Assessment of Medicaid Beneficiaries Included in Community Engagement Requirements in Kentucky

Atheendar S Venkataramani,Michelle K Strollo,Kristen Underhill,Elizabeth F Bair,Kristin A Linn,Margrethe Montgomery,Will Ferrell,Kevin G Volpp,Erica Dixon

doi:10.1001/jamanetworkopen.2019.7209

Abstract

States are pursuing Section 1115 Medicaid demonstration waiver authority to apply community engagement (CE) requirements (eg, participation in work, volunteer activities, or training) to beneficiaries deemed able-bodied as a condition of coverage. Understanding the size and characteristics of the populations included in these requirements can help inform policy initiatives and anticipate effects. To estimate the number and characteristics of Kentucky Medicaid beneficiaries who would have to meet CE requirements. Cross-sectional study in which administrative records for the entire population of Medicaid beneficiaries in Kentucky as of February 2018 and original survey data, based on responses from 9396 Medicaid beneficiaries included in the waiver program, were analyzed. Eligibility for Kentucky's Medicaid demonstration waiver as of the originally planned implementation date (July 2018). Number of beneficiaries included in CE requirements, including those already meeting vs not meeting hour quotas and those who may qualify for medical frailty exemptions. Among the 9396 individuals included in the Section 1115 waiver program who participated in the survey, the mean weighted (SD) age was 36.1 (11.9) years; a weighted 47.2% of respondents were female, and most beneficiaries (weighted percentage, 78.2%) were non-Hispanic white participants. We estimated that 132 790 (95% CI, 129 132-136 449) beneficiaries would have been required to meet CE requirements in July 2018, amounting to 40.2% of Medicaid beneficiaries included in the demonstration waiver. Of this group, 25 422 (95% CI, 23 135-27 710) beneficiaries may have qualified for a medical frailty exemption either by self-attestation (after confirmation by their Medicaid insurer) or by being identified as eligible by physicians or their insurer. Another 58 943 (95% CI, 55 687-62 196) beneficiaries likely would have met CE hour requirements and been required to report compliance. Ultimately, 48 427 (95% CI, 45 281-51 574) individuals would have had to add new activities to meet CE requirements, amounting to 14.7% of those included in the demonstration waiver as a whole and 36.3% of those included in the CE component of the waiver. Beneficiaries in the potentially medically frail group reported worse socioeconomic status, poorer health outcomes, and higher rates of hospital admission and emergency department use than those meeting CE requirements. Similarly, the group currently not meeting and not exempt from CE hour requirements reported worse socioeconomic status than those meeting the CE requirements, although magnitudes of the differences were smaller. Findings suggest that most beneficiaries who would be included in CE programs either already meet activity requirements, which they will be required to proactively report, or may qualify for a medical frailty exemption. Consequently, the outcomes of CE programs will depend on states' processes for addressing health-related, socioeconomic, and administrative barriers to participating in and reporting CE activities and identifying medical frailty.

Highlights

In January 2018, the Centers for Medicare & Medicaid Services announced they would, for the first time, consider Section 1115 Medicaid demonstration waivers applying community engagement (CE) requirements to beneficiaries considered able-bodied.[1]
We estimated that 132 790 beneficiaries would have been required to meet CE requirements in July 2018, amounting to 40.2% of Medicaid beneficiaries included in the demonstration waiver
48 427 individuals would have had to add new activities to meet CE requirements, amounting to 14.7% of those included in the demonstration waiver as a whole and 36.3% of those included in the CE component of the waiver

Summary

Introduction

In January 2018, the Centers for Medicare & Medicaid Services announced they would, for the first time, consider Section 1115 Medicaid demonstration waivers applying community engagement (CE) requirements to beneficiaries considered able-bodied.[1]. The rationale for making Medicaid benefits conditional on CE requirements is to motivate participation in activities that could improve health by allowing “able-bodied, working age adults to experience the dignity of a job, of contributing to their own care, and gaining a foothold on the path to independence.”[4] concerns have been raised that CE requirements may lead to coverage losses if beneficiaries are unable to meet requirements owing to poor health or other life circumstances. Even if beneficiaries do meet requirements, there may be barriers to reporting compliance.[5,6,7,8] These concerns stem from experiences with other public programs whose benefits have long been linked to work requirements.[9] the population-level impact of Medicaid CE programs will depend on the balance between the potential salutary effects of engagement in CE activities and the potential detrimental effects of coverage losses.[10,11]

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Conclusion