MEDICAID WORK REQUIREMENTS RETURN

 

In 2018, the Trump Administration and GOP made multiple attempts to reverse the ACA and establish federal spending caps on the Medicaid program to lower costs. These attempts were not successful; nonetheless, a number of states expanded their Medicaid programs and proposed work requirements during this time.

According to KFF, one out of five Americans receive health care through Medicaid. The program has become the country's largest source of health care coverage and accounts for 27% of state expenditures. Due to program expansion and costs, House Republicans renewed their push for work requirements over the spring during debt ceiling negotiations with Democrats. They also suggested expanding the work requirements for individuals receiving food and cash assistance through SNAP and TANF.

The Medicaid work requirement provision did not make it through negotiations; however, President Biden agreed to the expanded work requirements for food and cash support in exchange for a two-year suspension of the debt ceiling. Despite the outcome in Washington, some states are still pursuing work requirements for their Medicaid programs with special waivers. 

Even though Medicaid is a jointly funded government program between the federal government and states, the states are responsible for administering it, and the Social Security Act allows them the flexibility to customize their Medicaid programs through what are referred to as Section 1115 waivers. These waivers require approval from the Secretary of Health and Human Services. They can modify eligibility requirements or forgo provisions of federal law under the condition that the projects support the goals of the Medicaid program.

States first employed Section 1115 waivers to implement work requirements in 2017 under the Trump Administration. During that time, twelve states received approval from HHS. Shortly after, the Trump Administration was sued by health care advocates and civil rights groups, rescinding the work requirement legislation in Arkansas and Kansas. Because of this, other states were also prohibited from implementing their provisions.

GA's Work Requirements

Shortly after President Biden transitioned into office, he reversed a number of other waivers that provided states approval to implement Medicaid work requirements. Georgia was one of the states impacted by the decision and sued the administration. The District Court for the Southern District of Georgia ruled in support of Georgia, citing that the administration did not consider whether reversing the waiver would cause less Medicaid coverage. Georgia has become the only state with a work requirement for Medicaid eligibility, and the state's program, Pathways to Coverage, launched at the beginning of this month.

Work requirements have once again become a topic of debate among health care professionals and government officials. Some view the requirements as barriers to health coverage that go directly against the objectives of the Medicaid program. They argue that Medicaid is designed to provide insurance, not encourage employment. However, work requirement proponents say that the program has grown far beyond its original scope, and states must control costs. At the moment, states are navigating eligibility redeterminations, and it's important that vulnerable populations remain covered. Setting the work requirement debate aside, all states should be looking for ways to improve efficiency and cost avoid in their Medicaid plans.

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THE MEDICAID PROGRAM IN 2021

The Coronavirus pandemic and the resulting economic recession accentuated the importance of the Medicaid program last year. By February, the Medicaid enrollment rate increased to 7.4 percent, and 76.5 million people were enrolled in the jointly funded program. In 2021, the new Biden administration, economic climate, and ongoing public health crisis are sure to impact the safety net program. Some of the crucial areas to monitor in the new year will be enrollment, coverage, eligibility, Section 1115 demonstration waivers, and program financing. Here is an overview of what to expect and what state Medicaid plans can do to curb costs.

MEDICAID PROGRAM ENROLLMENT, COVERAGE, ELIGIBILITY

Millions of Americans became unemployed and lost their employer-sponsored healthcare coverage as a result of the pandemic. In response to the public health emergency, the Families First Coronavirus Response Act (FFCRA) was implemented to protect eligibility standards and provide continuous coverage to current Medicaid beneficiaries. The provisions of the FFCRA are due to expire in April but can be extended by Congress.

President Biden has proposed changes to the ACA that would expand coverage. The first proposal is to increase ACA marketplace premium assistance, and the second is to introduce a public option plan similar to Medicare. This plan would provide coverage automatically to low-income individuals in states that did not expand their Medicaid programs. Additionally, the new administration has plans to reduce the coverage gap by substituting the 90% Medicaid federal match rate with a temporary 100% increase.

Along with the Biden administration's initiatives, there are two bi-partisan efforts to expand Medicaid coverage in Congress.. H.R. 4996, Helping MOMS Act of 2020, will enable states to provide one year of postpartum coverage under Medicaid. It also removes the cap on the total rebate amount for single source and innovator multiple source drugs under the Medicaid Drug Rebate Program. H.R. 1329, Medicaid Reentry Act, will allow Medicaid payment for medical services provided to an incarcerated individual during the 30-day period prior to the individual's release.

