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Year End Review: December State Data for Medicaid Work Requirements in Arkansas

Arkansas is one of seven states for which CMS has approved a Section 1115 waiver to condition Medicaid eligibility on meeting work and reporting requirements and the first state to implement this type of waiver.1 CMS approved Arkansas’ waiver on March 5, 2018, and the new requirements took effect for the initial group of beneficiaries (those ages 30-49) on June 1, 2018. Unless exempt, enrollees must engage in 80 hours of work or other qualifying activities each month and must report their work or exemption status by the 5th of the following month using an online portal; as of mid-December, they also may report by phone.2 A review of monthly data related to the new requirements released by the Arkansas Department of Human Services shows that from September through December 2018, over 18,000 people were disenrolled for failure to comply with the new requirements for three months. In January, enrollees who were disenrolled can regain coverage (if they reapply) and enrollees ages 19 to 29 will be subject to the requirements for the first time.  Those who fail to comply with the requirements for three months could lose coverage in April 2019.  This brief looks at data for December 2018. Separate reports look at early implementation of the new requirements and enrollee experiences.

How many individuals have lost coverage due to the work and reporting requirements?

A total of 18,164 individuals have lost coverage since September 2018, due to failing to meet the work and reporting requirements (Figure 1). The most recent round of closures, effective December 31, 2018, for failure to comply for any three months between June and December 2018, includes 1,232 people as of January 7th.  Under the waiver, enrollees lose coverage for the rest of the calendar year after not meeting the requirements for any three months and are barred from reapplying for coverage until the following January. Unlike prior months, the state did not report those with one or two months of non-compliance in December 2018, because the clock starts again in January for non-compliance.  April 2019 will be the first month in which enrollees are at risk for losing coverage for failure to comply for any three months in the new plan year.  Individuals who lost coverage in 2018, including those disenrolled at the end of December, can reapply for coverage effective in January 2019.3

Figure 1: Over 18,000 AR Works enrollees have lost Medicaid coverage for failure to meet work and reporting requirements.

Few individuals have been found to have good cause for failing to meet the work and reporting requirements to date. Individuals who fail to complete 80 hours of qualifying work activities and/or fail to timely report their activities each month can request a good cause exception. The state reviewed 156 good cause requests in December 2018; of these, 106 were granted.4 From June through December 2018, the state reviewed a total of 904 good cause requests; of these, the state granted 577, denied 64 and determined that 263 were “not a good cause issue.”5

How many did not report work activities for December?

The large majority (90%, or 54,593 people) were exempt from the reporting requirement for December 2018, while 78% of those not exempt (4,776 out of 6,087) did not report 80 hours of qualifying work activities (Figure 2).   Nearly all of those 4,776 enrollees did not report any work activities. This could mean that they did not create and link the online accounts required to enable them to report or experienced difficulty accessing or navigating the online portal.

Figure 2: 78% of AR Works enrollees subject to the reporting requirement did not report 80 hours of qualifying activities in December 2018.

 A small number of enrollees (73 out of the 4,776) did report some work activities but not 80 hours of qualifying activities for December. Of those 73 enrollees, 10 reported 80 or more hours of job search or job search training; however, in each month, enrollees are only able to count 39 hours of job search or job search training toward the required 80 hours of qualifying work activities, which means that those engaged in job search or job search training also must complete 41 hours of another qualifying activity or activities to meet the monthly requirement. Twenty-nine (29) out of the 73 enrollees reported work that fell short of the 80-hour requirement in December, including 6 with at least 61 but fewer than 80 hours of work.

How many enrollees were exempt from the new requirements and why?

Most of the 54,593 enrollees exempt from the reporting or work requirement in December were already working at least 80 hours per month. These 54,593 enrollees represent 98% of those who met the requirements in December (because they were exempt). These enrollees were identified through a data match conducted by the state and therefore do not have to report their monthly work hours or exemption status using the online portal. They should have received a notice indicating that they were subject to the work requirement, but exempt from the reporting requirement. Overall, most exempt enrollees fell into four categories:  those who were already working at least 80 hours per month (46%), followed by those currently exempt from SNAP employment and training requirements (19%), those with a dependent child in the household (12%), and those who have been identified as medically frail (15%) (Figure 3).6 The shares in each of these groups were stable from June through December.

