COLUMBUS, Ohio – Ohioans who will be required to work to get health coverage through Medicaid will not be kicked off until a case worker talks to them first.

That’s according to the latest paperwork Ohio Medicaid has submitted to the federal Centers for Medicare and Medicaid Services -- technically called an implementation plan because it spells out how the work requirements will be carried out.

“Prior to initiating Medicaid termination, a caseworker must speak directly with the beneficiary over the phone or in person,” the implementation plan states. “If, after speaking with the beneficiary, the caseworker determines that the beneficiary should have Medicaid eligibility terminated for non-compliance with the (work) requirement, a pre-termination review will be completed to determine if the beneficiary qualifies for Medicaid under a different eligibility category.”

Medicaid is a joint state-federal health care program for people who are low-income or suffer specific medical conditions such as blindness or pregnancy. Ohio’s work requirements will only be imposed on those who qualify for Medicaid expansion through the Affordable Care Act.

The requirements, which the federal government OK’d in March, are expected to begin Jan. 1, 2021, but details in the implementation plan will also have to be OK’d by the feds. It’s unknown when the federal government will respond.

The Republican-controlled Ohio General Assembly ordered Ohio Medicaid to seek federal permission for work requirements. Under President Donald Trump, the federal government has been more friendly to such proposals. The state started developing the work requirements under Gov. John Kasich.

They were finalized under Gov. Mike DeWine, who wanted last-minute changes after he took office, Ohio Department of Medicaid Director Maureen Corcoran said.

“So we made some changes at the end of the process,” she said. “One of the things that the governor was very specific about was making this kind of more individualized – contact with a person, not just cutting people off. He was very specific with me about that. So we added (contact with a case worker) at the end of the time we were working with (the feds) to get approval.”

Critics of work requirements say the implementation plan in Ohio is less onerous than those in other states. Nevertheless, it will be a barrier to coverage that will result in more people being disenrolled from the program, they said.

“I think the DeWine administration deserves credit for acknowledging the challenges and trying to address them,” said Loren Anthes, a public policy fellow at the Center for Community Solutions, a Cleveland think tank. “They’re doing a lot. But at the same time there’s a fundamental question: If we all know and acknowledge the system isn’t ideally designed, it has challenges in maintaining people’s coverage, why are we trying to make that challenge more complex?”

How many people would have to work?

Taking Medicaid expansion enrollment numbers from February, state officials estimated:

253,000 Medicaid beneficiaries were already working.

250,193 beneficiaries wouldn’t have to work due to a number of exemptions– including being in school full-time, having to provide care to children or living in a county that the federal government doesn’t have work requirements for due to relatively high unemployment.

That left 109,258 beneficiaries who will have to get a job, increase their hours at work or quality for an exemption.

That’s an estimate for one period of time. Medicaid enrollment changes constantly. In recent years, enrollment has dropped.

80 hours a month

For expansion enrollees who fall under the work requirement, they must work a minimum of 20 hours a week -- or 80 hours a month, the implementation plan states.

Hours above 20 may be applied to any week within the month but not toward any other calendar month.

Beneficiaries will not have to participate in monthly monitoring of their hours, the plan states. They will have to provide the names of their employers.

Medicaid already collects the data to verify their income for eligibility purposes, Corcoran said.

Corcoran anticipates some people will report a combination of work and school or another activity that’s exempt. For instance, maybe someone attends school part-time and works 10 hours a week.

Exemptions

The state can figure out many of the people who are exempt from work requirements based on other information in their case files. While those people will be notified of work requirements, they won’t have to fill out assessments showing they are exempt.

The following are the exemptions:

Full-time student status in college, career training or a GED program

People age 50 and older

Physical and mental health frailty

Pregnancy and a 60-day post-partum period.

Some former foster care youth

People in treatment for substance use disorder

Beneficiaries receiving unemployment benefits

Caregivers of a minor child

Applicants or recipients of Supplemental Security Income

People who live in a county that the federal government has exempted from work requirements in the Supplemental Nutrition Assistance Program.

Medicaid work exemptions by county will be the same as those in SNAP. Currently, in Ohio, SNAP beneficiaries in 42 counties are exempt from 20 hours a week of work. They mostly live in Appalachia but this year, Cuyahoga and Summit counties are also exempt.

Each year, the counties change. The determination is made on an average unemployment rate over the last 24 months, said Rachel Hopmoen, Ohio Medicaid’s section chief over eligibility policy.

Likewise, people who meet SNAP’s work requirements are automatically complying with Medicaid work requirements.

.'..if contradictory information is provided'

The implementation plan states that for many of the exemptions, the state will accept people self-attesting -- or just indicating on a form what exactly they’re doing that allows them to not have to fulfill work requirements.

For instance, people would self-attest they’re attending school. Medicaid won’t necessarily double check, unless “contradictory information is provided to or known by the State," the implementation plan states.

Will Ohio Medicaid be analyzing the rolls at Cuyahoga County Community College? Not necessarily, Hopmoen said.

“It would be a scenario where an individual attests to having a medical condition that prevents them from working. For example, they have severe back pain," she said.

If coincidentally a case worker happens to see the Medicaid beneficiary roofing the neighbor’s house, “that would lead the case manager to request additional information as to whether this individual has this back pain and this medical condition,” Hopmoen said.

Extra administrative work?

The General Assembly approved $15.5 million in state and federal funds for this year and $12 million next year to help with administrative costs in state and county government.

Medicaid will send some money to the counties, based on how many work requirement beneficiaries they see, Corcoran said.

Some money will be kept at Ohio Medicaid as it prepares to build out the program and train counties on the requirements.

Anthes of the Center for Community Solutions questioned the state’s decision to spend over $10 million a year on work requirements only affecting 100,000 people.

“I think it’s a poor investment,” he said. “Why are we spending millions and millions of dollars to make people fill out paperwork, instead of reinvesting those dollars to make the system better or promoting economic well-being?"