Amber Christ: Hi everyone, and welcome to today’s webinar, Implementing New Medicaid Work Requirements: Strategies to Mitigate Harm in Your State. My name is Amber Christ, I use she/her pronouns, and I am the managing director of Justice In Aging’s Health Advocacy. I’m joined today by my colleagues, Natalie Kean and Gelila Selassie, directors on our health team who have been leading our advocacy on work requirements. If we go to the next slide, before we dive into content, just a few logistics: All participants are going to be on mute. If you have a question about the material being presented or a technical concern, please use the question function. We will leave time at the end for Q&A. If you experience difficulties accessing the webinar at any time, please email trainings@justiceinaging.org.
The materials we will discuss today are available on Justice In Aging’s website and our resource library. A recording of the webinar will also be posted in the resource library and made available on our Vimeo page. The links to the resources have also been shared in the chat box. If you would like to enable closed captioning, hit the CC function on your Zoom platform.
Just a little bit about Justice In Aging for those of you who might be new to us: we are a national legal organization focused on eradicating senior poverty by increasing access to affordable healthcare and increasing economic security for older adults with limited resources. And we focus on older adults who have been marginalized and excluded from justice, including older adults of color, women, LGBTQ+ older adults, older adults with disabilities, older immigrants, and those whose primary language is not English. To carry out our mission, we at Justice In Aging are committed to ensuring everyone has access to what they need as they age, without discrimination.
Our advocacy is rooted in ensuring that those experiencing the greatest barriers to economic security, healthcare, and housing can exercise their rights and fully access the services and programs they need. And if you would like to sign up for our network if you’re not already on it, on the next slide, you can do so on our website by navigating to the signup link, or by emailing us at info@justiceinaging.org.
If we move to the next slide, we’ll get into the agenda. In July, Congress passed and the president signed into law the Budget Reconciliation Act of 2025, also known as H.R.1. And that includes the largest cuts to Medicaid in history. The law also mandates that states add work requirements to their Medicaid programs, and that is the focus of this webinar. Adding work requirements is a fundamental change to Medicaid programs, and we are all still in this figuring it out phase of that change.
The Centers for Medicare and Medicaid Services is still issuing guidance to states on how to implement the law, and states are still figuring out their policies to operationalize the new work requirements in their programs. So because we’re still in this figuring it out phase, we cannot yet advise clients on how to navigate work requirements. The rules just aren’t there yet. Instead, our goal now and the purpose of this webinar is to provide you with tools to shape those rules and policies in your states, and a way to reduce the number of people who lose coverage.
And geez, there’s a lot to figure out and to learn before these requirements take effect. In fact, we received over 400 questions from you all before the webinar, many of which we hope to address over the next hour. So today, Natalie and Gelila are going to give an overview of work requirements, what we know about exclusions and exemptions, implementation challenges and advocacy strategies, and tools and resources currently available. And then we’ll end with some Q&A. So I’m going to kick it over now to Gelila to start with an overview of work requirements.
Gelila Selassie: Thank you so much, Natalie, and thank you all for joining us today. Just reemphasizing Amber’s… Or excuse me. Thank you, Amber. Reemphasizing Amber’s wonderful points that we are very much focusing on what’s in this statute related to Medicaid work requirements. I wish we had a lot more detailed information from you, but we don’t have that from the Feds yet. So stay tuned to our upcoming resources that will hopefully get that information out to you. But for now, we’re looking at the statute and H.R.1 and whatever specifics we do know about how to mitigate the harms for your clients. Next slide.
So as a quick overview, last July Congress passed H.R.1, which is also known as the One Big Beautiful Bill Act, and that implemented Medicaid work requirements. And just as a point of clarification: In this statute, these work requirements are known as community engagement requirements, but they’re effectively work requirements. So we’ll be referring to it as that, but it’s the same thing. These work requirements are distinct from SNAP, the food stamps program, or TANF. Those programs do have work requirements, and there might be some degree of overlap but these are definitely different. So we’re going to really just focus on the requirements under the Medicaid program, and not trying to conflate the two in a way that’s going to be more confusing.
Advocates are very, and rightly, concerned about work requirements because it’s always been a failure whenever it has been implemented in other states. Most Medicaid recipients, most people who receive Medicaid are working. And those who don’t are disabled, caregiving, or in school, meaning that there’s going to be a lot of coverage losses based on what we know the savings are going to be from these Medicaid work requirements. A lot of people who should not be subject to work requirements or who are working and just can’t get around the administrative bureaucracy will lose coverage.
