An Early Look at Implementation of Medicaid Work Requirements in Arkansas

Key Findings
  1. CMS also has approved work requirement waivers in Kentucky, Indiana, and New Hampshire. After being invalidated by a federal district court before implementation, the Kentucky waiver was reopened for additional public comment and is now awaiting a new decision from CMS. For more information about the court’s decision, see KFF, Explaining Stewart v. Azar, Implications of the Court’s Decision on Kentucky’s Medicaid Waiver (July, 2018), https://www.kff.org/medicaid/issue-brief/explaining-stewart-v-azar-implications-of-the-courts-decision-on-kentuckys-medicaid-waiver/. Indiana and New Hampshire plan to implement their waivers in 2019. As of Sept. 28, 2018, 10 other states (AL, AZ, KS, ME, MI, MS, OH, SD, UT, and WI) have work requirement waivers pending with CMS. KFF, Medicaid Waiver Tracker (Sept. 28, 2018), https://www.kff.org/medicaid/issue-brief/which-states-have-approved-and-pending-section-1115-medicaid-waivers/.

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  2. CMS, Special Terms & Conditions, Ark. Works, No. 11-W-00287/6 (March 5, 2018-Dec. 31, 2018), https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/ar/ar-works-ca.pdf.

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  3. Arkansas’ model is credited with substantially increasing enrollment, increasing the number of carriers, and contributing to premium reductions in the state’s Marketplace. Medicaid expansion in Arkansas also has resulted in a considerable reduction in the state’s uninsured rate. While the private option has been more administratively complex to implement than a traditional expansion, expanding Medicaid without a waiver was not seen as politically viable. Arkansas also was somewhat uniquely situated to adopt the private option, as it did not have an established Medicaid managed care delivery system prior to expansion, unlike most states, or a fee-for-service provider network equipped to serve a sizable number of new enrollees. KFF, A Look at the Private Option in Arkansas (Aug. 2015), https://www.kff.org/medicaid/issue-brief/a-look-at-the-private-option-in-arkansas/.

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  4. Most states adopting the Affordable Care Act’s Medicaid expansion did so without a waiver. KFF, Status of State Action on the Medicaid Expansion Decision (Sept. 11, 2018), https://www.kff.org/health-reform/state-indicator/state-activity-around-expanding-medicaid-under-the-affordable-care-act/.

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  5. KFF, A Look at the Private Option in Arkansas (Aug. 2015), https://www.kff.org/medicaid/issue-brief/a-look-at-the-private-option-in-arkansas/.

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  6. One point of confusion was whether the new requirements apply to enrollees with income from 101-138% FPL. The state clarified that the requirements currently apply to those with incomes up to 100% FPL and will apply to the 101-138% group in the future, if the state ultimately does not receive approval from CMS to cap expansion eligibility at 100% FPL. See also Ark. Dep’t of Human Servs., Ark. Works Sec. 1115 Demonstration Waiver Quarterly Report at 2 (April 1, 2018-June 30, 2018), https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/ar/Health-Care-Independence-Program-Private-Option/ar-works-qtrly-rpt-apr-jun-2018.pdf.

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  7. Prior to implementing the new requirements, Arkansas provided a voluntary referral for all enrollees to the state Department of Workforce Services (DWS) for free job search and job training assistance. State law enacted in April, 2016 required this referral for enrollees with income at or below 50% FPL. Beginning in January 2017, DWS referrals were made for all Arkansas Works beneficiaries. Id.

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  8. Implementation was phased in for existing enrollees ages 30 to 49 from June through September 2018, and the first group of enrollees lost coverage on September 1, 2018, for failure to meet the requirements for three months. Enrollees were phased in according to their Medicaid eligibility renewal month: those with Jan., Feb., or March renewal dates became subject to the new requirements in June; those with April, May, or June renewal dates became subject to the new requirements in July; those with July, Aug., or Sept. renewal dates became subject to the new requirements in Aug.; and those with Oct., Nov., or Dec. renewals dates became subject to the new requirements in Sept. Those ages 30-49 who are newly determined eligible on or after April 1, 2018 are subject to the new requirements as of the second month after approval. The requirements will be phased in for existing enrollees ages 19 to 29 from January through April 2019, with the first notices to be sent in early November 2018. Those ages 19-29 who are newly determined eligible on or after Nov. 1, 2018 will be subject to the new requirements as of the second month after approval. Eligibility and Enrollment Monitoring Plan, Ark. Works – Work and Comm’y Engagement Amendment at 6-8 (approved by CMS, May 31, 2018), https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/ar/Health-Care-Independence-Program-Private-Option/ar-works-elig-enrllmnt-plan-05312018.pdf.

