The Trump Administration announced last week that it will allow states to require Medicaid recipients to work, take job training, or do community service to stay eligible for the program, which provides both medical and long-term care services for people with low incomes. Ten states have asked to make this change, and the administration has given the greenlight to the first—Kentucky.
What will the requirement mean for older adults, younger people with disabilities, or their family caregivers? In general, older Medicaid recipients (starting between the ages of 50 and 65, depending on the state) would be exempt from the work requirement—as would children under 19 and pregnant women. Thus, an 85 year old widow with dementia will not have to get a job in order to keep her nursing home benefits.
But after that, it gets murky. The new guidelines, issued by the federal Centers for Medicare and Medicaid Services (CMS) give states broad flexibility in how they’d impose these new requirements.
This is what the CMS letter says:
“We look forward to working with states interested in testing innovative approaches to promote work and other community engagement, including approaches that make participation a condition of eligibility or coverage, among working-age, non-pregnant adult Medicaid beneficiaries who qualify for Medicaid on a basis other than a disability….States are in the best position to determine which approaches are most likely to succeed….Exemptions may include, but are not limited to age, disability, responsibility for a dependent, participation in a drug addiction or alcohol treatment and rehabilitation program, or another state-specified reason.”
This language is extremely broad. For example, what is a disability? Many people are too sick to work but have not met the formal definition of disabled. The Trump Administration would leave their Medicaid eligibility up to the states. The Kentucky program uses different language. It requires those who are “able-bodied” to work and exempts those who are “medically frail.” But what do those terms mean?
When it comes to caregivers, it gets even more complicated. Imagine, for example, an adult daughter who spends so much time caring for her aging parents that she loses her job. That’s not unusual: One-quarter of family caregivers say they spend 40 hours a week helping relatives. As a result, the daughter herself becomes a Medicaid beneficiary.
The administration guidance says that Medicaid recipients are exempt from the work requirement if they are caring for a “dependent.” But that may not mean what you think.
For some purposes, Medicaid uses the same definition of dependent as the Internal Revenue Service. According to the tax law, the rules for child dependents are pretty straightforward. Children qualify if they are under age 19, students under age 24, or if they are “permanently or totally disabled.” They must also live with their caregiver for at least half the year.
Who is a dependent?
It is different—and more complicated– for older adults. They are subject to a seven-part test to qualify as a non-child dependent. For example, only certain relatives–such as parents, spouses, or siblings–are eligible. They can’t have more than about $4,000 in annual income and half their total support must come from the person who claims them as a dependent. In effect, that means that many people receiving Social Security benefits, Supplemental Security Income (SSI) or who are themselves on Medicaid may not meet the definition of a dependent.
The result: Even though that daughter may be spending 40 hours a week caring for her parents, they may not count as dependents. And that means she may lose her Medicaid benefits—and thus access to health care– unless she gets a paying job or meets other requirements.
Where do you live?
But it will all depend on where she lives, and how strict her state is. In Kentucky, because her parents may not meet the definition of a dependent, she may be subject to the work requirement. But she may be able to satisfy that obligation by helping her parents. According to its proposal, “caregiving services for a non-dependent relative or other person with a disabling medical condition” satisfy the 80 hours per month work requirement. But Kentucky’s caregiving exception may not apply in other states that impose work requirements.
One additional kicker: In Kentucky, family members will have to document their caregiving. That could mean they’d have to keep logs or other records, something few do today. And as Jennifer Goldberg from the advocacy group Justice in Aging told me, “We know that the more administrative requirements Medicaid puts on people, the more likely they are to fall off the program.”
Medicaid’s new work requirement won’t encourage large numbers of non-disabled adults to get a job. Most who can work, already do. But it will generate a lot of uncertainty for people with disabilities and their family caregivers– who already have enough to worry about.
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