We’ve seen that in a couple instances where work requirements were implemented in Arkansas and in Georgia in their programs, where there was very slow processing. There was website problems in reporting hours. There was a massive, burdensome, restrictive process in trying to prove that people are actually exempt. So based on what we’ve learned from that and what’s in the law, we’re going to hopefully try to look at how to minimize some of those harms. And then it’s really important to note that these work requirements must be implemented by January 1st, 2027, but states do have the discretion to implement it sooner. Next slide.
So the law requires most adults who are ages 19 to 64 enrolled in Medicaid Expansion or Expansion-like coverage to engage in at least 80 hours a month of qualifying work activities. And those qualifying work activities can be paid employment, it can be schooling or education, volunteer work, or job training. Again, we have a lot of unknowns about the details about some of these. We know that those hours can be combined. So you could do 50 hours of work, 20 hours of volunteering, 10 hours of education in order to meet those 80 hours. But we’re waiting for additional guidance on how that’s actually going to be operationalized.
And then one really unique quality about these work requirements is that there is in fact a lockout provision in the statute. This means that if someone who’s subject to work requirements is not in compliance with it, then they also cannot receive ACA Marketplace subsidies. That’s really problematic because a lot of people, if they’re no longer eligible for Medicaid, could at least get the Marketplace subsidies if they meet that, if they’re above 100% of the federal poverty level. And now there’s this provision here that’s going to throw a wrench into that potential avenue for health access. Next slide.
And so states do have some discretion with some degree of these reporting requirements. H.R.1 requires enrollees to comply with work requirements, to show compliance with the work requirements at least one month prior to enrollment or their redeterminations. However, the statute also gives states discretion to require someone to show up to three months’ compliance prior to enrollment. So if someone were to be applying for Medicaid in December, they must, at a minimum, show that they’re working in November.
At the same time, this individual, the state could decide that that person has to actually show more than that. If they’re applying for coverage in December, they could say, “Well, we need you to show us that you’ve been working since September.” And then another area of discretion is with respect to how often these work requirements are reported. At a minimum the statute requires it to be done at redetermination or renewal time. This used to be on an annual basis, but H.R.1 changed that for the Medicaid Expansion population, who will now have to submit renewals or redeterminations every six months.
So at a minimum, people have to show that they’re complying with the work requirements at least every six months. But states can choose to require more frequent reporting periods. They could require it to be every other month, every three months, or even monthly, which would be the most burdensome. Next slide.
And so there was some guidance that was issued by CMS last month. For the most part it wasn’t terribly helpful. It kind of just reiterated what was in H.R.1, but it did provide this helpful chart that gives you a visual representation of what the state must do with respect to how they’re implementing work requirements. So states must provide beneficiary outreach at least three months before the individual has to show compliance with the work requirements. So under option one, if this state is implementing January First, 2027 and a person is applying in January, then they must show that they met those community engagement requirements in December. That means that the state has to start reaching out to beneficiaries, providing notices, providing education by September.
Option two is if that state, again, person’s applying January, but that state says you have to show us you were in compliance with the work requirements two months in advance before your application date. Well, then the state has to start issuing beneficiary notices and education by August. And then same idea if the state says, “You know what? Actually, prove to us that you’ve met the work requirements at least three months before your application date.” Then the state would have to issue outreach by July. So all this is to say that, at least by September of this year, all states should be engaging in beneficiary outreach. Ideally it would be way sooner, even if a state isn’t implementing until January, because we know how complicated and convoluted this process can be. Next slide.
And so now we talk about… We talked about how to meet the work requirements. We’ll look into the different exclusions and exemptions that are available. Next slide.
It’s really important to note that not all Medicaid enrollees are subject to work requirements. H.R.1 specifically defines applicable individuals who are subject to work requirements as individuals who are enrolled in ACA Medicaid Expansion or states that have programs that are Expansion-like, which are really just Georgia and Wisconsin. And just a point of clarification: Medicaid Expansion is the coverage pathway that became available under the Affordable Care Act that covers adults ages 19 to 64 with incomes up to 138% of the federal poverty level. So this is a group that does not have to show disability or that they belong to any other Medicaid category. If they’re between 19 to 64 with income below 138%, that is the Expansion population.