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  9. KFF, An Early Look at State Data for Medicaid Work Requirements in Arkansas (Sept. 2018), https://www.kff.org/medicaid/issue-brief/an-early-look-at-state-data-for-medicaid-work-requirements-in-arkansas/; see also Ark. Dep’t of Human Servs., Ark. Works Program, Aug. 2018 Report (data as of Sept. 9, 2018, released Sept. 12, 2018), https://humanservices.arkansas.gov/images/uploads/newsroom/091218_AWReport_Final.pdf.

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  10. Gresham v. Azar, No. 1:18-cv-1900, Compl. (D. D.C., Aug. 14, 2018), http://www.healthlaw.org/issues/litigation/gresham-azar-complaint#.W7eIdmhKjIUj. The lawsuit was filed on August 14, 2018 by three individual Arkansas Medicaid enrollees in DC federal district court. The plaintiffs are challenging CMS’s approval of Arkansas’ waiver amendment, including the work and reporting requirements and elimination of 3-month retroactive eligibility, and CMS guidance inviting states to apply for Section 1115 waivers that condition Medicaid eligibility on work. The plaintiffs argue that the waiver amendment and guidance are illegal because they exceed the Health and Human Services (HHS) Secretary’s authority under Section 1115. The plaintiffs also assert that they have been unable to meet the work requirement due to medical issues, including seizures, chronic back pain, and mental health conditions; lack of transportation; and seasonal work with fluctuating hours, and they are having difficulty accessing and navigating the online portal to fulfill the reporting requirement. The case was brought against HHS and CMS. Subsequently, the state of Arkansas joined the case as a defendant. The case is assigned to the same judge who invalidated CMS’s approval of Kentucky’s waiver, including a work requirement and other restrictive eligibility and enrollment provisions in June. KFF, Explaining Stewart v. Azar, Implications of the Court’s Decision on Kentucky’s Medicaid Waiver (July 2018), https://www.kff.org/medicaid/issue-brief/explaining-stewart-v-azar-implications-of-the-courts-decision-on-kentuckys-medicaid-waiver/. The case will be briefed from Nov. 5, 2018 through Jan. 14, 2019. Gresham v. Azar, no. 1:18-cv-01900-JEB, Joint Proposed Briefing Schedule, ECF no. 23 (D.D.C., Sept. 27, 2018), https://affordablecareactlitigation.files.wordpress.com/2018/09/5693453-0-9748.pdf.

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  11. The state Medicaid agency sent two informational mailings to enrollees before the work requirement took effect: first, a March 2018 mailing to all enrollees instructed them to call the state to provide their email address and indicated that they would receive a future notice if they were subject to the work requirement. AR Works Information, Notices and Flyer Samples, Example – March 2018 – Initial Work Requirement Info, last accessed Oct. 5, 2018, https://ardhs.sharepointsite.net/ARWorks/Notice_Samples/2.%20Example%20%E2%80%93%20March%202018%20%E2%80%93%

    20Initial%20Work%20Requirement%20Info.pdf; Ark. Dep’t of Human Servs., Ark. Works Sec. 1115 Demonstration Waiver Quarterly Report at 7 (Jan. 1, 2018-March 31, 2018), https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/ar/Health-Care-Independence-Program-Private-Option/ar-works-qtrly-rpt-jan-mar-2018.pdf. Second, an April 2018 mailing directed enrollees to create their “Access Arkansas” online account and log on to update and provide information so that the state could determine whether they were exempt from the new requirements. AR Works Information, Notices and Flyer Samples, Example – April 2018 – Get Ready for the Work Requirement, last accessed Oct. 5, 2018, https://ardhs.sharepointsite.net/ARWorks/Notice_Samples/3.%20Example%20%E2%80%93%20April%202018%20%E2%80%93

    %20Get%20Ready%20for%20the%20Work%20Requirement.pdf. Enrollees who are subject to the work requirement are sent a notice the month before, indicating when their work requirement begins and that, unless they get another notice saying that they are exempt from reporting, they must report their work activities by the fifth of the following month or will be considered non-compliant and will lose coverage after three months of non-compliance. AR Works Information, Notices and Flyer Samples, Example – Subject to Work Requirement – Work Activities, last accessed Oct. 5, 2018, https://ardhs.sharepointsite.net/ARWorks/Notice_Samples/4.%20Example%20%E2%80%93%20Subject%20to%20Work%20

