Trump Administration Approves Kentucky Work Requirements for Second Time

The Centers for Medicare and Medicaid Services (CMS) re-approved Kentucky’s request to add work requirements to the state’s Medicaid program last week, following a federal judge’s ruling earlier this year that overturned the first iteration of these requirements. These changes would require the population covered by Kentucky’s Medicaid expansion to report 80 hours of work or “work-related activities” each month, or face losing their coverage for a six-month lockout period. The approved 1115 waiver, which takes effect April 1, 2019, is almost identical to the state’s previously overturned application, and has been projected to result in at least 95,000 Kentuckians losing Medicaid coverage over the next five years.


In June of this year, District Court Judge James Boasberg blocked Kentucky’s original waiver request on the grounds that CMS had not properly considered whether the initiative would violate Medicaid’s central objective of providing medical assistance to the state’s citizens, nor had the agency adequately addressed concerns about the expected total loss of coverage for thousands of Kentuckians. The decision did not outlaw Medicaid work requirements outright, but rather required CMS to carefully assess each Medicaid Section 1115 waiver for its impact on individuals’ health care coverage. In response, CMS reopened a public comment period on the waiver, during which the National Council submitted comments strongly opposing work requirements and other harmful provisions included in the waiver.

In a letter to Kentucky’s Medicaid Director re-approving the 1115 waiver, CMS Chief of Staff Paul Mango outlined the agency’s assertion that work requirements and other measures included in the waiver “seek to improve beneficiary health and financial independence, improve the well-being of Medicaid beneficiaries and, at the same time, allow states to maintain the long-term fiscal sustainability of their Medicaid programs and to provide more medical services to more Medicaid beneficiaries.” He noted that CMS had considered public comments on the waiver, and that it had determined that the waiver was consistent with the goals of the Medicaid program. The letter also justifies experts’ projections that 95,000 Kentuckians will lose coverage by contending that they account for a small percentage of total Medicaid enrollees, and their disenrollment will likely be due to a variety of factors beyond the institution of work requirements, such as transitioning to commercial coverage.


CMS’s reapproval of Kentucky’s work requirements comes amid massive coverage losses for over 12,000 Arkansans operating under similar Medicaid restrictions as well as calls from many groups for CMS to halt approvals of new waivers that include work requirements. The Medicaid and CHIP Payment and Access Commission (MACPAC), a Congressionally-chartered body that advises Congress and CMS on Medicaid issues, submitted a formal request to Health and Human Services Secretary Alex Azar to cease approving these waivers.

Additionally, the National Council has joined many efforts to oppose work requirements, including submitting official comments on the Kentucky requirements, and sending a letter alongside other groups such as the Center on Budget and Policy Priorities, the Georgetown University Center on Children and Families and the March of Dimes, urging Secretary Azar to take immediate action to halt work requirements in the face of unnecessary coverage losses for Medicaid enrollees. Leonardo Cuello, Director of Health Policy at the National Health Law Program, one of the advocacy groups involved in the lawsuit which resulted in the initial blockage of these requirements said, “We do not believe HHS’s reapproval corrects the serious legal defects Judge Boasberg cited in his first opinion.”


Before the waiver goes into effect on April 1, 2019, Judge Boasberg will consider CMS’s reapproval of the Kentucky waiver, as well as the agency’s approval of the similar waiver currently active in Arkansas. Stay tuned to Capitol Connector each week for continued updates on Medicaid work requirements and their impact on individuals living with mental illness and substance use disorders.

Guest Author

Shelley Starkey