40 states and the District of Columbia have adopted Medicaid expansion, and then Georgia and Wisconsin did something a little bit differently, where they have Medicaid options that are very similar to Medicaid Expansion, but they went about it in a slightly different way and they have a little bit more restrictions on it. So in that way, that is the expansion-like programs, Georgia and Wisconsin, because it’s still covering these applicable individuals. So these 41 states plus Georgia and Wisconsin are the ones that are subject to the H.R.1 work requirements for their Medicaid Expansion enrollees ages 19 to 64.
And so another thing that is pretty complicated, because why not? About H.R.1, is a different terminology that’s used to describe who is not subject to the work requirements. So we know applicable individuals who are the Expansion population are subject to it, but there are people who are not, and the first are the categorically-excluded. These are people who are not enrolled in Medicaid Expansion or the Georgia and Wisconsin Expansion-like programs. They’re in a completely different Medicaid category. Then there are people who have individual exemptions, and these are applicable individuals in the Expansion population, but they’re exempted from these work requirements due to individual circumstances, which we’ll get into. And then the last category are for the short-term hardship exception. And this would apply to everyone subject to work requirements, but it is a state option. So a state may or may not take this up. And we’ll dive into this in a little bit more detail. Next slide.
And then just, again, to reiterate: This isn’t exactly the language that’s used in the statute, but we find it much easier to divvy it out this way. The first category are the categorical exclusions. So the state must exclude the following group from work requirements because they are not applicable individuals. They’re not in that Expansion program. Those are people under age 19 or age 65-plus, people who are enrolled in or entitled to Medicare, including the duly eligible and those who are receiving a Medicare savings program, anyone receiving Medicaid under the age, blind, or disabled program, which also includes people on SSI, because they receive SSI Medicaid. And then for the medically-needy share of cross enrollees. And then anyone receiving Medicaid for pregnancy or postpartum coverage. These individuals who are part of these Medicaid categories should not have to prove or require any kind of verification for exemption. They should not be anywhere in the work requirements world. So we don’t want states to try to loop them in and start requiring them to provide certain paperwork or certain types of verification because they are completely excluded. They’re not applicable. Next slide.
And then, within the world of the applicable individuals are those who have qualified for these individual exemptions. And it’s really important to note that we’re waiting again for guidance on exactly how these exemptions will be verified. But again, as we’ve seen in the past with the few states that have implemented work requirements for the limited period that they had, there are a lot of people who are unable to work, and so they should meet these exemptions.
This is particularly true for older adults, age 50 to 64, who have barriers to work related to chronic illness or disability. They could be retiring early or they could have caregiving responsibilities. So there’s quite a lot of individual exemptions, and we’ll list them all but we’re going to first focus on exemptions for a disability. So if you can move to the next slide.
And this is an exemption that is available to someone deemed medically frail. That is the language in the statute. We do not like that but, again, because that’s the language, we’ll refer to that. And in H.R.1, someone is medically frail if they belong to any one of these six categories: If they’re determined blind or disabled under the Social Security Administration’s rules, if they have a substance use disorder, if they have a disabling mental disorder, a physical, intellectual, or developmental disabilities impacting one of their ADLs, or activity of daily living, or if they have a serious or complex medical condition.
And there are two big points to raise here. First is that, note that the Social Security definition of disabled, which is the inability to work because of a disability, that is just one way of meeting the medically frail exemption. Congress clearly added these additional categories to say that states should not only defer to the blind or disabled under SSA rules type of definition. It’s what a lot of Medicaid agencies are familiar with because there are Medicaid disability pathways that are related to these social security rules. And so we want to make sure that states are broadening that exemption to include all of these categories that Congress specifically included.
And then another major point is this language at the end of serious or complex. And that’s not serious and complex. This could be a really great catchall for people who don’t meet one of the other categories for the medically frail exemption because if it was serious and complex, that could definitely be a lot more narrower. So again, we’re waiting on further guidance of this, but that’s something you need to keep in the back of your minds. Next slide.
There is also an exemption [inaudible 00:18:43]. H.R.1 provides the exemptions for parents, guardians, caretaker, relative, or family caregivers of a dependent child age 13 or under, or a disabled individual, which includes older adults, which I’ll get into. H.R.1 explicitly references the RAISE Family Caregiver Act for the definition of a caregiver, and the RAISE Act’s language, the exact definition of a caregiver is an adult family member or other individual who has a significant relationship with and who provides a broad range of assistance to an individual with a chronic or other health condition, disability, or functional limitation.
