Source: https://healthlaw.org/resource/medicaid-expansion-work-requirements/
Timestamp: 2019-04-21 14:31:02+00:00

Document:
Q: My state is considering submitting a state plan amendment or waiver request to extend Medicaid coverage to the ACA Expansion population. It wants to include a requirement that individuals be working or looking for work to qualify for coverage. Is this permissible?
A. No. States should not be able to impose work requirements on ACA Expansion individuals under either traditional Medicaid rules or via a waiver or demonstration project.
Prior to 2014, Medicaid coverage was generally limited to low income women and children, people with disabilities, and the aged.4 Beginning January 1, 2014, however, most citizens and qualified immigrants whose incomes do not exceed 138 percent of the federal poverty line will qualify for coverage if the state adopts the ACA Expansion.5 The expansion will particularly benefit non-disabled, non-elderly adults.
But Medicaid is not AFDC. While the AFDC program required states to establish a ?job opportunities and basic skills? program and was explicitly intended to move recipients to gainful employment, the Medicaid Act has no such goal. 19 Rather, Medicaid?s stated objective is clear: it is intended to provide ?medical assistance [to eligible individuals] whose income and resources are insufficient to meet the costs of necessary medical services? and ?rehabilitation and other services to help such families and individuals attain or retain capability for independence or self-care.? 20 In the 48 years of Medicaid?s existence, HHS has never approved a waiver permitting a work requirement.
Congress? objective in passing the Medicaid expansion is also clear: it is intended to provide nearly universal coverage for all qualifying adults with incomes below 138% of the poverty line.21 The ACA also emphasizes access to care, particularly preventive care, and provides an efficient, streamlined system for determining eligibility and reducing ?churning,? the inefficient movement of people between programs and eligibility statuses.22 Work requirements would require time-consuming and costly verification procedures, increase levels of churning, and reduce the number of people accessing preventive and other necessary care. None of those outcomes are consistent with the goals of the Medicaid Act or the ACA.
to protect? ? in this case, the persons who would be covered by the ACA Expansion.24 Work requirements would reduce access to preventive care, decrease efficiency, and complicate the ACA?s goal of near-universal coverage under a streamlined system, in defiance of the goals of Congress, the Medicaid Act, and the ACA.
1 See 42 U.S.C. §§ 1396-1396w-5. Medicaid is an entitlement for individuals who qualify. See 42 U.S.C. §§ 1396a(a)(10), 1396a(a)(8), 1396d(a); Bowen v. Roy, 476 U.S. 693, 731 (1986).
2 See 42 U.S.C. § 1396a(a) (listing required contents of state plan).
3 See generally 42 U.S.C. § 1396a; 42 C.F.R. § 430.10.
4 42 U.S.C. §§ 1396a(a)(10)(A)(i)(III),(IV),(VI), 1396a(l)(1)(A)-(D), 1396(n)(1) (financial requirements); 42 U.S.C. §§ 1396a(a)(10)(A)(i)(II); 1396a(f), 42 C.F.R. § 435.120, 121 (people with disabilities); 42 U.S.C. §§ 1396d(p); 1396d(p)(2)(C)(iv), 1396d(p)(4); 42 C.F.R. § 435.121(b) (Medicare beneficiaries).
5 42 U.S.C. § 1396a(a)(10)(A)(i)(VIII) (added by ACA § 2001(a)(1)). Although the ACA Expansion category remains a mandatory group, the Court in NFIB v. Sebelius ruled that HHS cannot terminate Medicaid funding for states that refuse to participate in the Expansion. See NFIB v. Sebelius, 132 S. Ct. 2566, 2607 (2012). HHS has clarified that states must extend coverage to the entire ACA expansion category to receive increased federal funds for that group. See CENTERS FOR MEDICARE AND MEDICAID SERVICES, FREQUENTLY ASKED QUESTIONS ON EXCHANGES, MARKET REFORMS, AND MEDICAID (2012), http://www.cms.gov/CCIIO/Resources/Files/Downloads/exchanges-faqs-12-10-2012.pdf.
