The early reports are in on state-by-state enforcement of the new Medicaid law requiring that enrollees either work or prove they are exempt from work requirements for reasons of disability, school attendance, caretaking or other reasons.
The Medicaid work requirements are complicated, and many industry experts expect that bureaucratic hassles and things like failure to receive a letter about the program because a person has moved will result in a large number of people losing coverage. The work requirements are applied state by state. Americans who say they are too sick to work are expected to have the most difficulty in certifying that the requirements do not apply to them, Particularly in the case of some more difficult-to-diagnose ailments like long Covid, myalgic encephalitis/chronic fatigue syndrome, and the like.
Nebraska was the first state to implement the Medicaid work reporting requirements, which will soon be mandatory nationwide. Nebraska started implementing rules for new applicants on May 1 and for existing enrollees on July 1.
According to state reporting, 46% of new applicants and 34% of people renewing their coverage met the qualifying exemption conditions — that is, they’re working at least 80 hours a month, having a monthly household income of at least $580 or are attending school.
Qualifying for exclusion from work requirements were 39% of new applicants and 57% of people renewing their coverage. This means people were excluded because they are a parent of a child under the age of 14 or are medically frail.
As for denials, 14% of new applicants and 7% of people renewing their coverage had their applications denied or lost coverage because they did not meet the work requirements. Only a very few people — 2% of new applicants and 2% of renewals — qualified for a short-term hardship exception.
Medical Daily reported: “Of 533 people denied at renewal in July and August, 490 were denied ‘for failing to provide requested information needed to verify compliance with, or exemption from, the new Medicaid work requirement,‘ according to draft meeting minutes from the state’s Sept. 17 Medicaid Advisory Committee meeting. Only 43 were denied for not meeting, or not being exempt from, the requirement.”
Montana soft launch
Montana is also an early state implementing work requirements. Nearly 71,000 people are subject to the new rules. Montana started work requirements with a soft launch in July, giving enrollees until Oct. 1 to comply.
Results are not in yet from the actual enrollment, but state officials are sending out danger signals, according to reporting from National Public Radio.
“Critics contend that isn’t enough time, because the state hasn’t finished setting up new computer systems or hiring the staff it said it would need,” NPR reported. “Of the 59 positions, only about 20 were filled, state health department officials told state lawmakers during the Sept. 9 hearing, adding that numbers had fluctuated amid staff turnover.”
In 2023, Montana got a taste of what this process would look like when Medicaid enrollees were required to re-certify after Covid Medicaid recertification waivers expired.
“Many Montanans who were financially eligible lost Medicaid coverage for technical reasons, such as incorrectly filling out paperwork — roughly 87,000, according to state data from two years ago,” NPR reported.
Refugees lose Medicaid
Thousands of refugees and legal immigrants also lost their Medicaid coverage Oct. 1. Refugees, asylees, domestic violence survivors and trafficking victims lost coverage, including people with longstanding serious health problems.
Hospitals are required to provide emergency care regardless of immigration status and are reimbursed by Emergency Medicaid, but that is a much smaller stream of funding than full Medicaid.
KFF Health News estimated that around 280,000 people in this category from nine states and the District of Columbia.would lose their Medicaid coverage in October.
“Florida alone identified nearly 177,000 immigrants who would no longer qualify for the state’s Medicaid program starting in October, said Anna Holaday, a spokesperson for the Florida Department of Children and Families,” NPR reported. “The agency verified the enrollees’ immigration status through government databases and sent notices to people to give them an opportunity to provide more information proving they remain eligible, Holaday said.
“Arizona predicts nearly 28,000 could lose eligibility. New Jersey expects 15,000 to 25,000 of its noncitizen residents to lose their Medicaid coverage. In North Carolina, it’s about 29,000, and in Washington state it’s 11,000. Final numbers from states on how many Medicaid enrollees have been terminated from the program won’t be available until later this fall.”
Arkansas earlier tried to impose work requirements, but they were struck down by a court, before the 2025 bill that brought them back.
The Congressional Research Service wrote that the Congressional Budget Office “estimates the Medicaid provisions in the [law] would reduce federal outlays by $840.2 billion and reduce revenues by $21.1 billion over the 10-year period from FY2025 to FY2034. The number of individuals without health insurance would increase by an estimated 7.8 million in FY2034 due to the Medicaid provisions.”