So again, here the RAISE Act is very broad and doesn’t just apply to caregivers for people with disabilities, but also that language of someone with a chronic or other health condition, disability, functional limitation. That is much broader than disability. And it’s really important for the older adult population because many older adults might not consider themselves as disabled, but they might refer to themselves as having a functional limitation, of having a health condition, and that they have somebody in their lives who’s helping them manage everything because of their condition or their limitations.
So again, it’s really, really important that states apply this broader RAISE Act definition that Congress explicitly included in H.R.1, rather than only limiting this Caregiver Exemption to people with disabilities. Next slide.
And then there are quite a lot of additional exemptions beyond just the medically frail and the caregivers that we’re not going to spend too much time on, but very much worth noting. Foster care youth or former foster care youth, American Indians, Alaska-natives, Californian Indians, and those who are eligible for Indian health services, disabled vets with total disability ratings, individuals who are already meeting the work requirements under SNAP or TANF qualify for an exemption here in the Medicaid world. So again, the rules for Medicaid work requirement are definitely different from these other public benefits programs, but at least if someone is meeting the SNAP or TANF requirements, then they should qualify for the exemption in the Medicaid world, even if they are different programs.
And then participants “In a qualifying substance use disorder treatment program,” or individuals who are incarcerated or recently incarcerated, which is defined as an individual who is an inmate of a public institution or was so within the prior three months. Next slide.
And then our last big category of people who are not subject to the work requirements are those who are eligible for these short-term hardship exceptions. Again, this is at the state’s discretion to implement. And if they do, it applies to individuals who have the following extenuating circumstances: Those could be individuals receiving care in hospitals, nurse facilities, psychiatric facilities, or a other intensive care setting, anyone living in a federally-declared disaster area. If they’re residing in counties with a unemployment rate higher than 8% or more than one and a half times the national unemployment rate, if they’re required to travel outside the community for medical care, either for themselves or their dependents to treat a serious or complex condition for an extended period of time. And again, none of these have been particularly defined by CMS yet, but we’ll be staying tuned for additional information there. And then next slide.
I’ve said this before but it’s really, really worth emphasizing again just because H.R.1 is very ambiguous and not very good at differentiating the groups that are not subject to work requirements: Individuals receiving Medicaid under one of the excluded groups, so they’re in a Medicaid category outside of the Expansion group, should not ever, ever have to apply for or verify that they’re excluded from work requirements. The state should not at all be including them in their systems when evaluating for work requirements. And that’s different from the exempted individuals who belong to the Medicaid group subject to work requirements, the Expansion population, but their individual circumstances qualify them for a particular exemption.
So just to compare: If you had a 61-year-old on SSI who’s receiving Medicaid because of SSI, they should never be evaluated for work requirements or exemptions. They should be completely out of that system. But if that 61-year-old has a pending application for SSI due to disability and has not yet been approved, and then they’re receiving Medicaid through Medicaid Expansion, then they must show that they are medically frail to be exempted from the work requirements. And in the latter case they don’t even need a pending application with SSI. They could be disabled and, for a variety of reasons, not be applying for SSI or SSDI, but they’re medically frail, they’re enrolled in Medicaid Expansion, and so they have to have some kind of verification to show that they meet that medically frail exemption. And so with that, I will turn it over to Natalie to discuss a little bit more about how the implementation will work.
Natalie Kean: Great. Thank you, Gelila. Good to be with everyone. Gelila reviewed a lot of what we know the law says, but there are still a lot of questions and uncertainty about how it will be implemented. I’m going to go over our recommendations for how to mitigate burden and harm on older adults, and caregivers in particular, and then provide some examples of the concerns we’ve seen and heard from advocates about how states are designing their policies and programs, and suggest some advocacy strategies to address those concerns. First are principles. These are based on how the law is written and trying to maximize the protections available.
First, we want states to automatically and permanently exclude non-Expansion populations from work requirement consideration. This is the categorical exclusion Gelila discussed, such as people age 65 and older, people with Medicare, people with SSI. They should never have to apply for an exemption from work requirements. The state should be automatically excluding them. Our second principle is that people who can work must be eligible to receive exemptions. The law does not make work and exemptions mutually exclusive. Many people such as caregivers and people with disabilities or serious health conditions do work. They are employed. But they should also be able to get an exemption that they’re eligible for to protect them from coverage loss.