SECTION 1115 DEMONSTRATION WAIVERS

Section 1115 demonstration waivers make it possible for states to forgo key provisions of federal Medicaid law and the flexibility to shape their own Medicaid policies to accommodate their unique priorities. These waivers must adhere to statutory requirements, are required to be budget neutral to the Federal government, and are permitted for an initial five-year period. Under the Trump administration's time in office, demonstration waivers included changes such as work requirements and eligibility restrictions. The new administration will most likely undo these waivers and rework the demonstration waiver policy while issuing new state guidance. Under the new administration, Section 1115 wavers are expected to advance public option proposals, make coverage more affordable, and broaden program eligibility.

STATE MEDICAID FINANCING

The pandemic driven recession has caused significant budget strains for states. To offset these deficits, states depend on the Federal government for relief to preserve their Medicaid programs. In the current public health crisis, the federal match percentage was raised to 6.2 percent. This provision was featured in the FFCRA and was extended through June 2021. While President Biden supports increasing the FMAP, it cannot be accomplished exclusively by administrative action. To raise the FMAP, the new administration will need legislation from Congress or a simple majority vote from the Senate in a budget reconciliation bill.

FURTHER EFFICIENCY AND COST AVOIDANCE

In addition to federal assistance and budget cuts, states generally curb costs by reducing Medicaid benefits, decreasing provider rates, and introducing restrictions. However, these approaches to lowering costs are prohibited due to MOE protections under the FFCRA. With that said, states should focus on cost avoidance technology solutions and additional efficiency in their Medicaid plans.

One area in particular where states could realize significant savings is in program oversight and mitigating improper payments. According to CMS, FY 2020 Medicaid improper payments totaled $86.49 billion. The vast majority of these improper payments take place in the coordination of benefits because Medicaid plans struggle to identify liable third parties of pharmacy and medical claims. Medicaid plans do not have access to reliable, complete, and accurate data, so they cannot help but make claims payments in error, and it costs them millions.

Medicaid enrollment has surged over the last year, and because of the ongoing public health emergency, it's not clear as to when enrollment numbers will taper back. As dependence on the safety net program increases, the new administration and states will need to consider policy and program changes to ensure healthcare coverage for the most vulnerable while also preserving the program's resources. States must look to improving efficiency and cost avoidance before reducing access to care and benefits.

Until recently, Medicaid administrators have struggled with ensuring that pharmacy and medical claims are paid properly. With the introduction of ProTPL, Medicaid plans no longer have to struggle with TPL discovery. If you are interested in details on how you can greatly improve the efficiency of your plan and save on claims paid in error, contact Syrtis Solutions.

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MEDICAID IN 2019

In 2018, there were numerous attempts to reform the Medicaid program. While initiatives at the federal level met resistance, several reform initiatives came about at the state level. These efforts included legislation, program expansion, demonstration waivers, eligibility restrictions, and work requirements. Some of these changes have been adopted and successfully incorporated while others are still waiting for approval. For 2019, it will be important to monitor the impact of these changes to understand how the Medicaid program will evolve.

Section 1115 Medicaid Waivers

In spite of the Trump administration's failed attempts to overturn the ACA and reform Medicaid, states have sought to make reforms by utilizing demonstration waivers. Section 1115 waivers provide states the flexibility to pursue test coverage models and forgo key provisions of federal law under the condition that the changes meet the objectives of the Medicaid program.

On January 11, 2018, CMS issued new guidance for the Section 1115 waivers that made it possible for states to impose work requirements on their program's beneficiaries. According to CMS, the decision was made to "support states helping Medicaid beneficiaries improve well-being and achieve self-sufficiency." In addition to the revised eligibility requirements, states also started considering provisions including time limits, lockout periods for unpaid premiums or untimely reporting, drug testing, and premiums. The guidance has been controversial with legislators and government officials.

As of January 9th, the federal government has approved waivers from seven states. Arkansas and Indiana introduced their waivers last year. Michigan, Kentucky, Maine, Wisconsin, and New Hampshire have obtained approval and are implementing the changes in 2019. Arizona, Mississippi, Ohio, Oklahoma, South Dakota, Tennessee, Utah, and Virginia have proposed waivers but are waiting for decisions from CMS.

