Today’s announcement by CMS is a step toward taking the power out of Washington and sending it back to the state while also ensuring the long term fiscal sustainability of the Medicaid program.”

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