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Urban Institute: 'Community Engagement' Rule Affects 531,000 Kentuckians On Medicaid

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Starting July 1, about 531,000 Kentuckians will need to prove they are fulfilling the state's new "community engagement" requirement — or prove they are otherwise exempt — in order to keep Medicaid coverage. That’s according to a new estimate from the Urban Institute

Adults without dependents and many people with children who making below 138 percent of the poverty line gained Medicaid eligibility under Kentucky’s expansion in 2014. But last month, the federal government approved Gov. Matt Bevin’s proposed changes to Kentucky’s Medicaid program. One of the many changes is the addition of a so-called community engagement requirement that “able-bodied” adults will have to meet in order to keep coverage.

People who fall into that category will have to either work, volunteer, take classes or participate in other activities for 80 hours a month to keep their Medicaid. 

Several advocacy groups are suing the federal government on behalf of 15 Kentuckians who are enrolled in Medicaid, saying that Kentucky’s Medicaid changes violate the Social Security Act.

Bevin said he will take away Medicaid expansion coverage from about half a million Kentuckians if a court blocks any of the approved changes.

Currently, about 1.4 million Kentuckians are covered by Medicaid, and about one-third will be affected by the changes. Some will have to prove every month that they are working, some will have to pay a premium or monthly payment for coverage and some will lose automatic dental and vision benefits.

(Click image to enlarge)

Covered, But Not Working

The Urban Institute estimated there are 188,000 people who gained Medicaid through the expansion and are not working. This is the group that Bevin says the community engagement requirement is primarily targeting.

“The key is to have them engaged in their communities because it is through that engagement that people have healthier outcomes,” Bevin said in an interview with PBS NewsHour in January.

About half the people in this group are over the age of 50, one quarter of them have less than a high school education and one quarter have no internet access at home, according to the report.

“So this group is relatively older, lower educated and has a high rate of health problems and limited access to information, suggesting that it’ll be difficult for these enrollees to find work and document fulfilled hours,” said Anuj Gangopadhyaya, co-author of the report.

“If they do qualify for exemptions, this suggests that they’ll have difficulty identifying them and reporting them as well, which could jeopardize coverage."

People with a chronic or serious health conditions could be exempt from the work/volunteer requirement, but they would have to go through a process with the state to qualify as “medically frail.” The state said the process for determining the medically frail status will begin in April.

Adding Up The Hours 

There were 169,000 people who had Medicaid coverage in 2016 but were already working, according to the Urban Institute’s analysis.

This group will have to report their 80 work-hours a month to the state in order to to keep coverage. People who work more than 120 hours a month will be exempt from the reporting requirement.

More than one third of these people, however, reported not working year-round, according to the Urban Institute. Gandopadhyaya said this could be because of seasonal work. But that’s where the problem lies. For an enrollee to keep coverage, they must work 80 hours every month out of the year, with no exception.

Cara Stewart, an advocate and former housing attorney, said people may also have lapses in employment because of the nature of lower-paying jobs. She described working with low-income clients.

“I would get them when they were facing an eviction and so often it was because they got sick or their kid got sick,” Stewart said. “There is no sick time, so when people would get sick and they can’t go into BP or Wendy’s, they get fired. A lot of places, it doesn’t matter if you call or not. You miss three times in six months and you’re fired no matter what.”

Stewart said many times, her clients would eventually find new jobs, but they’d be unemployed for some period of time. With Medicaid coverage, however, her clients could go to the doctor when they were sick.

“People can at least go to the doctor, get an antibiotic and be off for one day instead of three to five because they got sick and had nothing,” Stewart said.

People who don’t work 80 hours a month can regain coverage if they make it up within the following 30 days, or take a state-approved health or financial literacy course. Enrollees who haven’t done either will have their coverage terminated and will have to reapply for Medicaid.

The state says people could get a pass on not reporting enough hours for a “good cause” exemption, such as a death in the family or a divorce. People who haven’t had Medicaid insurance in the previous five years will have three months before the community engagement requirement kicks in.

Exemptions To The Rule

There are people who gained coverage through the Medicaid expansion who won’t have to meet the community engagement requirement. That includes former foster care youth, pregnant women, primary caregivers of a dependent (limited to one per household), people designated “medically frail” and full-time students.

The Urban Institute’s analysis looked at people who reported being a caregiver or going through some sort of schooling. The report estimated that 174,000 people would fall into this group. However, the survey did not ask respondents to specify if they were going to school full- or part-time.

Although caregivers with a dependent will be exempt from the engagement-work requirement, the exemption is only for one person per household. Gangopadhyaya, the co-author of the report, said this could adversely affect families with two parents staying at home — for example, a family where one parent stays home to take care of children and the other to tend to an elderly adult.

“In that family, only one parent would be classified as a primary caregiver,” Gangopadhyaya said.

There aren’t details yet on the process for claiming caregiver status, or for meeting any of the other exemptions. The state plans on rolling out the community engagement requirements by county — dependent on the jobs available — instead of statewide, all at once.

The Urban Institute based its estimates on the American Community Survey, which is conducted by the Census Bureau every year, and applied those numbers to the Medicaid population.

Lisa Gillespie is WFPL's Health and Innovation Reporter.