Regardless of its approval from CMS, Kentucky's waiver was blocked from going into effect last year after a group of 16 Kentucky Medicaid enrollees filed suit against it. U.S. District Judge James Boasberg then ruled the legislation unconstitutional. He specified that "The Secretary never adequately considered whether Kentucky HEALTH would, in fact, help the state furnish medical assistance to its citizens, a central objective of Medicaid." 

Since then, a reworked demonstration waiver was resubmitted to CMS with minor technical changes that require Kentucky to submit implementation and monitoring protocols for the eligibility requirements.

The key components submitted for approval are:

• Premiums instead of copays 
• Cost Sharing measures that would pull from HSAs for non-emergency use of the ER.
• Health Savings Accounts 
• Work Requirements 
• A six month lockout period for the failure to report a change in circumstances such as household income and hours worked.

On November 20, 2018, Kentucky's revised waiver was approved by CMS; however, health advocates argued that it was nearly identical to the original. Recently, the National Health Law Program, Kentucky Equal Justice Center, and the Southern Poverty Law Center joined together to file a lawsuit against the law. Kentucky is set to have the waiver carried out in April of this year but Governor Bevin is ready to pull coverage if the waiver does not survive the lawsuit.

Arkansas was the first state to implement its work requirement. It's waiver called for enrollees to report 80 hours of work or community engagement activities each month in order to be eligible for coverage. Merely six months since the implementation 17,000 members have been disenrolled either because they did not comply or they had failed to be given an exemption. According to state officials, enrollees were not informed of the requirements or they misunderstood them. Furthermore, enrollees reported having difficulty getting enrolled and accessing support. States intending to implement equivalent waivers can learn from Kentucky's uncoordinated implementation. It will be extremely critical for states to proficiently communicate their intended program changes to their communities. At the moment, there is litigation challenging Arkansas's waiver and the state has not received approval for its work requirement evaluation process.

States Adopt Medicaid Expansion

In states that had previously expanded Medicaid under the ACA, research studies have revealed that the decision to do so has been economically beneficial; moreover, it has also improved coverage, access to care, and service utilization. Due to the success, Medicaid expansion was a popular issue at the ballot box for voters in the midterm elections.

After the polls closed, Washington D.C. and 37 states approved expansion of their Medicaid programs. Idaho, Nebraska, and Utah adopted expansion using ballot initiatives. Maine also successfully passed a ballot initiative in 2017 but the governor at that time, Paul LePage (R), refused to carry it out referring to it as it "fiscally irresponsible". Fast-forward to this year, newly elected governor, Janet Mills (D) signed an executive order that began the expansion. In states such as Wisconsin and Kansas, Governor Tony Evers (D) and Governor Laura Kelly (D) ran on expansion and will now be working with legislators to pursue it.

Apart from the 37 states that have expanded or are expanding in 2019, there are also developments in other areas of the country. Historically, Mississippi and Georgia have fought Medicaid expansion but they might possibly consider the option this year.

Montana pushed to continue funding for their Medicaid program with the I-185 ballot initiative. However, the attempt failed to secure the necessary votes and the state is now in a similar situation to Alaska where expansion is in the hands of law-makers.

Regardless of the nationwide momentum to expand Medicaid under the ACA, there has also been a recent effort in Texas that would overturn the law for the entire country. In December, U.S. District Judge Reed O'Connor found the ACA unconstitutional as a result of changes in federal tax law. While the court's ruling could possibly dismantle the health-care law, appeals have been filed and it will not be addressed until it arrives at the Supreme Court.

Reform Of Medicaid Payment And Delivery Models

Medicaid relies on risk-based managed care as the program's main delivery system. This year, states will be seeking to utilize alternative delivery systems and payment models. These efforts will work to improve MCO's while also addressing social determinants of health.

On November 8th, CMS submitted considerable regulatory revisions aimed towards updating the managed care regulatory framework from 2016. According to CMS, these changes "reflect a broader strategy to relieve regulatory burdens; support state flexibility and local leadership; and promote transparency, flexibility, and innovation in care delivery." CMS, the National Association of Medicaid Directors (NAMD) and State Medicaid Directors organized a group to develop the framework. The group serves "to identify opportunities to achieve a better balance between appropriate federal oversight and state flexibility, while also maintaining critical beneficiary protections, ensuring fiscal integrity, and promoting accountability for providing quality of care for Medicaid beneficiaries."

