Medicaid and Work Requirements: What’s At Risk

Written by guest blogger, Andrea Callow, Associate Director of Medicaid Initiatives with the Medicaid team at Families USA.

Medicaid expansion under the Affordable Care Act has been a lifeline to health care access for some of our most vulnerable residents, including those experiencing homelessness. But there are efforts underway in states across the country to undercut this progress.

On January 12 the U.S. Department of Health and Human Services approved the Kentucky HEALTH Medicaid demonstration project. This action is commonly referred to as a “waiver” because it waives certain provisions of Medicaid law.

Kentucky HEALTH is the first approval in a line of waivers that seek to tie Medicaid eligibility to a recipient’s ability to find work. In addition, the waiver imposes a number of other elements that will create barriers to coverage, including punitive “lock-out” periods for failure to complete renewal paperwork or to pay premiums on time, and high cost-sharing for very low-income people. Further, the waiver eliminates coverage for critical services such as dental and vision. Retroactive coverage, which allowed applicants up to three months of coverage prior to completion of the Medicaid application, will also end.

It is noteworthy that most adults with Medicaid do work. Many who don’t are expected to qualify for an exemption to the new requirement. With that said, a substantial number of Kentuckians are still in danger of losing their coverage. This is because of the many challenges of properly documenting exemption eligibility. Additionally, a person could be locked out for not submitting documentation on time, submitting incomplete paperwork, or for failing to document small changes in income or hours worked. By Kentucky’s own estimate, 90,000 people will lose health coverage as a result of the waiver’s implementation.


The most concerning provisions in the Kentucky waiver are applicable to most adults, including low-income parents.

  • Work requirements: Most adult enrollees are required to work for at least thirty hours per week or eighty hours per month, unless they are pregnant, full-time students, or caretakers of a dependent child. Enrollees can also meet the work requirement through other “community engagement” activities like volunteering.
  • Premiums: All adult enrollees, including those with no income, are subject to premiums between $1 and $15 per month (on a sliding scale). The state has discretion to raise this amount up to 4 percent of income without federal approval.
  • Lock outs for up to six months: Any enrollee who fails to submit their annual recertification on time, and those who don’t report changes in income, work hours, or activities, can lose coverage for six months. These individuals are likely to be below the poverty line, ineligible for marketplace coverage, and at high risk of becoming uninsured.

People experiencing homelessness are not explicitly exempt from work requirements, although some might meet other criteria for an exemption. There are, however, a number of exemptions from lock out periods for homeless populations. Of note, those who have “experienced homelessness” may be exempt. However, the definition of homelessness (whether it be a HUD, HHS or other state-defined criteria) is not specified. Many of these individuals may fall through the cracks.


Kentucky’s Medicaid expansion program has been successful by any measure. Since the state expanded, the uninsured rate has dropped 20 percent. Moreover, enrollees report significant increases in access to care, improved financial security, and improved health. Kentucky HEALTH will roll back this progress. The most vulnerable populations — those that most need coverage — will lose access and coverage to vital care, including mental health and substance use disorder treatment services.


Troubling waivers are pending in a number of states. For up-to-date information on what states are doing and how you can get involved, visit Families USA’s waiver resource center. The waiver resource center includes basic information on Medicaid waivers, including tips on how to develop an effective waiver advocacy strategy in your state.

Andrea Callow is Associate Director of Medicaid Initiatives with the Medicaid team at Families USA. She focuses on preserving and strengthening the Medicaid program through federal and state advocacy, in collaboration with advocates, government officials, providers and other stakeholders.