    Requirement%20%E2%80%93%20Work%20Activities.pdf. Another notice informs enrollees that they are subject to the work requirement but do not have to report work activities because they qualify for an exemption and includes a specific exemption end date. The sample notice posted by the state online uses pregnancy as the exemption reason. AR Works Information, Notices and Flyer Samples, Example – Subject to Work Requirement – Exempt, last accessed Oct. 5, 2018, https://ardhs.sharepointsite.net/ARWorks/Notice_Samples/5.%20Example%20%E2%80%93%20Subject%20to%20Work%20

    Requirement%20%E2%80%93%20Exempt.pdf.

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  12. Multiple online videos go through how to set up an online account and report work activities. A one-minute video has a narrator announcing changes and holding up sheets of paper that enrollees should look for in the mail. This video also directs enrollees to follow the AR DHS Facebook page for more information and updates and directs enrollees to call DHS to report their email addresses. AR Works work requirement: Introduction to changes video (published March 20, 2018), https://www.youtube.com/watch?v=u8Dzra91Cz8&feature=youtu.be. Another 2.5-minute video goes through the need and process for setting up an online account. This video notes that even people who think they will be exempt from the requirement need to link accounts and report. AR Works work requirement: How to Link your Account video (published April 2, 2018), https://www.youtube.com/watch?v=pkfct7Px3MQ&feature=youtu.be.

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  13. See Ark. Dep’t of Human Servs., Ark. Works Sec. 1115 Demonstration Waiver Quarterly Report at 6 (April 1, 2018-June 30, 2018), https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/ar/Health-Care-Independence-Program-Private-Option/ar-works-qtrly-rpt-apr-jun-2018.pdf (listing state outreach activities).

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  14. AFMC also provides an inbound integrated voice response system where enrollees can receive information about the new requirements. Eligibility and Enrollment Monitoring Plan, Ark. Works – Work and Comm’y Engagement Amendment at 3 (approved by CMS, May 31, 2018), https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/ar/Health-Care-Independence-Program-Private-Option/ar-works-elig-enrllmnt-plan-05312018.pdf.

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  15. During the phase-in, AFMC begins outreach to existing beneficiaries 30 days before they become subject to the new requirements. Id.

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  16. AFMC does outreach to newly approved enrollees subject to the work requirement in the first 12 days after Medicaid eligibility is approved. Id.

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  17. Id.

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  18. Ark. Dep’t of Human Servs., Ark. Works Sec. 1115 Demonstration Waiver Quarterly Report at 5 (April 1, 2018-June 30, 2018), https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/ar/Health-Care-Independence-Program-Private-Option/ar-works-qtrly-rpt-apr-jun-2018.pdf.

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  19. Anuj Gangopadhyaya, et al. Medicaid Work Requirements in Arkansas: Who Could Be Affected? at 4 (May 2018), https://www.urban.org/sites/default/files/publication/98483/2001846_2018.05.23_arkansas_medicaid_finalized.pdf. Additional data show that among all states in 2015, Arkansas households reported the second-lowest rate of computer and internet use and the second-lowest rate of broadband access. Id. at n. 27 (citing “Table 702.60: Number and Percentage of Households with Computer and Internet Access, by State, 2015,” National Center for Education Statistics, Digest of Education Statistics, accessed May 8, 2018; and Ryan, Camille, and Jamie M. Lewis. 2017. “Computer and Internet Use in the United States: 2015.” ACS-37. Washington, DC: US Census Bureau.).

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  20. Ark. Works Introduction to Work Requirement video, https://ardhs.sharepointsite.net/ARWorks/work_requirement/index.html, last accessed with error screens, Oct. 5, 2018.

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  21. AR Works Information, Notices and Flyer Samples, Example – Subject to Work Requirement – Work Activities, last accessed Oct. 5, 2018, https://ardhs.sharepointsite.net/ARWorks/Notice_Samples/4.%20Example%20%E2%80%93%20Subject%20t%20Work%20

    Requirement%20%E2%80%93%20Work%20Activities.pdf.

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  22. AR Works work requirement: How to Link Your Account video, last accessed Oct. 5, 2018, https://ardhs.sharepointsite.net/ARWorks/default.aspx.