Our third principle is that medically frail criteria cannot be limited to strict Social Security disability criteria. This is what Gelila discussed. Most people eligible for Medicaid on the basis of disability are already excluded, so the medically frail criteria is clearly intended and must go beyond these strict criteria. Principle four: Explicitly include caregivers for older adults in the Family Caregiver Exemption. The statute includes these caregivers but does not name older adults. So we’re advocating that states should name caregivers of older adults in their policies and materials.
Principle five: Accept self-declarations to verify eligibility for exemptions, particularly for caregivers and people who qualify as medically frail. There are no data sources to identify many, many caregivers and to capture the breadth of people who might qualify as a caregiver or for the medically frail exemption. So it’s really important that states accept self-declarations for exemptions.
Number six: Use ex parte and other tools to minimize administrative burden and procedural terminations. And I’ll go into more detail on what ex parte is, but we want states to be making exemptions as automatic as possible. There aren’t always data sources to do this, but where there are, they should be used for exemptions as well as compliance with work.
Number seven: Provide advanced outreach, education, and accessible assistance, including information about due process and appeal rights. This is really about preparation and ensuring the process is also accessible. So how states are going about talking to people about the work requirements, how states are designing their applications, and then following the protections in law for Medicaid enrollees in this process as well.
So moving on to some of the issues we’ve seen on the ground already, states do have some options in how they implement the law, as Gelila went over. And what they choose can make it easier or harder for people to comply with these new requirements. Some of the ways states can make it harder are using a three-month rather than a one-month lookback period for new applicants and requiring monthly compliance for enrollees. A state could also be strict and narrow eligibility by increasing reporting periods to monthly instead of every six months, not take up the temporary hardship exceptions, and implement the work requirements early, that is before January First of next year.
Some strategies to address these concerns are to start by asking your state to protect older adults and other Medicaid enrollees by minimizing the compliance and reporting periods and not implementing work requirements early. To ensure your state does this and doesn’t change its mind later on, we recommend getting your legislature involved, and work on putting these protections into state law. I want to highlight Nebraska Appleseed here, who has been working with partners to introduce three bills in their state aimed at mitigating coverage loss under H.R.1, and work requirements specifically.
The bills are linked here on this page, and they are somewhat overlapping but they include things like prohibiting the state from implementing work requirements early or requiring more frequent verification than the federal law requires, requiring the state to adopt all possible exemptions, defining medically frail as comprehensively as possible, accepting self-declarations as verification of exemption, maximizing effective ex parte processes, collecting data. This is really important.
The bill would require collection of data on all sorts of things, but including how many people are losing coverage because of the red tape of work requirements. You can use these bills as models in your state. So again, the links to the bills are there. They provide a great starting point to try to get similar legislation introduced in your state. And Sarah at Nebraska Appleseed has offered to be a resource. If you’re looking to work on similar legislation, I’d be happy to connect you with Sarah. And also our colleagues in California are working on legislation to protect Medicaid enrollees from improper coverage loss under H.R.1. So please reach out if you’re interested in learning more.
We’ve also seen challenges with how states are implementing or describing how they’re going to implement the individual exemptions. We’ve seen states are interpreting exemptions incorrectly or too narrowly. So for example with the medically frail exemption, we’ve seen states putting in language that would apply the Social Security disability definition or similar criteria to medically frail. Using criteria such as inability to work due to a disability as what someone would need to show to be eligible for this exemption. That is not what is in H.R.1.
We’ve also seen states conflating categories or misstating the statute. So the categories of medically frail that Gelila discussed, they might not be listing all of those out. And in particular that last category that, as Gelila said, should be a catchall category of serious or complex medical conditions. Just making sure that your state has that on the list as its own category, to protect people who don’t fit into another category. We’ve also seen states putting out policies and information that would narrow the Caregiver Exemption. So we’ve seen a lot of use of dependent or caretaker-relative language only, and not talking about family caregivers.
