The Trump administration greenlit a work requirement for New Hampshire’s Medicaid expansion recipients on Friday in a long-awaited announcement that allows a crucial part of the program’s reauthorization to proceed.
In a letter to New Hampshire’s Medicaid director on Friday, the Centers for Medicare and Medicaid Services cheered on the program, saying it would promote “beneficiary health and independence” and boost employment.
And Gov. Chris Sununu championed the agency’s approval, calling the revamped Medicaid expansion a “critical program” that would allow recipients to “continue to receive health insurance while also building long-term job training skills and pursuing work and educational opportunities.”
But the announcement also raised hackles among advocates who argued it could result in recipients falling off of coverage.
Under New Hampshire’s newly approved plan, recipients of the Medicaid expansion program must log 100 hours a month of employment and other “community engagement” activities — and submit evidence of that work to the state’s Department of Health and Human Service every month — in order to stay on the program.
The work requirement applies to New Hampshire’s around-50,000 Medicaid expansion recipients, who include those making between 100 to 138 percent of the poverty level but exempts people meeting a number of conditions, including sickness, disability, pregnancy, parents of children under 6, those identified as “medically frail” and others.
It’s set to kick in as early as April 2019 for those currently on the program, or 75 days after enrollment for those not signed up.
The Medicaid expansion work requirement also includes the “Granite Workforce Pilot Work Program,” a workforce development plan that would use $3 million of the state’s Temporary Assistance for Needy Families funds to help those in the Medicaid expansion program with tuition assistance and job training to allow them to better enter the workforce.
The new requirement passed as part of the state’s five-year reauthorization of the program earlier this year. But in order to carve out the exemption necessary to add the requirement to the Medicaid expansion program — created under the Affordable Care Act in 2010 — New Hampshire officials required approval from CMS.
The plan submitted to the federal agency earlier this year included a safety net for those who fail to make 100 hours in a particular month. Those who didn’t could go through a “curing” process by which they make up the deficit the following month. (Someone logging only 80 hours in May could work 20 more in June to keep coverage.)
But an amendment by CMS limits the availability of that safety net. Starting May 1, 2020, those who fail to make their 100 monthly hours will not be allowed to use “curing” continuously; if they attempt to use the process consecutively they will be removed from coverage.
The tweak, first announced by state Health and Human Services Commissioner Jeffrey Meyers at a forum on Thursday night, does not necessarily mean that all who come up short will be booted from care, Meyers emphasized. The program includes numerous “good cause” exemptions to cover contingencies if people can’t reasonably make the hours, including disability, sickness, hospitalization of themselves or a family member, or even inclement weather.
Additionally, what qualifies as “community engagement” is broad, Meyers noted. It includes education, job training, community services, substance use disorder treatment and caregiving outside the home. And it includes those actively searching for work, potentially allowing those fired or laid off to retain coverage.
Meyers added that the program allows for recipients with suspended coverage to regain eligibility as soon as they come under the 100-hour compliance. And he said that the case-by-case leeway given to the department under the program would be used benevolently.
“We’re going to obviously … take everything into consideration to ensure that this program is not administered in a way that kicks people off their health care,” he said at the hearing on Thursday. “That’s not our objective. That’s not the Legislature’s objective.”
But some advocates said the new program could ensnare those either unaware of the reporting requirements or unable to consistently meet them — such as those with seasonal work or uncertain hours.
Dawn McKinney, policy director of New Hampshire Legal Assistance, pointed to a pair of lawsuits filed against work requirements by Kentucky and Arkansas — both of which are winding through the federal court system.
“Today, the federal government approved a waiver that would allow New Hampshire to implement a similar, costly and ineffective work reporting requirement that threatens the health insurance access of thousands of New Hampshire families,” McKinney said.
And she said that Arkansas’ work requirement has caused more than 12,000 recipients to lose health care coverage after falling out of compliance — out of 245,553 total program recipients, according to state officials.
“Do we want to risk health care coverage for thousands like they’ve seen in Arkansas?” she asked. “Do we want to spend New Hampshire’s limited state resources spinning new red tape for struggling families?”
New Hampshire’s program is not fully set in stone; while the CMS work requirement laid down hard boundaries, the state’s Joint Legislative Committee on Administrative Rules now must fill in the administrative details. Meyers said his department would submit to that committee interim rules that follow the new federal requirements.
Support for a work requirement among state Republicans has a long history. During the reauthorization effort in 2016, the program was nearly axed over its non-inclusion of the provision, scraping by with a tie-breaking vote from Republican House Speaker Shawn Jasper.
In 2017, the Legislature added a mandate to the budget trailer bill that held that the federal government must approve a work requirement waiver by the end of the 2018 session or the program would shut down.
Supporters have argued that the program helps lift those receiving health care into self-sufficiency and better income levels. And Sununu, speaking on Friday’s approval, celebrated those goals.
“The community engagement and work requirement will help bring more people into the workforce, empowering individuals with the dignity of work, self-reliability and access to high-quality health care,” the governor said.