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  23. Id.; see also Ark. Dep’t of Human Servs., Linking Your Online Account to Your Health Care Coverage slide set, last accessed Oct. 5, 2018, https://ardhs.sharepointsite.net/ARWorks/sso_linking/index.html.

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  24. Id.

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  25. Ark. Works Sec. 1115 Demonstration, Expenditure Authority, ¶ 2 (March 5, 2018 through Dec. 31, 2021, amended March 5, 2018), https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/ar/ar-works-ca.pdf. The online portal was available to enrollees beginning on March 30, 2018 to begin creating and linking their online accounts and reporting exemptions. Ark. Dep’t of Human Servs., Arkansas Works Section 1115 Demonstration Waiver Quarterly Report at 7 (Jan. 1, 2018-March 31, 2018), https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/ar/Health-Care-Independence-Program-Private-Option/ar-works-qtrly-rpt-jan-mar-2018.pdf.

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  26. The online reporting requirement is authorized through expenditure authority, authorizing spending for enrollee monthly reporting of work activities and exemptions only through the online portal, inconsistent with 42 CFR § 435.97 (a), which requires states to accept information by website, phone, mail, in person, and other commonly available electronic means. Ark. Works Sec. 1115 Demonstration, Expenditure Authority, ¶ 2 (March 5, 2018 through Dec. 31, 2021, amended March 5, 2018), https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/ar/ar-works-ca.pdf.

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  27. Ark. Dep’t of Human Servs., Ark. Works Sec. 1115 Demonstration Waiver Quarterly Report at 7 (April 1, 2018-June 30, 2018), https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/ar/Health-Care-Independence-Program-Private-Option/ar-works-qtrly-rpt-apr-jun-2018.pdf.

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  28. Individuals may become a registered reporter by reviewing specified online training material, signing a Registered Reporter Acknowledgement Form and emailing that form to Arkansas DHS. The online training material consists of two slidesets on how to report work activities and exemptions and how to link an enrollee’s online account with her health coverage. Ark. Works, Registered Reporter of Work and Community Engagement Activities Acknowledgement Form, last accessed Oct. 5, 2018, https://ardhs.sharepointsite.net/ARWorks/Forms/AR_Works_Registered_Reporter_Acknowledgment_Form.pdf.

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  29. KFF, An Early Look at State Data for Medicaid Work Requirements in Arkansas (Sept. 2018), https://www.kff.org/medicaid/issue-brief/an-early-look-at-state-data-for-medicaid-work-requirements-in-arkansas/; see also Ark. Dep’t of Human Servs,. Ark. Works Program, Aug. 2018 Report (data as of Sept. 9, 2018, released Sept. 12, 2018), https://humanservices.arkansas.gov/images/uploads/newsroom/091218_AWReport_Final.pdf.

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  30. In contrast to the monthly online Arkansas Works reporting requirement, the state confirmed that Arkansas SNAP enrollees report their employment and training compliance to their caseworker semi-annually or whenever they experience a change in circumstances.

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  31. Other exemptions, accounting for about 8% of total exemptions, include pregnancy, caring for someone who is incapacitated, short-term incapacity, receiving unemployment benefits, receiving education and training, participating in an alcohol or drug treatment program and American Indian / Alaska Natives. American Indian / Alaska Natives are subject to the requirements but will be phased in at a later date. KFF, An Early Look at State Data for Medicaid Work Requirements in Arkansas (Sept. 2018), https://www.kff.org/medicaid/issue-brief/an-early-look-at-state-data-for-medicaid-work-requirements-in-arkansas/; see also Ark. Dep’t of Human Servs,. Ark. Works Program, Aug. 2018 Report (data as of Sept. 9, 2018, released Sept. 12, 2018), https://humanservices.arkansas.gov/images/uploads/newsroom/091218_AWReport_Final.pdf.

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  32. Id.

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  33. Eligibility and Enrollment Monitoring Plan, Ark. Works – Work and Comm’y Engagement Amendment at 4 (approved by CMS, May 31, 2018), https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/ar/Health-Care-Independence-Program-Private-Option/ar-works-elig-enrllmnt-plan-05312018.pdf.

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  34. Ark. Dep’t of Human Servs., Reporting Work Activities and Exemptions for Arkansas Works slide set, last accessed Oct. 5, 2018, https://ardhs.sharepointsite.net/ARWorks/reporting/index.html.