6 See generally 42 U.S.C. § 1396a.
7 42 U.S.C. §§ 1396a(a)(10)(A),(B).
8 Camacho v. Texas Workforce Comm?n, 408 F.3d 229 (5th Cir. 2005), aff?g, 326 F. Supp. 2d 803 (W.D. Tex. 2004).
9 Id. at 235. See generally Carleson v. Remillard, 406 U.S. 598 (1972) (invalidating state law that denied AFDC benefits to children whose fathers were serving in the military where no such bar existed in federal law governing eligibility).
10 Various initiatives do exist to make it easier for certain people with disabilities to pursue work and still receive Medicaid, see 42 U.S.C. §§ 1396a(a)(10)(A)(ii)(XV), 1396a(r)(2; 42 C.F.R. §§ 1396a(a)(10)(A)(ii)(XVI), 1396d(v)(1)(D); 42 U.S.C. § 1396a (note).
11 These ?Section 1931? recipients must have qualified for the state?s AFDC program under rules in effect on July 16, 1996. 42 U.S.C. § 1396a(a)(10)(A)(i)(I); 42 U.S.C. § 1396u-1(a).
12 42 U.S.C. § 1396u?1(b)(3)(A). Pregnant women, infants, and minors who are not head of household may not have their Medicaid terminated. Id. at (A), (B).
13 Id. § 1396a(a)(10)(A)(i)(VIII). In fact, people who are dropped from the 1931 category will qualify for the Expansion category, if they are otherwise eligible.
14 See 42 U.S.C. § 1396n(b); 42 C.F.R. §§ 430.25, 431.55. See CMS, STATE MEDICAID MANUAL §§ 2108.A (cost effectiveness), 2108.B (access to services and quality of care).
15 Some Medicaid provisions cannot be waived. For example, Medicare cost sharing requirements cannot be waived. Id. § 1396a(a)(10)(E). The spousal impoverishment protections cannot be waived. Id. § 1396r-5(a)(4). Transitional medical assistance coverage cannot be waived. Id. § 1396r-6(c)(1).
16 Beno v. Shalala, 30 F.3d 1057, 1069 (9th Cir. 1994); see 42 U.S.C. § 1315(a) (§ 1115(a) of the Social Security Act).
17 See generally Aguayo v. Richardson, 473 F.2d 1090 (2nd Cir. 1973). In fact, by the late 1980?s ?virtually all states? had applied for and received waivers to apply more stringent work requirements to AFDC populations than were required under federal law. RICHARD MOFFITT, NATIONAL BUREAU OF ECONOMIC RESEARCH, MEANS-TESTED TRANSFER PROGRAMS IN THE UNITED STATES: THE TEMPORARY ASSISTANCE FOR NEEDY FAMILIES PROGRAM 296 (2003), available at http://www.nber.org/chapters/c10258.pdf.
18 UNITED STATES DEPARTMENT OF HEALTH AND HUMAN SERVICES, STATE WELFARE WAIVERS: AN OVERVIEW, http://aspe.hhs.gov/hsp/isp/waiver2/waivers.htm.
19 42 U.S.C. § 682(d)(1)(A) (repealed July 1, 1997).
20 42 U.S.C. § 1396-1.
21 42 U.S.C. § 1396a(a)(10)(A)(i)(VIII) (added by ACA § 2001(a)(1)).
22 See generally ACA § 1001 (reforms to individual and group markets, including coverage of many preventive services); ACA § 1311 (streamlined enrollment).
FAQ (2013), http://www.medicaid.gov/state-resource-center/FAQ-medicaid-and-chip-affordable- care-act-implementation/downloads/Affordable-Care-Act-FAQ-enhanced-funding-for- medicaid.pdf. States may desire to impose work requirements for reasons of politics, money or morality, but waivers cannot be granted for those reasons. See Beno, 30 F.3d at 1069, Newton- Nations v. Betlach, 660 F.3d 370, 382 (9th Cir. 2011).
24 Beno, 30 F.3d at 1070.

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