Figure 3: Most AR Works enrollees who are exempt from the monthly reporting or work requirement are already working 80 hours.

How many enrollees met the work and reporting requirements and through what activities?

Only 2% (1,311 enrollees) met the requirements by actively reporting activities in December 2018, with the majority of this group (849, or 65%) attributable to meeting comparable SNAP requirements (Figure 4). This pattern also has been consistent since June. Seventeen percent of those reporting were meeting the requirements through work, four percent through volunteer activities, and less than one percent through education and training. The remaining 13 percent were meeting the requirements through a combination of activities that include work, volunteer activities, education and training, job search, and/or job search training.

Figure 4: Most of AR Works enrollees meeting the new work and reporting requirements were already meeting comparable SNAP requirements.

A small number (462 enrollees) of those who met the work and reporting requirements in December reported doing so by working, volunteering, or another activity, other than meeting SNAP requirements. The data do not indicate whether these enrollees started working as a result of the new requirements. They already could have been engaged in work or another activity, but the state did not have this information. This is a small share of enrollees compared to the 18,164 people who have lost Medicaid coverage to date due to failure to comply with work or reporting requirements (Figure 5).

Figure 5: Arkansas coverage losses far exceed the number of enrollees who are meeting work and reporting requirements outside of SNAP requirements.

The number of enrollees reporting work has decreased since October 2018 (Figure 6). The new requirements were phased in for those ages 30 to 49 from June through September 2018. After the phase-in was completed, the number of enrollees meeting the new requirements who actively reported any work hours peaked at 401 in October 2018, and subsequently decreased, to 371 in November, and 313 in December. The subset of enrollees actively reporting that they satisfied their entire monthly requirement through work (81+ hours), as opposed to other qualifying activities, similarly peaked, at 254 enrollees, in October 2018, and subsequently declined to 248 enrollees in November, and 228 in December.

Figure 6: The number of AR Works enrollees reporting work has decreased since October 2018.

What will future data reporting and research show?

Looking ahead, it will be important to understand more about the group of enrollees who lost coverage. A November 8th letter to Secretary Azar from the Medicaid and CHIP Payment and Access Commission (MACPAC) raised concerns about the pace of disenrollment and the state’s lack of a CMS approved waiver evaluation plan. CMS and the state have not paused the demonstration, resulting in over 18,000 people losing coverage in Arkansas for failure to comply with the new requirements over the first seven months of implementation.  An early look at implementation found that many enrollees have not been successfully contacted about the new requirements, despite substantial outreach and education efforts, and concern that many who remain eligible could lose coverage for failure to navigate the process to verify work status or qualify for an exemption. On December 12, 2018, the state issued a press release indicating that beginning on December 19, enrollees would be able to report work activity by phone with DHS7 and that DHS will be launching an advertising campaign to provide additional outreach to enrollees as the younger group of enrollees is phased in during early 2019. DHS also plans to work with higher education institutions to inform students that school hours count toward meeting the requirement. While new reporting options may assist some enrollees, research shows that any additional reporting or administrative burdens create barriers to eligible people retaining coverage.

Follow-up with enrollees subject to the new requirements will provide additional information about awareness and understanding of the new work and reporting requirements as well as barriers to compliance. Follow-up with enrollees who lost coverage will reveal how many have other health insurance coverage and how many are uninsured; how many are newly working, in what types of jobs, and whether those jobs come with affordable health insurance; and how many remain eligible for Medicaid but lost coverage due to administrative or reporting barriers. Future months of state data may also provide information about how many who were disenrolled in 2018 will reapply for and regain coverage in 2019, and whether they will again lose coverage for failing to meet the work and reporting requirements in 2019. Early implementation findings also cite the potential that coverage losses will result in gaps in care and increased uncompensated care costs. Additional research can examine the longer-term effects of coverage losses and lock-outs for enrollees, providers, and health plans.

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