MHA Reacts to Guidance on New Medicaid Work Requirements

On January 11, the Centers for Medicare and Medicaid Services (CMS) issued a guidance letter to states indicating the nature of work requirements states could impose on non-elderly, non-pregnant Medicaid recipients “eligible on a basis other than disability.”

The programs must be designed “to promote better mental, physical, and emotional health.” Mental Health America (MHA) shares the concern that the broad goal of the guidance not be interpreted by states as permitting the imposition of work requirements on individuals with debilitating chronic conditions unrelated to physical disability, including serious behavioral health conditions.

The guidance was released after one state – Kentucky – received a waiver permitting it to impose work requirements on certain Medicaid recipients. The state’s approval caused alarm among mental health advocates, concerned that it could lead to the loss of Medicaid for people with behavioral health concerns. Estimates show Kentucky’s actions could translate into nearly 97,000 citizens losing coverage under the waiver. Eight other states – Utah, Wisconsin, Arizona, Arkansas, Indiana, Kansas, Maine, and New Hampshire –also applied for waivers to impose work requirements.

In the immediate aftermath of the guidance letter, additional states do not appear to be moving to require people with serious mental illnesses to work and at least one state applying for the waiver – Wisconsin – is also using Medicaid dollars to offer some training.

To date, MHA has communicated with officials and others in twelve states (three of which are seeking waivers) to get a sense of how they plan to respond to the letter.  These states are Ohio, Illinois, Wisconsin, Colorado, Arizona, New Jersey, Pennsylvania, Rhode Island, Indiana, New York, Connecticut, and Delaware.

The bottom line: the guidance letter is expected to have little or no short-term impact on these states.

• Ohio exempts those with “intensive physical health care needs or serious mental illness” from work requirements, as well as individuals in drug treatment, and indicates that it plans to continue to do so.
• Wisconsin – which has applied for a waiver – similarly exempts people with serious mental illnesses and those in drug treatment from work requirements, while offering some training in psycho-social rehab programs, supported with non-waiver Medicaid and county tax dollars.
• Illinois has indicated that it has no plans to pursue a waiver to impose work requirements.
• Similarly, Colorado is taking a “wait and see” approach, with no current plans to seek a waiver. It is researching what the impact would be if the state were required to impose a work requirement, noting that 75 percent of its Medicaid expansion population is already working, without being required to do so as a condition of receiving the benefit.
• Arizona, where – according to Kaiser Family Foundation – 80 percent of non-elderly Medicaid enrollees are currently employed full time, will continue to pursue its waiver, but with additional exemptions from work requirements for former foster youth, parents of children up to 13, full-time college and graduate students, a caregiver of an ALTCS member, medically fragile persons, victims of domestic violence, homeless individuals, and those participating in a wide variety of employment support and development programs.
• In New Jersey, a decision will be made by the new Governor about whether to pursue a waiver. To date, no policy or planning has taken place.
• In Pennsylvania, the Governor has resisted implementing work requirements attached to Medicaid in the past, and vetoed a budget related bill that would have included a work search requirement in the Medicaid program. He reiterated his opposition last week, saying it would impose “arbitrary limits around employment on an already extremely vulnerable population.”
• In Rhode Island, the State Medicaid Office issued the following statement in response to the letter: “There are currently no plans to pursue implementation of work or other community engagement requirements for the Rhode Island Medicaid Program. We remain continually focused on making the program run as effectively and efficiently as possible for the vulnerable Rhode Islanders we serve.”
• In Indiana – another state pursuing a waiver – people who are “chronically frail” remain exempted, and there is a work credit given to people in substance use treatment.
• Delaware is not currently considering implementation of Medicaid work requirements.
• To date, New York has given no indication that it would seek a waiver, and MHA is awaiting responses from Connecticut.

MHA notes that many individuals with serious mental illnesses continue to seek out competitive work opportunities and training programs, whether or not they are mandated to do so. Too many low-wage jobs do not offer adequate benefits, and the Medicaid program makes it possible for many people to work. MHA also urges enforcement of the Americans with Disabilities Act mandate to make jobs available to all qualified people, notwithstanding their health status. Even in an otherwise good economy, these opportunities are limited for people with behavioral health conditions.

In response, MHA has established a national Certified Peer Specialist Credential, aimed at providing more opportunities for people in recovery to apply both their talents and their skills at a competitive wage. More information about the MHA certified peer specialist credentialing program can be found here.

We will continue to monitor the situation, and update this statement as more information becomes available to us.