Supporting Work without the Requirement: State and Managed Care Initiatives

Issue Brief
  1. “Medicaid adults” refers to non-dual, non-SSI, non-elderly adult enrollees.

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  2. Rachel Garfield, Robin Rudowitz, Kendal Orgera, and Anthony Damico, “Understanding the Intersection of Medicaid and Work: What Does the Data Say?” (Washington, DC: Kaiser Family Foundation, August 2019), https://www.kff.org/medicaid/issue-brief/understanding-the-intersection-of-medicaid-and-work-what-does-the-data-say/.

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  3. Centers for Medicare & Medicaid Services (CMS), Dear State Medicaid Director Letter #18-002, Opportunities to Promote Work and Community Engagement Among Medicaid Beneficiaries (Jan. 11, 2018), https://www.medicaid.gov/federal-policy-guidance/downloads/smd18002.pdf.

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  4. Kaiser Family Foundation, “Medicaid Waiver Tracker: Approved and Pending Section 1115 Waivers by State” (Washington, DC: Kaiser Family Foundation, Nov. 11, 2019), https://www.kff.org/medicaid/issue-brief/medicaid-waiver-tracker-approved-and-pending-section-1115-waivers-by-state/.

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  5. The federal court that has ruled on this issue so far rejected the contention that the Secretary of Health and Human Services could focus on alternative criteria, including health and well-being, in approving the demonstration project, instead of the objective to promote affordable health coverage. See: https://ecf.dcd.uscourts.gov/cgi-bin/show_public_doc?2018cv1900-58.

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  6. Robin Rudowitz, MaryBeth Musumeci, and Cornelia Hall, “February State Data for Medicaid Work Requirements in Arkansas” (Washington, DC: Kaiser Family Foundation, March 2019), https://www.kff.org/medicaid/issue-brief/state-data-for-medicaid-work-requirements-in-arkansas/.

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  7. Benjamin Sommers, Anna Goldman, Robert Blendon, and John Orav, “Medicaid Work Requirements – Results from the First Year in Arkansas,” New England Journal of Medicine 381 (Sept. 12, 2019): 1073-1082 https://www.nejm.org/doi/full/10.1056/NEJMsr1901772.

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  8. The Ohio Department of Medicaid, “Ohio Medicaid Group VIII Assessment: A Report to the Ohio General Assembly (The Ohio Department of Medicaid, January 2017), https://medicaid.ohio.gov/Portals/0/Resources/Reports/Annual/Group-VIII-Assessment.pdf; Renuka Tipirneni et al., “Changes in Health and Ability to Work Among Medicaid Expansion Enrollees: a Mixed Methods Study,” Journal of General Internal Medicine 34:2 (February 2019): 272-280, https://link.springer.com/article/10.1007/s11606-018-4736-8.

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  9. Bryce Ward and Brandon Bridge, “The Economic Impact of Medicaid Expansion in Montana: Updated Findings” (University of Montana Bureau of Business and Economic Research, Prepared for the Montana Healthcare Foundation and Headwaters Foundation, January 2019), https://mthcf.org/wp-content/uploads/2019/01/Economic-Impact-of-MedEx-in-MT_1.28.19-FINAL.pdf.

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  10. MaryBeth Musumeci, Priya Chidambaram, and Molly O’Malley Watts, “Medicaid Home and Community-Based Services Enrollment and Spending” (Washington, DC: Kaiser Family Foundation, April 2019), https://www.kff.org/medicaid/issue-brief/medicaid-home-and-community-based-services-enrollment-and-spending/.

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  11. MaryBeth Musumeci, Priya Chidambaram, and Molly O’Malley Watts, “Medicaid Financial Eligibility for Seniors and People with Disabilities: Findings from a 50-State Survey” (Washington, DC: Kaiser Family Foundation, June 2019), https://www.kff.org/medicaid/issue-brief/medicaid-financial-eligibility-for-seniors-and-people-with-disabilities-findings-from-a-50-state-survey/.

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  12. For example, someone with a spinal cord injury may need personal care services for help with bathing, preparing meals, and dressing to get ready for work.

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  13. Within Medicaid, states can use a range of optional state plan and waiver authorities (e.g., 1915(i), 1915(c), or Section 1115) to add certain non-clinical services to the Medicaid benefit package, including case management, housing supports, employment supports, and peer support services for people who need help with self-care or household activities as a result of disability or chronic illness.

