Disability and Technical Issues Were Key Barriers to Meeting Arkansas’ Medicaid Work and Reporting Requirements in 2018

Over 18,000 people lost Medicaid coverage in Arkansas in 2018 due to the work and reporting requirements imposed under a Section 1115 demonstration waiver. There were four safeguards available to waiver enrollees that were intended to prevent people with disabilities and others who should not have been subject to the requirements from losing coverage. For example, the safeguards were intended to protect coverage for people who should not have been required to work due to a disability as well as for enrollees who did work the required number of hours but had difficulty navigating the monthly reporting process.

While proponents of the work and reporting requirements sometimes describe them as applying to “able-bodied” adults, some people with disabilities were subject to the requirements. Only people who receive federal Supplemental Security Income (SSI) benefits or are otherwise eligible for Medicaid based on a disability were entirely excluded from the requirements. Notably, 55% of nonelderly adults with Medicaid in Arkansas who report a disability do not receive SSI. At least some are eligible as ACA expansion adults and had to comply with the requirements or obtain an exemption to retain coverage under Arkansas’ waiver.

Two safeguards applied to protect coverage under the waiver for enrollees with disabilities. First, people with disabilities or health conditions that limited their ability to work were exempt from the requirements if they were determined to be “medically frail.” People with disabilities also could request a “reasonable accommodation” to receive assistance with meeting the requirements.

The other two safeguards applied to people with disabilities as well as other enrollees. Enrollees who were not exempt from the requirements and subsequently were determined to be non-compliant could have their status changed and be excused from the requirements by requesting a “good cause” exemption. Enrollees also could file an appeal to have a hearing to review the state’s decision to terminate their coverage under the new requirements.

This issue brief analyzes the impact of the four measures intended to safeguard coverage for people with disabilities and others who should not have been subject to the work and reporting requirements. It draws on data newly available from Arkansas’ 2018 annual waiver report to CMS and monthly data released by the state while the requirements were in effect. The data reveal that few people used these safeguard measures relative to the number of people who lost coverage due to the new requirements. Among those who accessed the safeguards, the vast majority did so due to disability/other health issues or technical issues such as those related to reporting. Key findings include the following:

• The four safeguards intended to protect coverage for people with disabilities and others who should not have been subject to the requirements are strikingly complex. Each safeguard has a different operational process and can be invoked at different times.
• Few enrollees utilized the processes intended to safeguard coverage relative to the over 18,000 people who lost coverage. While the medical frailty and good cause processes enabled some enrollees to retain the coverage for which they remained eligible, there were only 904 good cause requests, 17 reasonable accommodations, and 69 appeals in 2018. These low numbers may reflect a lack of enrollee knowledge about the safeguards and/or challenges navigating the required processes. Because over half of nonelderly adult Medicaid enrollees in Arkansas report a disability but do not receive SSI, it is likely that more enrollees qualified for relief from the requirements but did not navigate the process.
• People with disabilities were particularly vulnerable to losing coverage under the Arkansas work and reporting requirements, despite remaining eligible. As the requirements took effect, the share of enrollees identified as medically frail increased from 9% (about 2,200 people) in June to 14% (about 8,400 people) in December 2018. Still, this process did not identify all enrollees whose disabilities or health conditions prevented them from complying. Over one-third of approved good cause requests excused enrollees who had not been identified as medically frail from meeting the work or reporting requirements due to a disability or health issue.
• Administrative processes such as reporting requirements present barriers to eligible people retaining coverage beyond just those with disabilities. Over three-quarters of approved good cause requests excused enrollees from meeting the reporting requirement. This means that enrollees had completed the required number of hours but nevertheless initially had been found non-compliant because they were unable to successfully report. Technical issues were the most frequently cited basis for approved good cause requests, followed by enrollee disability or other health issues.

Looking ahead, the impact of measures intended to safeguard coverage for individuals with disabilities and others who should not have been subject to work and reporting requirements has implications for Arkansas as well as other states pursuing similar waivers. While the Arkansas requirements have been set aside by a court, they could be reinstated on appeal. The four safeguards are important protections to help eligible people remain covered, but their benefits may not have been fully realized due to the complexity of the processes. The extent of disability and technical issues, primarily related to reporting, experienced by those who ultimately were exempted from the requirements raises questions about whether additional individuals who lost coverage under the waiver might in fact remain eligible but were unable to retain coverage due to a disability or another difficulty navigating the reporting process.