Arkansas is one of five 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. CMS approved Arkansas’ waiver on March 5, 2018, and the new requirements took effect for the initial group of beneficiaries on June 1, 2018. The requirements were phased in for enrollees ages 30 to 49 from June through September, 2018, and will apply to those ages 19 to 29 beginning in 2019. Unless exempt, enrollees must engage in 80 hours of work or other qualifying activities each month and must report their work or exemption status using an online portal. Individuals need to report work activities or exemptions by the 5th of the following month. The Arkansas Department of Human Services has released monthly data related to the new requirements since June. September was the first month that enrollees could lose coverage for failure to meet the new requirements for three months. To date, nearly 17,000 people have been disenrolled due to the new requirements. This brief looks at the data for November 2018, released on December 17, 2018. A separate case study looks at early implementation of the new requirements and another report examines enrollee experiences.
How many individuals have lost coverage due to the work and reporting requirements?
A total of 16,932 individuals have lost coverage since September, 2018 due to non-compliance with the work and reporting requirements (Figure 1). The most recent round of closures, for failure to comply for any three months between June and November 2018, totals 4,655 people as of December 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. As of December 7th, another 1,936 individuals had two months of non-compliance and could be at risk for losing coverage if they fail to report qualifying work activities for another month. The state data show that 2,429 enrollees did not meet the work and reporting requirements for one month as of December 7, 2018.
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 152 good cause requests in November; of these, 101 were granted. In October, the state reviewed 291 good cause requests and granted 182, in September, the state reviewed 246 good cause requests and granted 140, and in August, the state granted 45 of the 55 good cause requests that it reviewed.
How many did not report work activities for November?
The large majority (83%, or 53,975 people) were exempt from the reporting requirement for November 2018, while 78% of those not exempt (8,426 out of 10,768) did not report 80 hours of qualifying work activities (Figure 2). Nearly all of those 8,426 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.
A small number of enrollees (118 out of the 8,426) did report some work activities but not 80 hours of qualifying activities for November. Of those 118 enrollees, 17 reported 80 or more hours of job search; 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. Forty-two (42) enrollees out of the 118 reported work that fell short of the 80-hour requirement in November, including 13 with at least 61 but fewer than 80 hours of work. Twenty (20) enrollees reported education and training hours, including 4 with at least 61 but fewer than 80 hours of education and training.
How many enrollees were exempt from the new requirements and why?
Most of the 54,889 enrollees exempt from the reporting or work requirement in November were already working at least 80 hours per month. The 54,889 includes 53,975 (98%) who 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. Another 2% (914) of the exempt enrollees were not identified through data matching but instead reported an exemption since receiving a notice. Overall, most exempt enrollees fell into four categories: those who were already working at least 80 hours per month (46%), followed by those currently meeting or exempt from SNAP employment and training requirements (18%), those with a dependent child in the household (12%), and those who have been identified as medically frail (15%) (Figure 3). The shares in each of these groups were stable from June through November.
How many enrollees met the work and reporting requirements and through what activities?
Only 1,428 (13% of those not exempt) met the work and reporting requirements, and compliance was largely attributable to meeting comparable SNAP requirements, in November 2018. This pattern also has been consistent since June. Of the 1,428 enrollees meeting the work and reporting requirements in October, nearly two out of three (64%) were doing so by meeting SNAP requirements (Figure 4). It is not clear why these individuals are not part of the larger group identified by the state data match (described above) and exempt from reporting. Seventeen percent were meeting the requirements through work, and three percent through volunteer activities. The remaining 16 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.
A small number (521 enrollees) of those who met the work and reporting requirements in November reported doing so by working, volunteering, or another activity, other than meeting SNAP requirements. In August, there were somewhat fewer enrollees that met the work and reporting requirements though an activity other than SNAP compliance compared to subsequent months. 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 16,932 people who have lost Medicaid coverage to date due to failure to comply with work or reporting requirements (Figure 5).
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 disenrollment saying that “the low-level of reporting is a strong warning signal that the current processes may not be structured in a way that provides individuals an opportunity to succeed, with high stakes for beneficiaries who fail…as a result the Commission calls for a pause in disenrollments.” The letter also cites concerns that that there was not an approved evaluation design in place at the time of implementation. According to the state’s quarterly waiver report to CMS for July to September 2018 (posted on Nov. 29, 2018), the state is obtaining feedback from CMS on its draft evaluation design plan and will engage an evaluator once the design plan is approved.
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 DHS and that DHS will be launching an advertising campaign to provide additional outreach to enrollees as the younger group of enrollees is phased in. 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.
Additional follow-up with individuals subject to the new requirements will provide additional information about whether individuals understand the new requirements and how to use the online portal and whether there are computer or internet access issues; 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; how many might have been eligible for an exemption but did not apply; how many subject to disenrollment will be found to have good cause for not meeting the requirements; how many of those disenrolled in 2018 will reapply for and regain coverage in January, 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.