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  14. Kathleen Gifford, et al., “A View from the States: Key Medicaid Policy Changes: Results from a 50-State Medicaid Budget Survey for State Fiscal Years 2019 and 2020” (Washington, DC: Kaiser Family Foundation, Oct. 2019), https://www.kff.org/medicaid/report/a-view-from-the-states-key-medicaid-policy-changes-results-from-a-50-state-medicaid-budget-survey-for-state-fiscal-years-2019-and-2020/.

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  15. Under federal Medicaid managed care rules, Medicaid MCOs may have flexibility to pay for non-medical services through “in-lieu-of” authority and/or “value-added” services. “In-lieu-of” services are a substitute for covered services and may qualify as a covered service for the purposes of capitation rate setting. “Value-added” services are extra services outside of covered contract services and do not qualify as a covered service for the purposes of capitation rate setting.

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  16. Additionally, the 2016 managed care final rule broadens federal standards for care coordination to include coordination between settings, with services provided outside the plan, and with community and social support providers.

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  17. Medicaid.gov, 1115 Demonstration State Monitoring & Evaluation Resources, last accessed Nov. 26, 2019, https://www.medicaid.gov/medicaid/section-1115-demo/evaluation-reports/evaluation-designs-and-reports/index.html.

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  18. Centers for Medicare & Medicaid Services (CMS), Medicaid Section 1115 Eligibility and Coverage Demonstration Implementation Plan, https://www.medicaid.gov/medicaid/section-1115-demo/downloads/evaluation-reports/ce-implementation-plan-template.pdf.

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  19. Indiana’s Healthy Indiana Plan (HIP) 2.0 included the voluntary “Gateway to Work” program, which offered participants case management, job support, and training services. In the state’s annual reports, the only enrollee outreach method that the state cites is mailing letters to all HIP members to inform them of the existence of Gateway to Work. See: https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/in/Healthy-Indiana-Plan-2/in-healthy-indiana-plan-support-20-annl-rpt-feb-jan-2016-04292016.pdf.

    Prior to implementing its work 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. See: https://www.kff.org/medicaid/issue-brief/an-early-look-at-implementation-of-medicaid-work-requirements-in-arkansas/view/footnotes/#footnote-371775-7.

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  20. Mike Dennison, “Montana’s Medicaid Expansion work requirements won’t take effect Jan. 1,” Missoula Current (Nov. 15, 2019), https://www.missoulacurrent.com/business/2019/11/montana-medicaid-expansion-7/.

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  21. Montana’s Medicaid program requires that expansion enrollees pay premiums. Nonpayment of premiums by expansion enrollees at or above 100% FPL can result in cancellation of coverage unless enrollees meet certain criteria. Participation in qualifying workforce programs, including HELP-Link, can prevent disenrollment when combined with other qualifying criteria. The state notes that HELP-Link can help enrollees maintain health coverage if they fall behind on payment of premiums, noting that 2,995 people used HELP-Link, WIOA, or RESEA to help meet the requirements for the workforce disenrollment exemption in SFY 2018. See: https://montanaworks.gov/Portals/180/Documents/help-link/HELP-Link_2018Report.pdf?ver=2019-08-16-105528-603.

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  22. Montana Department of Labor & Industry, “HELP-Link Program: 2019 Fiscal Year End Report,” http://lmi.mt.gov/Portals/193/Publications/LMI-Pubs/Special%20Reports%20and%20Studies/HELP-Link_2019Report.pdf.

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  23. Ibid.

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  24. Ibid.

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  25. Ibid.

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  26. H.B. 658, Montana State Legislature 2019 (enacted May 2019), https://leg.mt.gov/bills/2019/billhtml/HB0658.htm.

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  27. Montana Department of Labor & Industry, “Health and Economic Livelihood Partnership (HELP) Link Policy,” (Revised Oct. 3, 2018), http://wsd.dli.mt.gov/Portals/56/Documents/WSDPolicy/HELP%20Link%20Policy.pdf?ver=2017-11-30-111931-307.

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  28. Montana Department of Labor & Industry, “HELP-Link Program: 2019 Fiscal Year End Report,” http://lmi.mt.gov/Portals/193/Publications/LMI-Pubs/Special%20Reports%20and%20Studies/HELP-Link_2019Report.pdf.

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  29. In addition to wage data, the SFY 2019 state HELP-Link report indicates that 72% of the 13,093 individuals in MTDLI programs overall were employed in the year after completion of training. After report publication, the state shared that this number was 79% for the 388 participants receiving HELP-Link funding specifically. See: http://lmi.mt.gov/Portals/193/Publications/LMI-Pubs/Special%20Reports%20and%20Studies/HELP-Link_2019Report.pdf.

