Blueprinting Medicaid Work Requirements

The changes that states make to implement work requirements in Medicaid will likely be the largest to state health systems since the passage of the Affordable Care Act (ACA). The size of these changes, coupled with the short timeframe required to implement them, puts significant pressure on state agencies. With short implementation timelines and heavy consequences for people who get their health coverage from Medicaid, states must start now to set clear priorities for changes to their systems. Maintaining access to essential health coverage must remain a key focus, despite competing pressures. Code for America has spent the past months mapping and documenting the new requirements in Medicaid; based on the work we’ve done, there are three large pieces we recommend states focus on first.

Service Blueprint for Work Requirements in Medicaid Eligibility

Service blueprints are a valuable visual tool used in human-centered design to understand how a service is currently being delivered. A service blueprint maps out each step of the process: what actions clients and staff take, and what tools and systems are used. We leverage blueprints to locate pain points and opportunity areas along a service journey and to serve as a starting point to discuss where to prioritize improvements, anchoring people in shared understanding.

Check out the blueprint on Figma, or download to print in two different sizes (8.5” x 11”) or (11” x 17”).

1. Automating exemptions

While income and compliance verification will be a large part of any work requirements flow, many people covered by Medicaid or applying for coverage will actually be exempt from the program’s new work reporting rules for one or more reasons. Many of these exemption reasons can be determined via data sources, but these data sources can be costly to integrate. As a result, states should decide which data sources are most important to integrate first.

When prioritizing data sources, states should consider two important factors:

• Impacted population: How many people will likely be exempted by this data source?
• Ease of integration: How difficult is it to integrate into the system?

For example, H.R. 1 specifies that anyone in a Supplemental Nutrition Assistance Program (SNAP) household who is not exempt from SNAP work requirements is automatically exempt from the new Medicaid rules (H.R. 1 §71119(a)(xx)(9)(A)(ii)(V)(bb)). While a state may not have exact numbers on SNAP/Medicaid cross-enrollment, estimates can be helpful: KFF reports that 78% of SNAP participants nationwide are covered by Medicaid. While some SNAP systems are distinct and separate from Medicaid systems, in over half of states these systems are integrated, and in others they are already exchanging data. The existing couplings can make integration less difficult. This, combined with the size of the impacted population, can make SNAP data a high priority for integration. Similar analysis can guide states in making decisions about which integrations to pursue first.

2. Changing application and renewal forms

Medicaid application and renewal forms in use today don’t ask many of the questions they would need to determine if applicants should qualify for an exemption or if they’re meeting the program’s new rules in ways that may not be captured by work information alone (for example, by participating in a training program or by volunteering). While Medicaid agencies could modify their forms by simply adding a list of questions corresponding to each exemption or compliance reason, this approach could lead to questions that reproduce language from the program’s regulations in ways that are hard for applicants to understand, and to respond to accurately, creating undue burden on clients and caseworkers.

When evaluating the new information needed to determine a client’s compliance status, states can consider the following questions:

• Is this information provided by existing questions? For example, American Indian and/or Alaska Native status is already asked on Medicaid applications. This information could be used to determine an exemption from work requirements.
• Can this question be combined with another question? For example, many exemption reasons overlap with existing SNAP exemption reasons. Combining these questions in integrated applications can reduce the number of requests for the same information.
• Where in the “flow” is this question best placed? For example, if an applicant has an exemption, they won’t need to list the hours they’ve worked. A paper application could instruct clients to skip certain questions if they’ve answered “yes” to any exemption questions. An online application could be even smarter—it may not ask clients about hours at all in this case.

The dynamic nature of online applications and renewal forms provides states with important flexibility, allowing clients to skip entire pages or sections as a result of earlier answers while still providing the most important information to states. This can reduce time to apply or report while reducing applicant drop-off and program churn. Focusing on the client’s experience of using both paper and digital forms can result in less burden during application and renewal.

Focusing on the client’s experience of using both paper and digital forms can result in less burden during application and renewal.

3. Lookback period and verification frequency

H.R. 1 requires states to look backward from the date that a person applies for coverage or renewal to determine whether they are in compliance with new work rules. States have options for this “lookback” period: at application, they can choose one to three months for their lookback period, and at renewal, states can look at anywhere between one to six months to verify compliance. While these decisions may be made at the legislative level, state agencies can and should provide information to decision makers to help them understand the impact of each option.

Every verification has a cost—this includes the cost of data that states purchase through private data exchanges, the cost of caseworker time, the cost of fielding phone calls from clients asking about changes in their coverage, and even the cost of printing and mailing paper notices. Verifying additional months does not benefit the state or the client. Even before processes are defined, state agencies can begin estimating and informing decision makers about the budgetary impact of this sweeping new policy.

Additional verifications have non-monetary impacts as well because of the significant additional work they will require from caseworkers. The end of the Public Health Emergency saw a massive increase in workload for Medicaid caseworkers, as states processed eligibility for millions of people who had not had to renew their coverage in years. A large number of these caseworkers also worked SNAP cases or were shifted from working SNAP to Medicaid in order to accommodate the demand. The focus on Medicaid resulted in under-resourcing for SNAP, and contributed to severe timeliness delays in many states. With the increased focus and penalties on SNAP quality control metrics, a similar “spillover” of Medicaid work requirements casework could be catastrophic for a state’s SNAP processes and could lead to costly errors in SNAP determinations.

Moving forward

The items outlined here are not the only priorities states will have for work requirement implementation in Medicaid—but they are some of the most impactful. With limited resourcing and tight timelines, states will have to prioritize to ensure that as many clients retain their Medicaid coverage as possible and that agency workforces are not shouldering an insurmountable burden. Code for America is ready to be an active partner in this effort, and we look forward to assisting states, counties, and other partners in this space to ensure success for all involved.

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