States will want to improve access to care within rural communities in 2019. Some of the components used to accomplish this include: e-Consult, telehealth, telemonitoring, and telemedicine. Additionally, there will probably be increases in funding for primary care residency programs and providers in these communities, increased SUD services, and the incorporation of multi-payer models. Additionally, the reduction of skyrocketing pharmaceutical drug costs will certainly be another issue on the new year's agenda. To lower this spending, states will look to implement cost containment initiatives that will maximize rebate opportunities and enact revised utilization controls.

Lastly, states are also focused on LTSS issues and expanding coverage within community settings this year by extending provisions from existing support programs. Money Follows the Person (MFP) and Spousal Impoverishment are two programs being considered by Congress. MFP helps states in rebalancing their Medicaid long-term care systems. The Spousal Impoverishment provision dates back to 1988 and serves to protect the financial resources of elderly couples when employing nursing home care. CMS has also reached out to State Medicaid Directors in a November letter "to announce opportunities to design innovative service delivery systems including systems for providing community-based services for adults with a serious mental illness (SMI) or children with a serious emotional disturbance (SED) who are receiving medical assistance." The invitation authorizes states to waive the federal IMD payment exclusion in order to improve care for beneficiaries.

2018 was a significant year for Medicaid, the largest public health care provider in the United States. A variety of attempts were made to reform the program at the federal and state levels. Some of these efforts have turned out to be beneficial while others have become contentious with legislatures and enrollees. In 2019, Medicaid expansion, Section 1115 waivers, and new payment and delivery models will be some of the key issues to keep an eye on.

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TRUMP ADMINISTRATION INDICATING POTENTIAL LIMITS TO MEDICAID 1115 WAIVER APPROVALS

From the very start of Donald Trump's presidency, he has vowed to grant states the flexibility they need to design their own Medicaid policies. HHS, collaborating with governors and state legislatures, could make dramatic state-by-state modifications to Medicaid using section 1115 waivers allowed under federal law.

Section 1115 waivers give states the possibility to forgo key provisions of federal Medicaid law. The changes made possible by Section 1115 waivers are not as dramatic as those featured in the failed bills. For example, states cannot use 1115 waivers to fully restructure Medicaid under block grants or per capita caps, neither can the federal government use them to eliminate federal reimbursements for Medicaid expansion; however, they are still significant.

Under the President Trump's administration, CMS has authorized 1115 waivers that the former administration consistently rejected. Many states, for instance, have been allowed to make employment a condition for Medicaid enrollment. (The state of Kentucky; however, is presently in court proceedings over the new policy.).

Trump's administration is likewise allowing Kentucky to require beneficiaries to report income changes while Arkansas is disenrolling beneficiaries for the remainder of the calendar year if they do not comply with the work requirement.

The list below is what CMS has previously declined, as well as what is still under deliberations:

MEDICAID 1115 WAIVERS THAT HAVE BEEN REJECTED BY CMS

Lifetime limits

In May, CMS rejected an 1115 waiver application from Kansas to set up a three-year time limit for people enrolled in the Medicaid program.

Joan Alker, executive director of the Center for Children and Families at Georgetown University, said in a statement that she was "... pleasantly surprised by that."

Utah, Wisconsin and Arizona have also sent similar 1115 waiver applications to CMS for lifetime limits, which Alker anticipates will also get rejected.

In a statement by Seema Verma concerning Kentucky's attempt to sanction lifetime limits on Medicaid enrollees, she stated "We seek to create a pathway out of poverty, but we also understand that people's circumstances change, and we must ensure that our programs are sustainable and available to them when they need and qualify for them."

Partial expansion

CMS rejected Arkansas' bid to decrease the number of people who qualify for the state's Medicaid program. Arkansas was looking to reduce the eligibility requirement from 138 percent of the federal poverty to 100 percent; however, it was not a firm denial, rather, CMS stated it could not back the waiver application "at this time."

Whenever states vote to expand Medicaid the federal government pays 90 to 100 percent of the program's expenses. If Arkansas were permitted to simply cover people up to 100 percent of poverty, the formerly enrolled members who lose their Medicaid coverage would be eligible for federal health insurance subsidies. This would shift the liability to pay healthcare expenses from the state to the federal government. This scenario is most likely not attractive to the Trump administration.