We’ve seen a lot of focus on children and the parent-child caregiving relationship, but not caregiving for older adults. We’ve seen states suggesting that they would require someone, the care recipient, to be disabled or have a specific medical diagnosis for their caregiver to receive an exemption. Again, this is not in HR-1, and we would urge states to be more flexible with this Caregiver Exemption.
Some advocacy strategies here are, again, to engage your state as they are developing these policies and materials. So you can send a letter to your state. We have a template that I’ll go over later, but it’s really important to ask to review the materials before they’re finalized. So these are things like the Medicaid applications, notices. Any sort of educational materials that are going out to the public, as well as the policies themselves. It’s important to use examples to illustrate the wide array of caregivers and people with serious or complex health conditions that states must consider. So this can help avoid you trying to define these terms. Instead of defining them for the state, show them who the people are that need to be exempted.
Okay. Ex parte review. I said I would get into more detail about what this is. So ex parte is when the state uses existing records within their systems to verify eligibility. It’s an existing process that states already use for Medicaid. Some examples of ex parte data that might be used is payroll data that could show someone has worked at least 80 hours a month, or SNAP data. Generally, ex parte is useful and really helps. It helps avoid complicated paperwork, allows for some of that automatic verification to happen so that people can be identified with as minimal burden as possible. And H.R.1 in fact requires states to use ex parte processes and data to verify compliance or to verify that someone is exempt whenever possible.
The challenge is making sure this data and process is not used incorrectly. One way it could be used incorrectly is to automatically exclude someone from an exemption. So for example, as we spoke about, people who have a health condition, have a disability, are caregiving, they often are working, and payroll data may show that they are working. But that data, the fact that they are working, should not be used to deem them ineligible for an exemption.
The other concern is states over-relying on data for exemptions in particular. People must have the option to identify themselves as eligible for an exemption on an application, and that declaration should not require further verification when there are no data sources to verify. Some advocacy strategies here are, again, to consider legislation or other advocacy to encourage robust use of ex parte data to verify both work and eligibility for exemptions wherever possible. Also, urge your state to accept self-declarations to verify eligibility for exemptions, particularly for caregivers and people who qualify as medically frail. H.R.1, again, allows and encourages states to reduce the burden, would allow a state to use a self-declaration without further verification. And so it’s important that states take this option.
And then really, really important here is to urge your state to test its systems, particularly around data and verification, before they enforce work requirements. Is the system correctly identifying the categorically-excluded groups and automatically excluding them? Are the ex parte data sources identifying exempted individuals? Many states are going to be relying on vendors, third-party vendors to implement all of this. And unfortunately these vendors have been shown to be problematic when it comes to verifying eligibility in the Medicaid program. So testing and accountability is really important.
I’m going to go over some of our advocacy tools and additional resources. We have a work requirements toolkit that, again, is focused on mitigating the harms for older adults, but we think it’s applicable beyond that and urge you to use it and share it and adapt it however is helpful to you and your clients and communities. It includes a template letter with recommendations that can be customized. And I will go over that letter here. This slide shows a picture of the letter. And again, we encourage you to customize it as much as possible. Only use the parts that make sense for your community, and combine it with other templates and resources from other organizations to address your state. The bracketed and highlighted info in this letter are places to fill in your state’s specific information.
So in this letter and throughout your advocacy, as I mentioned before, using examples is really important. We’ve heard from the Centers for Medicare and Medicaid Services and from state Medicaid agencies that examples are really helpful. So we want to use examples to illustrate who exemptions should cover. So who might the state not be thinking about as medically frail? Who might have barriers to working 80 or more hours every month? Who are the older adults in your community who rely on Medicaid and have retired early? Why did they retire early? Show that with examples. Who is caregiving but might not identify themselves as a caregiver? And who are they caregiving for? Older adults or other individuals who may not identify as having a disability.
KFF has a work requirements tracker online, and they have some quotes from Medicaid Expansion enrollees in that toolkit that I think really help illustrate why examples are important to show states who they need to be thinking about. The first example is from a 52-year-old man who says, “I do self-work with Instacart because I get to pick and choose the days I’m able to work. And dealing with my dad, getting in that nursing home, and also dealing with my mom now, because she’s getting into that phase where she’s needing more doctor appointments.”
So this person is clearly a caregiver for his parents, his aging parents, but he’s not identifying himself as a caregiver. But he should be able to do that in his Medicaid application or renewal, to say, “Oh, yes. I am taking care of my parents. And that’s why I need Medicaid. And it impacts the work that I do.” So I think this is a good example of showing that caregivers both, they do work, but their caregiving responsibilities are also there and should qualify them for an exemption from the work requirements.