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  35. Id.

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  36. Ark. Dep’t of Human Servs., AR Works Information for Students, last accessed Oct. 5, 2018, https://ardhs.sharepointsite.net/ARWorks/Outreach/Information_for_Students.pdf.

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  37. Id.

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  38. The state outreach materials, such as enrollee flyers, do not specify timeframes for particular exemption types, although they are contained in the state policy manual. Compare Ark. Dep’t of Human Servs., AR Works Work Requirement Work Activities and Exemptions, last accessed Oct. 5, 2018, https://ardhs.sharepointsite.net/ARWorks/Outreach/Work_Requirement_Activities_and_Exemptions.pdf, with Ark. Dep’t of Human Servs., Div. of Cnty. Operations, Med. Servs. Pol’y Manual, § G-190 Verification of the Adult Expansion Group Work and Cmty. Engagement Requirement (May 1, 2018), https://ardhs.sharepointsite.net/DHSPolicy/DCOPublishedPolicy/Section%20G-100%20Verification%20Standards.pdf.

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  39. Ark. Dep’t of Human Servs, Div. of Cnty Operations, Med. Servs. Pol’y Manual, Appendix Y (May 1, 2018), https://ardhs.sharepointsite.net/DHSPolicy/DCOPublishedPolicy/Appendix%20Y-Work%20Activity%20Chart.pdf.

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  40. Ark. Dep’t of Human Servs., Flyer – AR Works Work Requirement Info, “What You Need to Know About the Work Requirement”, last accessed Oct. 5, 2018, https://ardhs.sharepointsite.net/ARWorks/Notice_Samples/1.%20Flyer%20%E2%80%93%20AR%20Works%20Work%20

    Requirement%20Info.pdf.

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  41. See, e.g., Eligibility and Enrollment Monitoring Plan, Ark. Works – Work and Comm’y Engagement Amendment at 4-5, 13 (approved by CMS, May 31, 2018), https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/ar/Health-Care-Independence-Program-Private-Option/ar-works-elig-enrllmnt-plan-05312018.pdf.

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  42. Compare AR Works Information, Notices and Flyer Samples, Example – Post Closure Letter, last accessed Oct. 5, 2018, https://ardhs.sharepointsite.net/ARWorks/Notice_Samples/8.%20Example%20%E2%80%93%20Post%20Closure%20Letter.pdf, with AR Works Information, Notices and Flyer Samples, Example – Subject to Work Requirement – Work Activities, last accessed Oct. 5, 2018, https://ardhs.sharepointsite.net/ARWorks/Notice_Samples/4.%20Example%20%E2%80%93%20Subject%20to%20Work%20

    Requirement%20%E2%80%93%20Work%20Activities.pdf.

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  43. Ark. Dep’t of Human Servs, Div. of Cnty. Operations, Med. Servs. Pol’y Manual, § F-201 Good Cause Exemptions (May 1, 2018), https://ardhs.sharepointsite.net/DHSPolicy/DCOPublishedPolicy/Section%20F-200%20Work%20Requirement%20for%20the%20Adult%20Expansion%20Group.pdf; AR Works Information, Notices and Flyer Samples, Example - Post Closure Letter, last accessed Oct. 5, 2018, https://ardhs.sharepointsite.net/ARWorks/Notice_Samples/8.%20Example%20%E2%80%93%20Post%20Closure%20Letter.pdf.

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  44. See, e.g., Despite elimination of backlog, Medicaid re-determination process not quick, Ark. News (Sept. 21, 2015), http://www.arkansasnews.com/news/arkansas/despite-elimination-backlog-medicaid-re-determination-process-not-quick.

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  45. Eligibility and Enrollment Monitoring Plan, Ark. Works – Work and Comm’y Engagement Amendment at 4 (approved by CMS, May 31, 2018), https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/ar/Health-Care-Independence-Program-Private-Option/ar-works-elig-enrllmnt-plan-05312018.pdf.

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  46. KFF, An Early Look at State Data for Medicaid Work Requirements in Arkansas (Sept. 2018), https://www.kff.org/medicaid/issue-brief/an-early-look-at-state-data-for-medicaid-work-requirements-in-arkansas/; see also Ark. Dep’t of Human Servs., Ark. Works Program, Aug. 2018 Report (data as of Sept. 9, 2018, released Sept. 12, 2018), https://humanservices.arkansas.gov/images/uploads/newsroom/091218_AWReport_Final.pdf.