OTHER 1115 WAIVERS CURRENTLY PENDING

Work requirements for non-expansion states

Besides the denial of permitting lifetime limits on Medicaid enrollees, an additional component of Kansas' 1115 waiver application is still pending; namely, a work requirement. But unlike Arkansas, Indiana and Kentucky, Kansas didn't expand Medicaid by way of the Affordable Care Act (ACA); so demanding individuals to maintain an employment (minimally 80-hours per week) would most likely exclude them for the state's Medicaid program since they would be making too much money.

Oklahoma, Alabama, South Dakota and Mississippi are other states that didn't expand under the ACA exploring work requirements. The Center on Budget and Policy Priorities issued a report that highlights the catch-22 of these proposals.

In the state of Mississippi, for example, a single parent can not earn over $370 per month to receive Medicaid. Nonetheless, if they acquired 20-hour per week employment at minimum wage, they would earn $580 a month, which is too much income to qualify for Medicaid.

"They will be complying with the work requirement but still lose coverage. You're in this situation that can't be fixed," says Jessica Schubel, a senior policy analyst for the Center on Budget and Policy Priorities.

CMS' Verma has stated that she is concerned about this "subsidy cliff" and wants to find a "pragmatic and empathetic" approach to work requirements and other new Medicaid initiatives.

Drug testing for Medicaid enrollment

Finally, last year Wisconsin was the first state to ask for authorization to drug test Medicaid applicants allowing the denial of enrollment if they test positive. Specialists say that there is no way to tell where the federal government will decide the issue. Having said that, CMS has indicated that they would advocate the use of Medicaid funds to cover neonatal abstinence syndrome (a withdrawal ailment that takes place when an infant is born with an opioid addiction from their mother's use during pregnancy). Medicaid experts say it is hypocritical for the federal government to cover babies with drug-related problems but not their parents.

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STATES PLAN TO USE MEDICAID 1115 WAIVERS TO WAIVE KEY PROVISIONS OF THE PROGRAM

The repeal of the Affordable Care Act with its existing provisions for Medicaid did not materialize at the national level in 2017; nevertheless, states are looking into reform independently by way of Medicaid 1115 waivers. These waivers concentrate on priorities within the states and allow local governments the flexibility to test coverage models that do not reflect program rules of the federal government.

Medicaid 1115 waivers provide states the opportunity to waive key provisions of federal law. The changes made possible by Section 1115 waivers are not as dramatic as those included in the failed bills-- for instance, states cannot use these waivers to fully restructure Medicaid under block grants or per capita caps, neither can the federal government use them to take away federal reimbursements for Medicaid expansion-- yet they are still significant.

In an attempt to "support states helping Medicaid beneficiaries improve well-being and achieve self-sufficiency", CMS released new guidance for waivers that imposed work requirements on January 11, 2018. Along with work requirements, states are also looking into provisions such as eligibility time limits, drug testing, and premiums. Because of this, these waivers are controversial and have brought up policy issues throughout the country.

At the moment, a number of states have submitted waivers for approval from the federal government. Here is some of the highlighting waiver activity within the states.

NEW HAMPSHIRE'S MEDICAID 1115 WAIVER FOR WORK REQUIREMENTS

New Hampshire was the fourth state to be permitted by the Trump administration for Medicaid work requirements. Under the state's Medicaid 1115 waiver, able-bodied adults will either need to work, develop job skills, or be involved in community service in order to receive premium assistance and program benefits from the state's Medicaid expansion.

Chief of CMS, Seema Verma congratulated the state and pointed out, "the Trump Administration has helped create one of the strongest job markets in our nation's history and we want to make sure able-bodied, working-age adults receive the necessary skills to join our growing workforce."

Governor Chris Sununu (R-- NH) said, "Work requirements help lift able-bodied individuals out of poverty by empowering them with the dignity of work and self-reliability while also allowing states to control the costs of their Medicaid programs."

Critics of the waiver are concerned that its ramifications will not support the original goals of the Medicaid program. A number of Democratic lawmakers are in opposition to the work requirements, strongly believing that they undermine access to the healthcare program. Supporters of the waiver see it as means of safeguarding the program's sustainability. They assert that Medicaid should be reserved for the country's most vulnerable and low-income individuals and families.