The next quote is from a 51-year-old woman who says, “Ever since I haven’t been working, I haven’t been able to find a job that’s legal or decent enough for working from home. They all want somebody in the office to stand up or sit down for long periods of time. I can’t even walk to my vehicle without being in pain, or get into a vehicle and drive that vehicle because of the stress all behind that.” So this person should be eligible for the medically frail exemption. It shows the struggle with the types of work that are available to people who rely on Medicaid, and to older adults in particular. And that Medicaid is this person’s source of health coverage. They need Medicaid in order to treat these conditions and their pain.
The other recommendation for this letter and all of your advocacy is to include as much state-specific data as possible. I wanted to highlight data from AARP and the National Alliance for Caregiving that is particularly relevant to older adults and caregivers that we talked about today. So AARP has an interactive map where you can see how many older adults, ages 50 to 64, rely on Medicaid Expansion in your state. AARP and NAC have caregiving state data profiles. And the third resource talks specifically about family caregivers and how many rely on Medicaid in your state. We have some additional resources. These are all included in our toolkit as well, so I’m not going to spend a lot of time, but these go into a lot more detail on the serious or complex medical condition, as well as caregiving and all the other issues and things, changes and cuts that were passed as part of H.R.1, that we’re tracking.
So what are next steps as advocates? Now is really the time to be reaching out to partners, engaging with your state, and engaging your state and federal elected representatives about your concerns with work requirements and how they’re being implemented. It’s also the time to share materials with others in your community to combat misinformation about these upcoming changes, and to continue to be on the lookout for additional guidance from the federal government as well as your state. And Justice In Aging will be sharing more on any guidance and information that we get with our network, so make sure you’re signed up for our emails.
And before we take a few question and answers, we have a question for you. A poll question to learn more about what advocacy strategies you are currently using. So the poll should be up. And the options are letters and/or meetings with state policymakers, joining a coalition or making new partnerships, developing or advocating on state legislation, educating clients and the public, or something else. And you can tell us what you’re doing in the question and answer. We would love to hear other ideas as well. And I realize many of you are probably doing multiple things on this list, so share one that you’re most excited about or that you feel has been successful, or maybe something new you’re going to try.
So we’ll give folks another few seconds to answer that poll, and then we can share the results. All right. It looks like educating clients and the public is by far the top strategy. 72% of you answered that. Next highest is letters and meetings with state policymakers, joining coalitions and partnerships. A few people are developing or advocating on state legislation. That’s great to hear. And also I hope that we can get those numbers up after this webinar. So thank you all. We will put up our questions slide, and then I think Amber has queued up a few questions for us.
Amber Christ: Yeah. And thank you all for your questions. I do want to point out that so many of you included questions outlining specific client examples. Like, “What if my client fits in this?” Or, “What if my client is experiencing this?” Those are exactly the types of stories and examples that Natalie was describing that your policymakers need to hear to understand why an exemption… Both how an exemption should be applied, and then how someone might go about proving that exemption. Or if not the person proving it, how the state might approach getting documentation of that exemption.
So all of those stories are in fact illustrative for policymakers in determining how to make these exemptions actually work for people. So I encourage you all to share those with your policymakers either through a coalition space or your own letters, and whatever advocacy avenue makes sense for you.
So turning to some question and answer. First of all, starting high-level, we did get a number of questions. And I think this is for Gelila. What if I’m in one of the 10 states that did not expand Medicaid under the Affordable Care Act, like a Florida or Kansas or a Texas? Do these work requirements apply there?
Gelila Selassie: Yeah. Good question. These really just apply to those 41 states and then the two Expansion-like states of Wisconsin and Georgia. There is a chance that a state might try to use a waiver or some other funky Medicaid pathway to implement these for other Medicaid populations like for caregivers, for other groups like that, but these H.R.1 work requirements are just specific to the expansion and expansion-like populations.
Amber Christ: Okay, great. And we got a lot of questions about whether seniors or people on Medicare are subject to work requirements. Could you just, again, review who’s categorically excluded from work requirements under H.R.1?