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  47. Id.

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  48. The waiver terms and conditions require the state, “[p]rior to implementation of community engagement requirements as a condition of eligibility,” to “[e]nsure [that] the state will assess areas within the state that experience high rates of unemployment, areas with limited economies and/or educational opportunities, and areas with lack of public transportation to determine whether there should be further exemptions or alternative compliance standards from the community engagement requirements and/or additional mitigation strategies, so that the community engagement requirements will not be impossible or unreasonably burdensome for beneficiaries to meet in impacted areas.” CMS, Special Terms & Conditions, Ark. Works, No. 11-W-00287/6 at ¶ 54 (e) (March 5-Dec. 31, 2018), https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/ar/ar-works-ca.pdf.

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  49. DHS is in negotiations to add 15 more counties by the end of 2018, leaving 25 counties without a SNAP E&T physical location during the initial 7 months of implementation, and 10 counties remaining in 2019. Eligibility and Enrollment Monitoring Plan, Arkansas Works – Work and Community Engagement Amendment at 1 (approved by CMS, May 31, 2018), https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/ar/Health-Care-Independence-Program-Private-Option/ar-works-elig-enrllmnt-plan-05312018.pdf.

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  50. See, e.g., AR. Works Information, Notices and Flyer Samples, Example – Subject to Work Requirement – Work Activities, last accessed Aug. 10, 2018, https://ardhs.sharepointsite.net/ARWorks/Notice_Samples/4.%20Example%20%E2%80%93%20Subject%20to%20Work%20

    Requirement%20%E2%80%93%20Work%20Activities.pdf.

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  51. Eligibility and Enrollment Monitoring Plan, Ark. Works – Work and Comm’y Engagement Amendment at 2 (approved by CMS, May 31, 2018), https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/ar/Health-Care-Independence-Program-Private-Option/ar-works-elig-enrllmnt-plan-05312018.pdf. Specific services listed on DWS’s website include job search training, resume assistance, job listings, occupational skills assessments, registered apprenticeships, college and career planning, and career readiness certification. See generally Ark. Dep’t of Workforce Servs., Jobseeker Servs., last accessed Oct. 5, 2018, https://www.dws.arkansas.gov/jobseekers/. Career readiness certification is described as a credential that individuals can obtain to demonstrate to potential employers that they possess basic workplace skills such as reading for information, applied mathematics, and locating information in graphics. Ark. Career Readiness Certificate Brochure, last accessed Oct. 5, 2018, http://www.state.ar.us/esd/Programs/CRC/PDF/CRC%20Job%20Seeker%20Brochure%20(Final%20Copy%20%2715).pdf

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  52. Eligibility and Enrollment Monitoring Plan, Ark. Works – Work and Comm’y Engagement Amendment at 2-3 (approved by CMS, May 31, 2018), https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/ar/Health-Care-Independence-Program-Private-Option/ar-works-elig-enrllmnt-plan-05312018.pdf.

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  53. KFF, Medicaid and Work Requirements: New Guidance, State Waiver Details and Key Issues (Jan. 2018), https://www.kff.org/medicaid/issue-brief/medicaid-and-work-requirements-new-guidance-state-waiver-details-and-key-issues/.

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  54. The state also reported that there are no waiting lists for SNAP employment and training services.

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  55. Eligibility and Enrollment Monitoring Plan, Ark. Works – Work and Comm’y Engagement Amendment, at 2 (approved by CMS, May 31, 2018), https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/ar/Health-Care-Independence-Program-Private-Option/ar-works-elig-enrllmnt-plan-05312018.pdf.

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  56. House Appropriations Comm., Minibus #2 Summary: The Fiscal Year 2019 Labor, Health and Human Servs., Education Funding Bill (Div. B) at 1, last accessed Oct. 5, 2018, https://appropriations.house.gov/uploadedfiles/minibus_2_-_fy_2019_labor_hhs_appropriations_bill_-_summary.pdf.

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  57. Ark. Works Resource Dashboard, last accessed Oct. 5, 2018, https://ardhs.sharepointsite.net/ARWorks/resource_dashboard/index.html.

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  58. Ark. Workforce Centers, Resources, last accessed Oct. 5, 2018, https://www.arjoblink.arkansas.gov/ada/r/resources.

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  59. Ark. Found. for Med’l Care, Arkansans on Arkansas Works, last accessed Oct. 5, 2018, https://afmc.org/individuals/arkansans-on-arkansas-works/.