KANSAS IS DENIED 1115 WAIVER FOR LIFETIME LIMITS

Support for Medicaid expansion in Kansas came to a halt in February despite efforts from the Senate Public Health and Welfare Committee and House Democrats. Kansas Governor, Sam Brownback (R) vetoed the bill. Had it been approved, an estimated 150,000 residents would have been eligible.

While expansion failed, Kansas is one of five states, including Utah, Maine, Arizona, and Wisconsin, to ask for lifetime limits from CMS. This would have made it possible for the state to restrict coverage to three years/36 months for some of its recipients. CMS has declined the request making Kansas the first of the five states requesting lifetime limits to be denied.

Verma defended the decision saying, "we seek to create a pathway out of poverty, but we also understand that people's circumstances change, and we must ensure that our programs are sustainable and available to them when they need and qualify for them."

MEDICAID REFORM IN KENTUCKY 

Kentucky was the very first state to get approval from CMS for an 1115 waiver (January 12, 2017). The waiver will implement work requirements, monthly premiums for low-income parents and expansion adults, dis-enrollment and coverage lockouts, the elimination of retroactive eligibility, the addition of deductible and incentive accounts, and waiving non-emergency medical transportation.

Kentucky's governor, Matt Bevin (R), plans to start the overhaul of the state's Medicaid program on July 1, 2018. It will begin in Campbell County and reach across the state over a period of six months. These changes will predominantly affect able-bodied beneficiaries with incomes up to 138% of the federal poverty level that obtained coverage during the program's expansion in 2014. Due to the overhaul, it's approximated that Kentucky and the federal government will save $2.2 billion over five years. Additionally, the Center On Budget and Policy Priorities expects that over the duration there will be a 15 percent drop in adult Medicaid enrollment.

On January 24, sixteen Kentucky Medicaid beneficiaries took legal action and sued the federal government over the waivers provisions. The group sees the Trump administration's approval as a violation of several federal laws and a threat to the lives of tens of thousands of low-income families.

HEALTHY INDIANA 2.0 CLAMPS DOWN ON ENROLLMENT AND ELIGIBILITY

CMS signed off on the amended extension of Healthy Indiana 2.0 on February 1. Initially, the state's waiver expanded the program under the Affordable Care Act (ACA) from February 2015 through January 2018 by changing the states pre-ACA limited coverage expansion waiver, Healthy Indiana Program 1.0. While other state's waivers focus on adults enrolled during expansion, Indiana's also includes changes to the terms of coverage for non-expansion adults. This encompasses low-income parents as well as those eligible for transitional medical assistance.

Healthy Indiana Program 2.0 features provisions such as: raising premiums by 50% for tobacco using members beginning the second year of enrollment, eligibility work requirements for most adults in 2019, dis-enrollment and coverage lockouts, introducing a tiered premium structure, and restricting transitional medical assistance eligibility to between 139% and 185% of the federal poverty level.

While there are a number of exemptions in place to help beneficiaries secure and keep coverage, the launch of these provisions will definitely alter program eligibility. Now that the state has received approval for their provisions, Indiana confronts the task of implementing them.

ARIZONA'S FOUR 1115 WAIVERS UNDER REVIEW 

Arizona is looking to update and reform their Medicaid program, Arizona Health Care Cost Containment System (AHCCCS). Currently, the state has pending Medicaid 1115 waivers with CMS. The amendments include a retroactive eligibility request, an Institution for Mental Disease (IMD) waiver, work requirements, and an uncompensated care payment model.

Originally, Arizona also requested for approval of a 5-year lifetime time limit on Medicaid enrollment. However, this was recently taken out from the state's requests after CMS turned down Kansas's similar request for a 3-year time limit. No other state at this time has lifetime limits. In regards to the decision to delay the lifetime limit request, Deputy Director of AHCCCS, Jami Snyder said, "We have removed the lifetime limit from the waiver request, really for the purpose of expediting approval of the work requirements request." Right now, Arizona is still in discussions with CMS.

Regardless of the federal government's inability to reform Medicaid, states are now taking action to do it themselves through submitting 1115 waiver requests to CMS. Around the nation, local governments are now taking into consideration provisions such as work requirements, drug testing, lifetime limits, and premiums. A few states have received approval while others are encountering strong resistance. While reform through Medicaid 1115 waivers is supported by many state legislators, the way in which they are carried out will be vital to ensuring the future of the Medicaid program.

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