Gelila Selassie: Yeah. Older adults, people who are 65 and up, who are under age 19, or who are Medicare-eligible or entitled, or receiving Medicare or duals, they should not be at all included into this Medicaid work requirement world. Same for the folks who are receiving Medicaid on a disability pathway or in the age, blind, disabled programs, SSI for pregnancy, postpartum coverage. All of those groups that are getting Medicaid because they fit into this very specific category of people should not be under that world at all. So again, they shouldn’t have to prove anything regarding any individual exemptions.
Amber Christ: Yeah. So again, really it’s the Expansion population, people ages 19 to 64 who are eligible through the Medicaid Expansion pathway. But to be clear, it is possible that the way that the state operationalizes work requirements, that people who are supposed to be categorically excluded could get wrapped up in this. And so we want to make sure that people understand that they’re actually not subject to these work requirements in the event that they get a notice about being subject to them. So just want to point that out, that they’re supposed to be categorically excluded, but this is a really big change and Medicaid systems are really complicated. And it’s still possible for people who are not supposed to be subject to these at all to get wrapped up in it.
People also had a lot of questions about state flexibility. Can states create their own exemptions or waive requirements under the law? And so could we speak to that?
Natalie Kean: Yeah. This is Natalie. I can answer that. The Statute itself says that states cannot waive anything in the Statute for work requirements. So that means states cannot opt out of implementing work requirements for the Medicaid Expansion population. They cannot add exemptions that are not in the Statute. They can choose to make those exemptions as comprehensive and generous as possible, but they can’t… For example, they can’t say, “We want to exempt everyone age 50 and older.” That is not allowed under the federal law. So there is limited flexibility for states. And as Gelila hinted at, some states could use these other strange Medicaid maneuvers, waivers to expand Medicaid work requirements to other populations, but there’s very little that a state could do to exempt or further exclude populations from work requirements.
Amber Christ: Thanks. People also had a lot of questions about proof. How people are going to prove that they’re either meeting work requirements or volunteering, or how they would prove exemptions. And so can you share, just high-level, where we are in terms of understanding that kind of proof piece? Because I think that that’s where things are really going to get operationalized.
Natalie Kean: Yeah. I think we’re still at the point, especially on exemptions, of wanting to, again, encourage states to allow as much self-declaration as possible so that people can get the exemption in place and not have to come up with paperwork or data that simply might not exist to prove that they are in fact eligible for an exemption. So we don’t know yet what the proof will mean. Verify has many different meanings in the Medicaid context. And we know that there will have to be some verification, but the person’s own identification, their own knowledge of their life is one way to verify that they are eligible for an exemption, or it should be one way.
Amber Christ: And again, another area for advocacy is encouraging your states to make that verification as least burdensome as possible, self-declaration being the least burdensome. We had some questions around the family caregivers and the definition of family caregivers and the Caregiver Exemption. And I thought that this was just an interesting question in terms of illustration. What can be considered a significant relationship? And whether there’s been any guidance from CMS on the Caregiver Exemption. And I thought maybe we could just broadly speak to the Caregiver Exemption and some of the things we know and don’t know. And again, emphasize where we want people to be pushing their states in terms of that definition.
Gelila Selassie: Yeah. I can jump in. Again, we really don’t have much information from CMS about the details of the caregiver relationship, or the documentation or verification that’s required. We keep reiterating that Congress intentionally included that RAISE Act definition, which is very broad. It’s very broad not only to the individual who’s receiving care, but also the type of relationship.
So in terms of our advocacy opportunities, it’s really important to elevate that because that is one of the better ways of capturing the greatest group of caregivers. It doesn’t have to be a close, intimate family member and anything like that under the RAISE Act. So that’s why we keep elevating that, to make sure that states are aware that this is what Congress put in. They could’ve applied a different definition, a more limited definition, but they didn’t. And this is a broad definition. So that should be applied with respect to the caregiving relationship. Doesn’t have to be an adult child or a romantic partner or anything like that under the Caregiver Act. And then again, also that it applies beyond just people who identify as disabled.
Amber Christ: Great. I think we’re right at time, so I just want to thank everybody for their participation in the webinar and for all of your questions. As both Natalie and Gelila stated, please stay connected to us by signing up for our listserv if you’re not already. As we do get more guidance from the Centers for Medicare and Medicaid Services and as we learn more about how individual states are implementing work requirements, we will be sharing additional resources and information. So thank you again for participating, and have a wonderful afternoon.