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  60. KFF, An Early Look at State Data for Medicaid Work Requirements in Arkansas (Sept. 2018), https://www.kff.org/medicaid/issue-brief/an-early-look-at-state-data-for-medicaid-work-requirements-in-arkansas/; see also Ark. Dep’t of Human Servs., Ark. Works Program, Aug. 2018 Report (data as of Sept. 9, 2018, released Sept. 12, 2018), https://humanservices.arkansas.gov/images/uploads/newsroom/091218_AWReport_Final.pdf. The Arkansas Department of Human Services has released monthly data about the new requirements since June 2018.

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  61. AR Works Information, Notices and Flyer Samples, Example – Non-Compliance Closure, last accessed Oct. 5, 2018, https://ardhs.sharepointsite.net/ARWorks/Notice_Samples/7.%20Example%20%E2%80%93%20Non-Compliance%20Closure.pdf.

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  62. Arkansas reported enrollment of 334,113 individuals in Jan. 2017. Ark. Dep’t of Human Servs., Ark. Works Sec. 1115 Demonstration Waiver Final Report at 3 (Jan. 1, 2017-Dec. 31, 2017), https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/ar/Health-Care-Independence-Program-Private-Option/ar-works-qtrly-rpt-jan-dec-2017.pdf. Enrollment was 301,745 in Jan. 2018. Ark. Dep’t of Human Servs., Ark. Works Sec. 1115 Demonstration Waiver Quarterly Report at 3 (Jan. 1, 2018-March 31, 2018), https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/ar/Health-Care-Independence-Program-Private-Option/ar-works-qtrly-rpt-jan-mar-2018.pdf. Enrollment was 284,031 in June 2018.   Ark. Dep’t of Human Servs., Ark. Works Sec. 1115 Demonstration Waiver Quarterly Report at 3 (April 1, 2018-June 30, 2018), https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/ar/Health-Care-Independence-Program-Private-Option/ar-works-qtrly-rpt-apr-jun-2018.pdf

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  63. KFF, A Look at the Private Option in Arkansas (Aug. 2015), https://www.kff.org/medicaid/issue-brief/a-look-at-the-private-option-in-arkansas/.

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  64. Ark. Dep’t of Human Servs., Ark. Works Sec. 1115 Demonstration Waiver Quarterly Report at 9 (April 1, 2018-June 30, 2018), https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/ar/Health-Care-Independence-Program-Private-Option/ar-works-qtrly-rpt-apr-jun-2018.pdf.

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  65. CMS, Special Terms & Conditions, Ark. Works, No. 11-W-00287/6 at ¶ ¶ 77, 85 (March 5-Dec. 31, 2018), https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/ar/ar-works-ca.pdf.

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  66. KFF, Implications of a Medicaid Work Requirement: National Estimates of Potential Coverage Losses (June, 2018), https://www.kff.org/medicaid/issue-brief/implications-of-a-medicaid-work-requirement-national-estimates-of-potential-coverage-losses/; KFF, Implications of Emerging Waivers on Streamlined Medicaid Enrollment and Renewal Processes (Feb. 2018), https://www.kff.org/medicaid/fact-sheet/implications-of-emerging-waivers-on-streamlined-medicaid-enrollment-and-renewal-processes/.

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  67. KFF, An Early Look at State Data for Medicaid Work Requirements in Arkansas (Sept. 2018), https://www.kff.org/medicaid/issue-brief/an-early-look-at-state-data-for-medicaid-work-requirements-in-arkansas/; see also Ark. Dep’t of Human Servs., Ark. Works Program, Aug. 2018 Report (data as of Sept. 9, 2018, released Sept. 12, 2018), https://humanservices.arkansas.gov/images/uploads/newsroom/091218_AWReport_Final.pdf. The Arkansas Department of Human Services has released monthly data about the new requirements since June 2018.

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  68. Stakeholders expressed particular concern about potential adverse impacts of the new requirements on individuals with substance use disorders, although it was too early to determine the extent of coverage losses among this population.

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  69. J. Craig Wilson and Joseph Thompson. Nation’s First Medicaid Work Requirement Sheds Thousands From Rolls In Arkansas. Health Affairs Blog (Oct. 2, 2018), https://www.healthaffairs.org/do/10.1377/hblog20181001.233969/full/#.W7Os7jIuWjc.twitter.

     

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