Arkansas seeks work-requirement waiver for Medicaid expansion

Plan differs from voided 2018 rule by saying no one would lose health coverage

By: - June 6, 2023 5:00 am
Valencia White, right, talks about her concerns about Medicaid during an event Friday in Little Rock.

The state of Arkansas is proposing another work requirement rule for Medicaid recipients. The main difference from a 2018 work requirement that was struck down by a federal judge is that recipients won't lose health coverage but be switched from ARHOME to fee-for-service Medicaid. In this photo, Valencia White (right) speaks about her concerns regarding Arkansas' Medicaid expansion program during a March 2023 rally in downtown Little Rock. (John Sykes/Arkansas Advocate)

Arkansas Gov. Sarah Huckabee Sanders’ administration outlined to the federal government last week its plan to provide the broadest coverage option to Medicaid recipients who work, volunteer, go to school or receive workforce training.

No Arkansas Medicaid recipient should lose coverage under the proposed plan, called the Opportunities for Success Initiative, the state Department of Human Services emphasized in its letter to the U.S. Centers for Medicare and Medicaid Services (CMS) asking to amend the state’s current program.

Sanders and DHS Secretary Kristi Putnam announced in February that they would submit the proposal to CMS on June 1 and, if approved, would implement the plan Jan. 1, 2024.

Sanders: Arkansas will seek federal OK for new Medicaid work requirement

Arkansas expanded Medicaid coverage through a federal waiver in 2013 and implemented a work requirement in 2018. The Arkansas Works program, as it was known, cut 18,000 people from Medicaid coverage, even though it exempted people who were over 50 or had dependent children. A federal judge struck down the requirement in 2019. 

In 2021, Arkansas received a new federal waiver for the ARHOME Medicaid expansion program.

“DHS heavily considered the lessons learned from its prior implementation [of the work requirement] in the design of the Opportunities for Success initiative,” the letter states.

Under DHS’ proposed changes to ARHOME, able-bodied adults who do not meet the work requirement would receive fee-for-service Medicaid coverage instead of a qualified health plan.

Qualified health plans meet the federal Affordable Care Act requirement for “minimum essential coverage” and follow federal limits on deductibles, copayments and out-of-pocket maximum amounts. Under fee-for-service coverage, the state pays health care providers for services rendered.

Medicaid clients might lose access to the health care providers and resources that best suit their needs if they transition from qualified health plans to fee-for-service coverage because they do not meet the proposed employment standards, said Kevin De Liban, an attorney with Legal Aid of Arkansas who challenged the 2018 work requirement in court.

“We’ve had many clients who for other reasons were shifted from a qualified health plan to fee-for-service Medicaid, and suddenly they couldn’t get the medications or see the doctors they were used to,” De Liban said in an interview.

Legal Aid of Arkansas represents low-income Arkansans in civil legal matters. De Liban co-authored a May 23 letter from the organization criticizing DHS’ proposed plan during the 30-day public comment period in April and May.

“The ARHOME proposal would likely harm our client communities by discouraging Medicaid enrollment and frustrating use of Medicaid services,” the letter states.

DHS stated in the proposal that those who already receive qualified health plans under Medicaid will not be subject to the Opportunities for Success initiative.

As of February, ARHOME covers more than 348,000 non-disabled Arkansans between the ages of 19 and 64, according to the proposal. Beneficiaries are either childless adults with household income at or below 138% of the federal poverty level ($18,754 for an individual and $38,295 for a family of four) or parents with dependent children and income between roughly 14% and 138% of the federal poverty level.

Success coaches

Under Opportunities for Success, “success coaches” from DHS will assess Medicaid recipients’ health needs and help them seek employment, education or job training with an “individualized Action Plan.” Success coaches will be immediately assigned to Medicaid recipients at or below 20% of the federal poverty level, and “unengaged beneficiaries” will receive help from success coaches at any income or employment level, according to the plan.

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The 100 success coaches and 10 supervisors already work at DHS, though the department “has not yet identified prospective Success Coaches,” spokesman Gavin Lesnick said in a Monday email.

Lesnick said success coaches will be “qualified care coordination professionals who will undergo extensive training” to help them assist Medicaid recipients in finding work, training or volunteer opportunities.

The coaches will be required to get in touch with their assigned beneficiaries once a month and come up with action plans based on their needs and goals within 30 days of first contacting them, according to the proposal.

The responsibility of monitoring and reporting work participation or engagement in finding work will be on the success coaches, not the Medicaid recipients, the plan states.

“Beneficiaries will not be required to work a minimum number of hours per month, nor will they be required to report any activities to DHS outside of their required contacts with their Success Coach,” the plan states.

Medicaid recipients who have not demonstrated sufficient engagement with their success coaches and their available work or volunteer options will be moved from qualified health plans to fee-for-service coverage, according to the proposal.

De Liban said the proposed monitoring process is “invasive” and puts unnecessary conditions on receiving qualified health plans.

“It doesn’t make sense to have a whole new layer of bureaucracy that’s not focusing on making it easier for people to get or to have insurance, but rather is meant to invade the lives of people receiving Medicaid and essentially punish them if they don’t comply with a mandatory plan for action,” De Liban said.

He added that Medicaid recipients already have trouble getting in contact with DHS, as some have said while protesting in front of the department’s Little Rock headquarters earlier this year.

40K Arkansans lose Medicaid coverage after their eligibility is left unknown

Some enrollees have also expressed concern that they will be disenrolled from Medicaid coverage despite continued eligibility. DHS has been reviewing the eligibility of about 420,000 Medicaid enrollees who had their coverage extended over the last three years due to the COVID-19 pandemic, and more than 40,000 Arkansans lost coverage in April because they did not provide required information to determine their eligibility, DHS reported.

A 2021 Arkansas law gives DHS six months to complete its eligibility review. Many other states have one-year grace periods that started April 1, allowing Medicaid enrollees to confirm during that time whether they are still eligible for coverage.

Arkansas Medicaid recipients asked DHS in March for a one-year grace period, to no avail.

Half a million people in 11 states have lost Medicaid coverage, often due to incomplete paperwork, since April because the COVID-19 coverage extension ended.

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Tess Vrbin
Tess Vrbin

Tess Vrbin came to the Advocate from the Arkansas Democrat-Gazette, where she reported on low-income housing and tenants' rights, and won awards for her coverage of 2021 flooding and tornado damage in rural Arkansas. She previously covered local government for The Commercial Dispatch in Mississippi and state government for the Columbia Daily Tribune in Missouri.