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  30. Montana Department of Labor & Industry, “HELP-Link Program: 2019 Fiscal Year End Report,” http://lmi.mt.gov/Portals/193/Publications/LMI-Pubs/Special%20Reports%20and%20Studies/HELP-Link_2019Report.pdf.

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  31. Montana presents full-year views of wage earning data due to the fact that the state’s seasonal economy results in large variations in earnings from quarter to quarter.

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  32. State of Louisiana, “Memorandum of Understanding Between Louisiana Department of Health (LDH) and Louisiana Delta Community College,” (2019), http://gov.louisiana.gov/assets/MOU-LDH.pdf.

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  33. Louisiana Office of the Governor, “Gov. Edwards, Officials Establish Work Training Program for Medicaid Expansion Recipients” (April 1, 2019), http://gov.louisiana.gov/index.cfm/newsroom/detail/1858.

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  34. H.B. 735, Louisiana State Legislature 2019 Regular Session (enacted May 2018), https://legiscan.com/LA/text/HB735/2018.

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  35. Maine Office of the Governor, Letter from Governor Janet Mills to CMS Administrator Seema Verma (Jan. 22, 2019), https://www.maine.gov/governor/mills/sites/maine.gov.governor.mills/files/inline-files/01-22-19%20CMS%201115%20Waiver.pdf

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  36. Maine Office of the Governor, “In Lieu of Medicaid Restrictions, Governor Mills Directs DHHS & Labor to Promote Work Opportunities” (Jan. 22, 2019), https://www.maine.gov/governor/mills/news/lieu-medicaid-restrictions-governor-mills-directs-dhhs-labor-promote-work-opportunities-2019.

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  37. Maine Office of the Governor, Letter from Governor Janet Mills to CMS Administrator Seema Verma (Jan. 22, 2019), https://www.maine.gov/governor/mills/sites/maine.gov.governor.mills/files/inline-files/01-22-19%20CMS%201115%20Waiver.pdf

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  38. State of West Virginia Department of Health and Human Resources, State Fiscal Year 2019 Model Purchase of Service Provider Agreement Between State of West Virginia Department of Health and Human Resources Bureau for Medical Services and (Managed Care Organization), https://dhhr.wv.gov/bms/Members/Managed%20Care/MCOcontracts/Documents/LEWINVWVSFY19MCOModel_Contract.pdf.

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  39. Center for Health Care Strategies, “Addressing Social Determinants of Health via Medicaid Managed Care Contracts and Section 1115 Demonstrations” (Dec. 2018), https://www.chcs.org/media/Addressing-SDOH-Medicaid-Contracts-1115-Demonstrations-121118.pdf.

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  40. CareSource, Annual Stakeholder Report, “Promise” (2018), https://www.caresource.com/documents/2018-annual-stakeholder-report/.

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  41. CareSource Life Services, “Life Services and JobConnect: Indiana” (Oct. 17, 2017), https://www.in.gov/medicaid/files/caresource%20life%20services.pdf.

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  42. Association for Community Affiliated Plans, “Where Education, Employment, and Health Meet” (May 2019), https://www.communityplans.net/wp-content/uploads/2019/09/Where-Education-Employment-and-Health-Meet.pdf.

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  43. CareSource Life Services, “Life Services and JobConnect” (2017), http://www.rootcausecoalition.org/wp-content/uploads/2017/10/Vanzant.pdf.

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  44. State of Louisiana, “Memorandum of Understanding Between Louisiana Department of Health (LDH) and Louisiana Delta Community College,” (2019), http://gov.louisiana.gov/assets/MOU-LDH.pdf.

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  45. Montana Department of Labor & Industry, “HELP-Link Program: 2019 Fiscal Year End Report,” http://lmi.mt.gov/Portals/193/Publications/LMI-Pubs/Special%20Reports%20and%20Studies/HELP-Link_2019Report.pdf.

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  46. Montana Department of Labor & Industry, “Montana HELP-Link Program Reports,” last accessed Nov. 26, 2019, https://montanaworks.gov/help-link/program-reports; Montana Department of Labor & Industry, “HELP-Link Program: 2019 Fiscal Year End Report,” http://lmi.mt.gov/Portals/193/Publications/LMI-Pubs/Special%20Reports%20and%20Studies/HELP-Link_2019Report.pdf.

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  47. Mike Dennison, “Montana’s Medicaid Expansion work requirements won’t take effect Jan. 1,” Missoula Current (Nov. 15, 2019), https://www.missoulacurrent.com/business/2019/11/montana-medicaid-expansion-7/.

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